Using co-design to develop a culturally responsive reproductive health learning resource for Aboriginal and Torres Strait Islander youth

ISSUE ADDRESSED

Healthy behaviours prior to conception can improve pregnancy outcomes and intergenerational health. Adolescence is an important period to promote preconception health, but education resources need to be age and culturally appropriate. Few studies have addressed preconception awareness and knowledge among Aboriginal and Torres Strait Islander youth, and few culturally appropriate resources exist.

METHODS

A mixed methods, co-design process engaging Aboriginal and Torres Strait Islander youth and an Indigenous Reference Group (IRG). Additionally, a survey was carried out to identify preconception health awareness and interest among a broader youth audience.

RESULTS

Several main themes emerged from consultation meetings with youth reflecting an awareness of preconception health, but limited understanding. Youth revealed an interest in fertility, and a need for more information on lifestyle factors associated with infertility. Preconception information related to the opposite sex was seen as important as well as information incorporating current local knowledge and world views. Among the survey respondents, 46% (11/24) had a pre-existing understanding of preconception health. Optimising lifestyle behaviours prior to pregnancy was perceived as important for women (21/24; 88%), but less so for men (16/24; 67%), highlighting a gap in knowledge regarding the importance of preconception health for men.

CONCLUSION

The co-designed resource "Getting healthy before pregnancy" is available in print and electronically, with illustrations and synchronised audio overlay in Aboriginal English or East-side Kriol. The resource includes information on preconception health and behavioural risk factors.

SO WHAT

We present a co-designed preconception health resource for evaluation with Aboriginal and Torres Strait Islander youth.

Cancer Screening Participation and Gender Stratification in Europe

The current study examines whether the extent of macrolevel gender inequality affects the association between women's educational attainment and their participation in cervical and breast cancer screening and how this relationship is moderated by a country's cancer screening strategy (organized vs. opportunistic). A multilevel design with women (N_cervical = 99,794; N_breast = 55,021) nested in 30 European countries was used to analyze data from the European Health Interview Survey (2013-2015). Results of multilevel logistic regression models demonstrate that higher macrolevel gender inequality is associated with (a) a lower overall likelihood that women have had a mammography and Pap smear and (b) a larger gap in participation between women with low and high levels of education, regardless of a country's screening strategy (i.e., no moderation by a country's screening strategy was found). We conclude that macrolevel gender stratification should not be neglected when designing cancer screening policy.

Intergenerational social mobility predicts midlife well-being: Prospective evidence from two large British cohorts

RATIONALE

It is often assumed that experiencing an upward shift in social position from one generation to the next will provide happiness, yet empirical evidence demonstrating such a connection is limited.

OBJECTIVE

We provide a large-scale test of the relationship between intergenerational mobility and midlife life satisfaction using data from two prospective UK studies (N = 20,948).

METHOD

Intergenerational mobility was modelled as a formative construct gauging the extent to which individuals moved up or down the social hierarchy compared to their parents, on a continuum ranging from high levels of downward mobility to high levels of upward mobility.

RESULTS

An intergenerational increase in social mobility, captured by greater educational attainment, social status, and home size than one's parents was positively associated with life satisfaction at age 42 in both cohorts. Mediation analyses revealed that almost half of this relationship was explained by better self-reported health and fewer perceived financial difficulties amongst the upwardly mobile.

CONCLUSION

This study provides evidence that enhanced satisfaction with life may be a key outcome of intergenerational increases in social status.

Changes in the depression gender gap from 1992 to 2014: Cohort effects and mediation by gendered social position

The depression gap (i.e., higher rates of depression among women than men) represents an important mental health disparity in the US. Differences in gendered social position (i.e., the roles, responsibilities, and opportunities available to women and men), which have been changing since the mid-20th Century may contribute to this gender gap. The present study examined the evidence for a changing depression gap across birth cohorts and tested the extent to which any changes over time were mediated by changes in relative social position between women and men. Data were from the National Longitudinal Surveys. The depression gap was defined as differences in mean CESD scores for women vs. men. The analytic sample included 13,666 respondents interviewed from 1992 to 2014. Hierarchical mixed models estimated the magnitude of the gender depression gap over time, its association with 10-year birth cohort (range: 1957-1994), and whether any variation was mediated by ratios among women relative to men of obtaining a college degree, being employed full-time, and the average number of hours spent doing housework per week, three indicators of gendered social position. There was a linear decrease in the depression gap by 0.18 points across birth cohort (95% CI = -0.26, -0.10). The results of the mediation analysis estimated that an increasing ratio of college degree attainment mediated 39% of the gender depression gap across cohorts (95% CI = 0.18, 0.78). There was no evidence of mediation due to changing employment or housework ratios. These findings partially support the hypothesis that the depression gap is changing over time and is meaningfully related to the social environment. Understanding the social causes of the depression gap can illuminate the fundamental processes through which depression disparities may be perpetuated or attenuated over time and may aid in the identification of strategies to reduce them.

The Effects of Education on Mortality: Evidence From Linked U.S. Census and Administrative Mortality Data

Does education change people's lives in a way that delays mortality? Or is education primarily a proxy for unobserved endowments that promote longevity? Most scholars conclude that the former is true, but recent evidence based on Danish twin data calls this conclusion into question. Unfortunately, these potentially field-changing findings-that obtaining additional schooling has no independent effect on survival net of other hard-to-observe characteristics-have not yet been subject to replication outside Scandinavia. In this article, we produce the first U.S.-based estimates of the effects of education on mortality using a representative panel of male twin pairs drawn from linked complete-count census and death records. For comparison purposes, and to shed additional light on the roles that neighborhood, family, and genetic factors play in confounding associations between education and mortality, we also produce parallel estimates of the education-mortality relationship using data on (1) unrelated males who lived in different neighborhoods during childhood, (2) unrelated males who shared the same neighborhood growing up, and (3) non-twin siblings who shared the same family environment but whose genetic endowments vary to a greater degree. We find robust associations between education and mortality across all four samples, although estimates are modestly attenuated among twins and non-twin siblings. These findings-coupled with several robustness checks and sensitivity analyses-support a causal interpretation of the association between education and mortality for cohorts of boys born in the United States in the first part of the twentieth century.

Educational differences in mortality associated with central obesity: Decomposing the contribution of risk and prevalence

Thousands of preventable deaths are attributed to obesity in the United States. However, the harmfulness of obesity varies across the population; individuals' education determines access to healthful resources and exposure to competing risks, dampening/amplifying obesity-associated mortality risk. Using restricted U.S. National Health and Nutrition Examination Survey data (N = 40,058; 1988-2015), this study estimates educational differences in mortality attributable to central obesity (waist-to-height ratio ≥0.5) - a dangerous form of abdominal adiposity. Over 30% of excess deaths are attributable to central obesity among college-educated adults, compared to 1-10% among their less-educated counterparts. This difference is larger for cardiometabolic-related mortality, as central obesity may explain 60-70% of excess deaths among college-educated adults. Decomposition analyses show differences are driven by greater obesity-associated risk among college-educated adults, rather than prevalence. Policies targeting health disparities should recognize central obesity as a key risk among highly-educated adults, but only one of many encountered by those with less education.

Changing Educational Differentials in Female Sterilization

CONTEXT

Female surgical sterilization is widely used in the United States. Educational differentials in sterilization are large, but poorly understood. Improved understanding of these differences is important to ensure that all women have access to the full range of contraceptive methods.

METHODS

Data from the National Survey of Family Growth (1973-2015) from 8,100 women aged 40-44 were used to describe trends in sterilization and other contraceptive methods by educational attainment. Demographic standardization was employed to examine how compositional changes in marital status and age at first birth contribute to aggregate changes in sterilization prevalence.

RESULTS

In 1982, women with a high school diploma and those with at least a bachelor's degree reported similar levels of sterilization use (38% and 32%, respectively), but by 2011-2015, prevalence had declined to 19% among college-educated women and had increased to 44% among those with a diploma. The trend among college graduates was largely attributable to delayed fertility; all other things being equal, if their age at first birth had not increased, the prevalence of sterilization would have declined by approximately 3% instead of 14% between 1982 and 2002. Increased use of sterilization among women with a high school diploma was only weakly related to changes in birth timing and marital status.

CONCLUSIONS

Among women with a high school diploma, elements other than childbearing and marital status-such as contraceptive preferences and access-appeared to influence their contraceptive behavior. Sterilization differentials between high school and college graduates may reflect or exacerbate other socioeconomic disparities that affect women's health and well-being.

Knowledge, attitudes, harm perception, and practice related to waterpipe smoking in Lebanon

Waterpipe smoking (WPS) is one of the most emerging popular trends in Lebanon, with a prevalence of 36.9%, the highest among all Middle Eastern countries. Thus, the primary objective of the study was to examine the factors associated with knowledge, attitudes, and practice (KAP) related to WPS among a representative sample of waterpipe smokers. The secondary objective was to examine the effect of KAP on cumulative waterpipe dose and dependence. This cross-sectional study was carried out between May and December 2018 and enrolled a representative sample of 1550 waterpipe smokers from all Lebanese districts. The questionnaire used was specifically designed for this study. High knowledge score (Beta = 0.02, p = 0.002) were significantly associated with higher waterpipe harm perception score. In addition, high knowledge score (Beta = 0.32, p = 0.007) were significantly associated with higher attitude score toward smoking ban. Higher waterpipe harm perception score (Beta = - 1.30, p < 0.001), higher attitude (Beta = - 0.21, p < 0.001), and higher knowledge score (Beta = - 0.11, p < 0.001) were significantly associated with lower waterpipe dependence. In addition, higher waterpipe dependence (Beta = 2.02, p < 0.001) was significantly associated with higher cumulative waterpipe smoking, while higher waterpipe harm perception score (Beta = - 1.96, p = 0.009) and higher knowledge score (Beta = 0.27, p < 0.001) were significantly associated with lower cumulative waterpipe smoking. Our main finding was that better knowledge and perception of the harmful effects of waterpipe were related to a better attitude toward smoking bans and a lower waterpipe smoking. Therefore, health care providers and policymakers should join efforts to make awareness campaigns across Lebanon and develop adequate interventions to curb the use of waterpipe among the population.

Cross-Cultural Examination of University Education and Ego Integrity in Late Adulthood: Implications for Policy and Practice

Studies on education generally find that higher education has a positive impact on various aspects of life. Nevertheless, studies focused on elderly people and their psychosocial health and development seldom view higher education as an important factor. Our aim was to explore the relation between higher education and ego integrity, a measure based on Erikson's concept of psychological maturity in later life. We used four national samples of non-institutionalized elderly people from Cameroon (N = 238), China (N = 254), Czech Republic (N = 167), and Germany (N = 240). Relationships between ego integrity and several possible moderator variables were tested by multivariate regressions in each sample. Between-subject ANOVA was employed to test differences in ego integrity between university educated and non-university educated people. We found that ego integrity is affected by culture in interaction with gender and the level of education attained. University-educated people reported higher ego integrity than persons with lower education in three of four cultural samples, which suggests a relatively stable relationship between university education and ego integrity when controlling for gender, age, and working status. These findings highlight the importance of education in late adulthood. In terms of policies and practice, they underscore the importance of reduction of educational inequalities as well as desirability of improved access to higher education, expansion of opportunities for the achievement of complete education in later life, and facilitation and support of lifelong learning.

Barriers to Economic Security: Disability, Employment, and Asset Disparities in Canada

Although ample research shows that people with disabilities face significant labor market barriers, questions remain about whether and how disadvantages in employment and earnings contribute to economic insecurity. We use 1999 to 2012 Canadian Survey of Financial Security data to study disparities in nonhousing assets, which include household savings, stocks, and pensions, across households with and without disabilities. We find that households where the respondent or their spouse reported a disability held 25 percent less in nonhousing assets after accounting for key employment, education, and demographic factors. Demonstrating the more complicated relationship between disability, employment, and assets, these direct effects were further strengthened by disability's indirect effects on assets through its relationship with employment income.

Why does the importance of education for health differ across the United States?

The positive association between educational attainment and adult health ("the gradient") is stronger in some areas of the United States than in others. Explanations for the geographic pattern have not been rigorously investigated. Grounded in a contextual and life course perspective, this study assesses childhood circumstances (e.g., childhood health, compulsory schooling laws) and adult circumstances (e.g., wealth, lifestyles, economic policies) as potential explanations. Using data on US-born adults aged 50-59 at baseline (N=13,095) and followed for up to 16 years across the 1998-2014 waves of the Health and Retirement Study, this study examined how and why educational gradients in morbidity, functioning, and mortality vary across nine U.S. regions. The findings indicate that the gradient is stronger in some areas than others partly because of geographic differences in childhood socioeconomic conditions and health, but mostly because of geographic differences in adult circumstances such as wealth, lifestyles, and economic and tobacco policies.

Alcohol Advertisements, Hazard Warnings, Knowledge of Alcohol-Related Harm and Health-Profession Students' Drinking in Inner Mongolia

Background: Consumption of alcohol among adults in Inner Mongolia is high even among health professionals. Little is known of the alcohol consumption patterns of health-profession students. Objectives: To assess the association of knowledge of alcohol-related harm (KAH), and exposure to media-based promotional alcohol sales advertisements (PASA) and alcohol hazard warnings (AHW) with drinking frequency of health-profession university students. Methods: Health-profession students (N = 1277) in the Medical University of Inner Mongolia were interviewed in 2017 regarding their alcohol drinking frequency, KAH, and exposure to PASA and AHW. Multinomial logistic regression was used to evaluate associations between exposure and drinking frequency. Results: Overall, 9% were nondrinkers, 35% occasional drinkers, and 56% frequent drinkers. Females were slightly less commonly drinkers but more commonly frequent drinkers. The prevalence of drinking decreased with age. Mongolians were more commonly frequent drinkers than Han. A majority of students had low KAH. Exposure to PASA was more common among drinkers, and exposure to AHW more common among nondrinkers. The main reason for drinking was social gathering. The relative probability of being an occasional or frequent drinker was lower among older students, those with higher KAH, and those exposed to AHW on television and internet but higher among those exposed to PASA in mini-supermarkets on campus. Conclusions: Students' drinking behavior was associated with low KAH and exposure to alcohol advertisements and warning media messages. Prevalence of frequent drinking might be reduced by wider use of AHW on internet and television and improving the level of knowledge of alcohol-related harm.

The Impact of Educational Attainment on Black Women's Obesity Rate in the United States

Over the last two decades, Black women have been disproportionately impacted by the obesity epidemic in the USA. According to the Centers for Disease Control and Prevention (CDC), 56.6% of Black women are overweight or obese compared with 44.4% Hispanic and 32.8% of white women. Social scientists and public health researchers have argued that increasing educational attainment would lead to overall improvements in health outcomes. Using the National Health and Nutrition Examination Survey (NHANES), a nationally representative cross-sectional survey, Cycles 1999–2010, I examined how educational attainment impacts Black women’s rate of obesity and C-reactive protein levels (N = 2685). Multiple linear regression was used to analyze the association between body mass index (BMI) and educational attainment. C-reactive protein, inflammation response, was used to measure the body’s reaction to being exposed to stress. The results demonstrated that educational attainment among Black women does not decrease their risk of being obese or levels of C-reactive protein. This article provides evidence to support a need to increase awareness of health disparities that disproportionately impact Black women.

The complex genetics and biology of human temperament: a review of traditional concepts in relation to new molecular findings

Recent genome-wide association studies (GWAS) have shown that temperament is strongly influenced by more than 700 genes that modulate associative conditioning by molecular processes for synaptic plasticity and long-term learning and memory. The results were replicated in three independent samples despite variable cultures and environments. The identified genes were enriched in pathways activated by behavioral conditioning in animals, including the two major molecular pathways for response to extracellular stimuli, the Ras-MEK-ERK and the PI3K-AKT-mTOR cascades. These pathways are activated by a wide variety of physiological and psychosocial stimuli that vary in positive and negative valence and in consequences for health and survival. Changes in these pathways are orchestrated to maintain cellular homeostasis despite changing conditions by modulating temperament and its circadian and seasonal rhythms. In this review we first consider traditional concepts of temperament in relation to the new genetic findings by examining the partial overlap of alternative measures of temperament. Then we propose a definition of temperament as the disposition of a person to learn how to behave, react emotionally, and form attachments automatically by associative conditioning. This definition provides necessary and sufficient criteria to distinguish temperament from other aspects of personality that become integrated with it across the life span. We describe the effects of specific stimuli on the molecular processes underlying temperament from functional, developmental, and evolutionary perspectives. Our new knowledge can improve communication among investigators, increase the power and efficacy of clinical trials, and improve the effectiveness of treatment of personality and its disorders.

Socioeconomic disparities in psychological health: Testing the Reserve Capacity Model in a population-based sample of Chinese migrants

Based on the Reserve Capacity Model, this study investigated the associations of objective socioeconomic status and subjective social status with psychological health and the underlying psychosocial mechanisms in a population-based sample of Chinese migrants (n = 15,999). Results showed that subjective social status was positively associated with life satisfaction and self-rated health through the mediation of psychological distress and perceived stress. Whereas education showed a very weak association with life satisfaction, income was directly associated with life satisfaction only. The findings suggest that reducing psychosocial vulnerabilities may be a potential impetus to eliminate socioeconomic health disparities among Chinese migrants.

Environmental health in Australia: overlooked and underrated

Improvements in environmental health have had the most significant impact on health status. In Australia, life expectancy has significantly increased through provision of vaccination, safe food and drinking water, appropriate sewage disposal and other environmental health measures. Yet the profession that is instrumental in delivering environmental health services at the local community level is overlooked. Rarely featuring in mainstream media, the successes of Environmental Health Officers (EHOs) are invisible to the general public. As a consequence, students entering university are unaware of the profession and its significant role in society. This has resulted in there being too few EHOs to meet the current regulatory requirements, much less deal with the emerging environmental health issues arising as a consequence of changing global conditions including climate change. To futureproof Australian society and public health this workforce issue, and the associated oversight of environmental health must be addressed now.

Linking Mastery Across the Life Course to Mobility Device Use in Later Life

OBJECTIVES

Mastery in older ages is shaped by earlier-life experiences. Prior research has demonstrated that mastery is associated with health-promoting behaviors; however, little research has examined whether mastery histories influence health behaviors such as mobility device use in later life.

METHOD

Using 25 years of data from the Americans' Changing Lives Survey (N = 1,427), this research explores whether different trajectories of life course mastery influence the odds that an older adult will use a mobility device when experiencing functional impairment. We used growth mixture models with a distal outcome and examined the relationship between functional limitations and mobility device use as it varies across latent classes of life course mastery, controlling for social and health factors.

RESULTS

The odds of device use in the face of functional limitations were significantly higher among those with a history of high life course mastery, relative to those with low life course mastery, all things being equal.

DISCUSSION

Our findings suggest that mastery over the life course is a source of psychological human capital that is associated with health-promoting behaviors in later life among those with functional limitations.

Education and Psychosocial Functioning Among Older Adults: 4-Year Change in Sense of Control and Hopelessness

Objectives

This study investigates education differences in levels and change in sense of control and hopelessness among older adults.

Method

We used data from the Health and Retirement Study, an ongoing biennial survey of a nationally representative sample of older Americans, to examine education differences in sense of control (e.g., mastery and perceived constraints) and hopelessness. Our sample included 8,495 adults aged 52 and older who were interviewed in 2006/2008 and 2010/2012. We assessed separate models for change in sense of control and hopelessness, accounting for recent changes in social circumstances and health status.

Results

Low mastery, perceived constraints, and hopelessness were highest among individuals with less than a high school education. Over a 4-year period, this group experienced the greatest declines in psychosocial functioning, as indicated by greater increases in low mastery, perceived constraints, and hopelessness. Education differences existed net of recent negative experiences, specifically the loss of intimate social relationships and social support and increases in disease and disability.

Discussion

These findings highlight the importance of education for sense of control and hopelessness in older adulthood and demonstrate the cumulative advantage of higher levels of education for psychosocial functioning.

Does social globalisation through access to information communication technologies drive obesity among youth? An empirical analysis, 1990-2013

Scholars debate the effects of globalisation on obesity. Using the latest data on access to ICTs and the Global Burden of Disease data on excess weight gain and obesity, we find that both social globalisation and access to ICTs lower the overweight and obese share among the global youth cohort aged 15-19. Previous studies report mixed results, which are hard to evaluate because of the use of different data, sample sizes, and estimating strategies. Using fixed-effects analyses on a global sample of over 160 countries spanning 24 years, we show that 'social globalization' reduces the obesity share of youth when fixed effects are estimated. Greater access to ICTs also independently lowers youth obesity rates. We speculate that greater access to information and knowledge about current trends, the benefits of physical activity and diet, and trends in healthy consumption spreading through ICTs might be a boon despite risks associated with greater consumption from increasing wealth and political freedoms. These results are robust to several estimating methods, including instrumental variables analysis. Our results suggest that increased access to ICTs does not increase obesity and that policy might even usefully target youth via ICTs for encouraging better health.

The role of adult socioeconomic and relational reserves regarding the effect of childhood misfortune on late-life depressive symptoms

Background

Childhood misfortune is associated with late-life depressive symptoms, but it remains an open question whether adult socioeconomic and relational reserves could reduce the association between childhood misfortune and late-life depressive symptoms.

Methods

Using the Survey of Health, Ageing and Retirement in Europe (SHARE), data from 8'357 individuals (35'260 observations) aged 50–96 years and living in 11 European countries were used to examine associations between three indicators of childhood misfortune (adverse childhood events, poor childhood health, and childhood socioeconomic circumstances) and late-life depressive symptoms. Subsequently, we tested whether these associations were mediated by education, occupational position, the ability to make ends meet, and potential or perceived relational reserves; that is family members or significant others who can provide help in case of need, respectively. Analyses were stratified by gender and adjusted for confounding and control variables.

Results

Adult socioeconomic reserves partly mediated the associations between adverse childhood events, poor childhood health and late-life depressive symptoms. The associations with the third indicator of childhood misfortune (childhood socioeconomic circumstances) were fully mediated by adult socioeconomic reserves in men, and partly mediated in women. None of the associations were mediated by relational reserves. However, perceived relational reserves were associated with fewer late-life depressive symptoms.

Conclusion

Childhood socioeconomic disadvantage can be mitigated more easily over the life course than adverse childhood events and poor childhood health, especially in men. Perceived relational reserves work primarily as a protective force against late-life depressive symptoms and may be particularly important in the context of the cumulative effect of childhood adversities.

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Socioeconomic reserves can mediate the effect of childhood socioeconomic disadvantage on late-life depressive symptoms.

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Education turned out to be the strongest mediator.

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Findings showed a lasting effect of adverse childhood experiences and poor childhood health on late-life depressive symptoms.

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Relational reserves did not mediate the effect of any of the childhood misfortune indicators on late-life depressive symptoms.

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Relational reserves were associated with fewer late-life depressive symptoms suggesting a potential protective function.

Estimation of Prevalence of Osteoporosis Using OSTA and Its Correlation with Sociodemographic Factors, Disability and Comorbidities

Osteoporosis is a growing concern for an aging society. The study aimed to estimate the prevalence of older adults who were at risk of osteoporosis and explore factors associated with osteoporosis. The relationship between the risk of osteoporosis, chronic conditions and disability was also explored. We hypothesized that respondents with high risk index of osteoporosis would be associated with greater disability. Participants aged 60 years and above (N = 2565) who were representative of Singapore’s multiethnic population were recruited. The Osteoporosis Self-Assessment Tool for Asians (OSTA) was used to classify the risk of osteoporosis. Information on sociodemographic details and chronic diseases were collected, while severity of disability was measured using the World Health Organization Disability Assessment Schedule 2.0. The overall prevalence of the respondents who were at risk of osteoporosis was 52%. Those belonging to an older age, Chinese, female, never married or widowed, lower education and retired were associated with a higher risk of osteoporosis. A diagnosis of diabetes or hypertension was a protective factor against the risk of osteoporosis. High risk of osteoporosis was not associated with disability. Our findings highlighted specific factors associated with the risk of osteoporosis that could be useful for the prevention of osteoporosis and fractures.

Theoretical framework and protocol for the evaluation of Strong Through Every Mile (STEM), a structured running program for survivors of intimate partner violence

BACKGROUND

Intimate partner violence can have a devastating impact on victims' psychological and physical health and ability to maintain and preserve interpersonal relationships. The aim of the current study is to empirically test the effectiveness of Strong Through Every Mile (STEM), a 10-week structured running (exercise) program designed to increase psychological, social, and physical well-being among survivors of intimate partner violence. To the authors' knowledge, STEM is the only community-based structured running program designed to improve the quality of life of survivors of intimate partner violence. This paper will describe the STEM program and present the theoretical basis of the program and the program evaluation design.

METHODS

The current study will utilize an interdisciplinary lens to evaluate a community-based intervention aimed at decreasing the negative effects of intimate partner violence on women's lives. The study will use a mixed method approach (qualitative and quantitative), including a pre- and post-test evaluation of the STEM running program. Primary data will be collected using paper and pencil surveys which assess women's psychological, social, and physical well-being prior to participation in the program and following the completion of the program. Qualitative data from focus groups will also be collected and allow for a more rich understanding of the changes that women experience over the course of the program and specific mechanisms underlying these changes.

DISCUSSION

The current study will employ an interdisciplinary lens to examine the extent to which a structured exercise program, specifically running, impacts the psychological, social and physical well-being of women survivors of intimate partner violence. Findings of this study can influence the development and implementation of similar programs for survivors of intimate partner violence and other types of trauma by identifying mechanisms central in achieving positive outcomes for participants.

Association between child marriage and institutional delivery care services use in Bangladesh: intersections between education and place of residence

OBJECTIVES

To examine the association between child marriage and women's use of institutional delivery care services and whether education and place of residence moderate this association.

STUDY DESIGN

The study used de-identified data from four rounds (2004, 2007, 2011, and 2014) of the Bangladesh Demographic and Health Survey (BDHS). The BDHS is a cross-sectional survey conducted every three years. The analysis was based on 16,099 ever-married women aged 15-49 years with at least one live birth in the three years before the survey.

METHODS

The study used multivariable logistic regression models with interaction terms between age at marriage, education, and place of residence. Adjusted predicted probabilities of outcome variables were computed from interaction models.

RESULTS

Child marriage is significantly associated with decreased use of institutional delivery care services. Compared to women who married at adult ages (≥18 years), women who married between ages of 12-14 years were the most disadvantaged in having delivered at a health facility (odds ratio [OR]: 0.62; 95% confidence interval [CI]: 0.51-0.74) and having a skilled attendant present (OR: 0.63; 95% CI: 0.53-0.75) at the birth of their last child. The analysis suggests that the effect of education on the use of institutional delivery care is stronger among women married at age 18 or older compared to women who married younger than age 18 years. Further, the joint effect of age at marriage and education is stronger for women living in urban than rural place of residence.

CONCLUSIONS

Increasing the age at marriage and discouraging child marriage may be a fruitful way to improve mother and child health in Bangladesh. Encouraging girls to complete high school and pursue college education would also help decline the rate of child marriage and, in turn, benefit social mobility and health.

A life course study of the effects of experienced life events on the onset and continuity of preventive healthcare behaviors

This study offers the life course paradigm as a viable framework for studying the onset and continuity of three preventive healthcare behaviors at different stages in life. The results reveal that life events experienced earlier in life significantly affect the likelihood of the onset of some certain behaviors and have a different impact on the risk of discontinuation of such a behavior at different life stages. The findings also support the notion that the longer people engage in a certain preventive healthcare activity, the more likely they are to continue that activity. Implications for research and practice are discussed.

Perceived control among migrant live-in and local live-out home care workers in Israel

OBJECTIVE

To examine perceived control among live-in and live-out home care workers and to identify factors that contribute to perceived control among both types of caregiving.

METHOD

338 migrant live-in home care workers and 185 local live-out home care workers were asked to report their perceived control. Burnout, satisfaction with the relationship with the care recipient and the care recipient's family, and satisfaction with social relationship were also gathered.

RESULTS

Both types of caregivers reported high levels of perceived control, although live-in home care workers expressed more perceived control. Higher age, higher levels of satisfaction with the relationship with the care recipient and the care recipient's family and lower levels of burnout, predicted perceived control. Satisfaction with social relationship was a stronger predictor of one's perceived control among live-in home care workers.

CONCLUSIONS

Promoting social relationships outside the home care context by allowing migrant live-in home care workers to take part in social gatherings is recommended as this can strengthen their sense of perceived control.

Interpreting mutual adjustment for multiple indicators of socioeconomic position without committing mutual adjustment fallacies

Research into the effects of Socioeconomic Position (SEP) on health will sometimes compare effects from multiple, different measures of SEP in "mutually adjusted" regression models. Interpreting each effect estimate from such models equivalently as the "independent" effect of each measure may be misleading, a mutual adjustment (or Table 2) fallacy. We use directed acyclic graphs (DAGs) to explain how interpretation of such models rests on assumptions about the causal relationships between those various SEP measures. We use an example DAG whereby education leads to occupation and both determine income, and explain implications for the interpretation of mutually adjusted coefficients for these three SEP indicators. Under this DAG, the mutually adjusted coefficient for education will represent the direct effect of education, not mediated via occupation or income. The coefficient for occupation represents the direct effect of occupation, not mediated via income, or confounded by education. The coefficient for income represents the effect of income, after adjusting for confounding by education and occupation. Direct comparisons of mutually adjusted coefficients are not comparing like with like. A theoretical understanding of how SEP measures relate to each other can influence conclusions as to which measures of SEP are most important. Additionally, in some situations adjustment for confounding from more distal SEP measures (like education and occupation) may be sufficient to block unmeasured socioeconomic confounding, allowing for greater causal confidence in adjusted effect estimates for more proximal measures of SEP (like income).

Educational Disparities in Adult Health: U.S. States as Institutional Actors on the Association

Despite numerous studies on educational disparities in U.S. adult health, explanations for the disparities and their growth over time remain incomplete. We argue that this knowledge gap partly reflects an individualist paradigm in U.S. studies of educational disparities in health. These studies have largely focused on proximal explanations (e.g., individual behaviors) to the neglect of contextual explanations (e.g., economic policies). We draw on contextual theories of health disparities to illustrate how U.S. states, as institutional actors, shape the importance of education for health. Using two nationally-representative datasets and seven health measures for adults aged 45-89, we show that the size of the educational gradient in health varies markedly across states. The size varies because of variation in the health of lower-educated adults. We use state excise taxes on cigarettes to illustrate one way that states shape educational disparities in health. Our findings underscore the necessity of contextualizing these disparities.

Children Present a Window of Opportunity for Promoting Health: JACC Review Topic of the Week

Cardiovascular disease is the leading cause of death and disability in the world, largely because of risk factors modifiable by changes in behavior. There is evolving evidence that our behavior as adults has its roots in the environment that we live in from early childhood. Early sustained multicomponent educational programs focused on health promotion in children may represent a window of opportunity to potentially prevent disease in adulthood. The integration of school-based, family-based, and community-based strategies, along with the support of public policies, are likely necessary for the success of these programs. In this review, the authors describe the future of promoting health. Specifically: 1) reasons why children should be a focus for health promotion (alarming trends of risk factors, association between unhealthy factors and subclinical disease, and cost-effectiveness); 2) strategies for health promotion in children (school-based, family-based, and community-based approaches) along with legislative efforts; and 3) research gaps are discussed.

Association between socioeconomic attainments and suicidal ideation by age groups in Korea

BACKGROUND:

Suicidal ideation is a strong antecedent of suicidal behavior, associated with increased likelihood of suicide. Thus, suicidal ideation serves to identify which groups are at more risk of suicide and has policy implications for targeting groups to prevent suicide.

AIMS:

A substantial body of research has addressed potential determinants of suicide ideation in Korea. Little attention has been paid, however, to analyzing the extent to which socioeconomic attainments (education, household income, and employment status) are associated with risk of suicidal ideation, drawing on nationally representative data.

METHODS:

Data were drawn from the 2012 Korea Welfare Panel Study (KOWEPS). Among the 12,606 respondents, the findings are based on 1,500 young adults (age 18-35) and 3,469 middle-aged adults (age 36-55) who answered a question about suicidal ideation.

RESULTS:

For young adults, respondents from 2-year and 4-year colleges and higher had lower probabilities of suicidal ideation compared with respondents from high school. People out of the labor force also exhibited an elevated risk of suicidal ideation compared with those in waged employment. Middle-aged adults displayed different patterns. Middle-aged respondents from 4-year colleges or higher had an increased likelihood of suicidal ideation. The likelihood of reporting suicidal ideation was predicted to decrease as household income increased only for middle-aged adults.

CONCLUSIONS:

The information about suicidal ideation was obtained from only one question of self-response, which limits the validity of the suicidal ideation measurement. The cross-sectional setting of the data prevents us from estimating causal relationships. Nevertheless, the findings imply that age-specific policy should be implemented to ameliorate differential risk for suicidal ideation and benefit public mental health in the long run.

Social Disadvantage and Instability in Older Adults' Ties to Their Adult Children

OBJECTIVE

We examine whether racial and socioeconomic factors influence older adults' likelihood of experiencing instability in their social network ties with their adult children.

BACKGROUND

Recent work shows that socially disadvantaged older adults' social networks are more unstable and exhibit higher rates of turnover, perhaps due to greater exposure to broader social-environmental instability. We consider whether this network instability applies to older adults' ties with their adult children, which are often the closest and most reliable social ties in later life.

METHODS

We use two waves of data from the National Social Life, Health, and Aging Project (N=1,456), a nationally representative, longitudinal study of older Americans. Through a series of multivariate regression models, we examine how race and education are associated with how frequently older adults reported being in contact with child network members, and how likely older adults were to stop naming their children as network members over time.

RESULTS

African American and less educated individuals reported significantly more frequent contact with their adult child network members than did whites and more educated individuals. Nevertheless, these populations were also more likely to stop naming their children as network confidants over time.

CONCLUSION

African American and less educated older adults are at greater risk of losing access to the supports and other resources that are often provided by adult children, or of not being able to consistently draw on them as they age, despite the fact that these ties demonstrate greater potential for support exchange at baseline.

Unpacking the link between socioeconomic status and behavior problems: A second-order meta-analysis

Substantial evidence links socioeconomic status to internalizing and externalizing behavior problems. However, it is unclear how these two categories of behavior problems relate to specific components of socioeconomic status (e.g., income, educational attainment, and occupational prestige) or overall social status. In this study, we conducted a second-order meta-analysis to estimate the average associations of income, education, occupation, and overall socioeconomic status with internalizing and externalizing behavior problems, and to examine if age, sex, and race/ethnicity moderated these associations. Our systematic search in PsycINFO, PubMed, Google Scholar, Web of Science, and ProQuest Dissertations and Theses Global identified 12 meta-analyses (17% unpublished), including approximately 474 primary studies and 327,617 participants. In relation to internalizing, we found small average associations with income, r+ = -.18, 95% confidence interval (CI) [-.31, -.04], and education, r+ = -.12, 95% CI [-.15, -.09]. In relation to externalizing, we found smaller associations with income, r+ = -.02, 95% CI [-.15, .10], education, r+ = -.03, 95% CI [-.16, .10], and overall socioeconomic status, r+ = -.05, 95% CI [-.11, .01], but these CIs included zero. Only sex composition of the samples moderated the latter association. We provide recommendations for best practices and future research directions.

The prevalence of anxiety and associated factors in persons with multiple sclerosis

BACKGROUND

The prevalence of anxiety and its association with sociodemographic and clinical factors is not well characterized in those with multiple sclerosis (MS). We aimed to estimate the prevalence and examine associated factors of anxiety in persons with MS.

METHODS

A cross-sectional analysis was conducted utilizing data from 244 participants from the Neurological Disease and Depression study. Anxiety was assessed using the Hospital Anxiety and Depression Scale (HADS). Descriptive statistics and multiple logistic regression was used to examine anxiety and associated factors.

RESULTS

Nearly 30.0% of participants had anxiety according to the HADS. The most prevalent symptom of anxiety was "worrying thoughts" (26.6%). After adjustment for various confounders, depression (OR: 7.31 95% CI 3.29-16.26) was found to be associated with higher odds of anxiety, while lower odds of anxiety were associated with higher education (OR: 0.51, 95% CI 0.28-0.94). Furthermore, anxiety was strongly associated with decreased quality of life.

CONCLUSION

Anxiety represents a substantial burden for those with MS and is associated with a variety of adverse outcomes including decreased quality of life. Our results further emphasize the importance of understanding the impact of anxiety in this population.

Validation of the Arabic version of the MADRS scale among Lebanese patients with depression

AIM

To use the Arabic version of the MADRS in Lebanese depressed patients, check its validity and reproducibility compared to other versions of the questionnaire and assess risk factors affecting the total MADRS score.

METHODS

This case-control study, performed between September 2016 and January 2017, included 200 patients (100 patients, 100 controls). The questionnaire included two parts, the first one concerning the socio-demographic characteristics another one that included the Montgomery-Asberg Depression Rating Scale (MADRS) questions, which was translated from English to Arabic through an initial translation and back translation process.

RESULTS

The MADRS scale items converged over a solution of one factor that had an Eigenvalue over 1, explaining a total of 83.90% of the variance. A Kaiser-Meyer-Olkin measure of sampling adequacy of 0.953 was found, with a significant Bartlett's test of sphericity (P<0.001). A stepwise linear regression, using the total MADRS score as continuous variable, showed that a university level of education would significantly decrease the total MADRS score by 20 points (beta=-20.02, CI: from -26.337 to -13.709, P<0.001). Unemployment was significantly more associated with an increase in the total MADRS score level by 10.23 points (beta=10.23, CI: 3.944-16.526, P=0.002).

CONCLUSION

This study shows that the Arabic version of the MADRS has promising psychometric properties, and thus it is a good tool to use for the diagnosis of patients with depression. Based on this study, health care professionals and researchers can readily use the MADRS questionnaire to estimate the overall severity of depression among psychiatric patients in Lebanon.

The case of the middle class: Social determinants of health in Mumbai

In India, a growing middle class and rising lifestyle diseases put prevention in the spotlight. This study assesses the impact of health behaviors (tobacco use and exercise) as well as psychological states (positive emotional style, hope, and perceived stress) on the health of 314 middle class participants from Mumbai. Logistic regression predicting objective health revealed that positive emotional style was a protective factor. Linear regression predicting perceived health indicated perceived stress and positive emotional style as the significant factors. An intersectional approach focusing on psychological factors and health behaviors, nested within class and gender, will lead to effective preventive strategies.

Is Women's Empowerment Associated With Help-Seeking for Spousal Violence in India?

Violence against women by their husbands is a problem for women worldwide. However, the majority of women do not seek help. This article presents findings from a national survey in India on empowerment-related correlates of help-seeking behaviors for currently married women who experienced spousal violence. We examined individual-, relationship-, and state-level measures of empowerment on help-seeking from informal and formal sources. Findings indicate that help-seeking is largely not associated with typical measures of empowerment or socio-economic development, whereas state-level indicators of empowerment may influence help-seeking. Although not a target of this study, we also note that injury from violence and the severity of the violence were among the strongest factors related to seeking help. Taken together, the low prevalence of help-seeking and lack of strong individual-level correlates, apart from severe harm, suggests widespread barriers to seeking help. Interventions that affect social norms and reach women and men across social classes in society are needed in addition to any individual-level efforts to promote seeking help for spousal violence.

Family lifestyle dynamics and childhood obesity: evidence from the millennium cohort study

Background

The prevalence of childhood obesity has been increasing but the causes are not fully understood. Recent public health interventions and guidance aiming to reduce childhood obesity have focused on the whole family, as opposed to just the child but there remains a lack of empirical evidence examining this relationship.

Methods

Using data from the longitudinal Millennium Cohort Study (MCS), we investigate the dynamic relationship between underlying family lifestyle and childhood obesity during early childhood. The MCS interviewed parents shortly after the birth of their child and follow up interviews were carried out when the child was 3, 5 and 7 years. We use a dynamic latent factor model, an approach that allows us to identify family lifestyle, its evolution over time (in this case between birth and 7 years) and its influence on childhood obesity and other observable outcomes.

Results

We find that family lifestyle is persistent, 87.43% of families which were above the 95th percentile on the lifestyle distribution, remained above the 95th percentile when the child was 7 years old. Family lifestyle has a significant influence on all outcomes in the study, including diet, exercise and parental weight status; family lifestyle accounts for 11.3% of the variation in child weight by age 7 years.

Conclusion

The analysis suggests that interventions should therefore be prolonged and persuasive and target the underlying lifestyle of a family as early as possible during childhood in order to have the greatest cumulative influence. Our results suggest that children from advantaged backgrounds are more likely to be exposed to healthier lifestyles and that this leads to inequalities in the prevalence of obesity. To reduce inequalities in childhood obesity, policy makers should target disadvantaged families and design interventions specifically for these families.

Depression hurts, depression costs: The medical spending attributable to depression and depressive symptoms in China

Due to its fast economic growth and lifestyle changes, China is experiencing a rapid epidemiological transition from communicable to noncommunicable diseases (NCDs). Mental disorder such as depression is an important yet often neglected NCD and is becoming a growing cause of disability, suicides, and disease burden. This paper provides the first nationally representative estimate of the medical cost attributable to depression and depressive symptoms among the adult population in China. On the basis of the 2012 China Family Panel Studies survey, our results indicate that these mental health conditions have significant impacts on the individual medical expenditure, and they jointly contribute to 14.7% of total personal expected medical spending in China, with depression and depressive symptoms accounting for 6.9% and 7.8%, respectively. Given that patients with mental illness face multiple psychological and institutional barriers in seeking appropriate treatment, the high depression-induced medical costs may be primarily driven by the cost-shifting effect from mental health care to general health care, as mental disorders often coexist with other NCDs such as diabetes and hypertension. As an implication, our study calls for an urgent reform of China's mental health and insurance systems to remove the policy-induced obstacles for the access to mental health care resources.

Body Mass Index and Subjective Social Status: The Coronary Artery Risk Development in Young Adults Study

OBJECTIVE

Subjective social status (SSS), or perceived social status, may explain, in part, the relationship between socioeconomic status (SES) and obesity. The objective of this study was to test whether SSS mediates the relationship between two indicators of SES (income and education) and body mass index (BMI).

METHODS

A cross-sectional, structural equation path analysis was applied to the Coronary Artery Risk Development in Young Adults (CARDIA) study (n = 2,624). The analysis tested whether SSS (MacArthur scale), education, and income were associated with BMI at the year 20 examination (adjusting for sex, age, and race), and it was hypothesized that the associations of education and income with BMI would be at least partly mediated by SSS.

RESULTS

SSS had a significant direct effect on BMI (-0.21, P = 0.018). Education had a significant direct relationship with SSS (0.11, P < 0.001) and a small but significant indirect relationship with BMI through SSS (-0.02, P = 0.022). Although income did not have a significant direct relationship with BMI, it did have a significant indirect relationship through SSS (b = -0.05, P = 0.019).

CONCLUSIONS

Results are consistent with the hypothesized model in which SSS partially mediates the relationship between SES indicators and BMI.

Sex-related illness perception and self-management of a Thai type 2 diabetes population: a cross-sectional descriptive design

BACKGROUND

Increased knowledge concerning the differences in the illness perception and self-management among sexes is needed for planning proper support programs for patients with diabetes. The aim of this study was to investigate the illness perception and self-management among Thai women and Thai men with type 2 diabetes and to investigate the psychometric properties of the translated instruments used.

METHODS

In a suburban province of Thailand, 220 women and men with type 2 diabetes participated in a cross-sectional descriptive study. The participants were selected using a multistage sampling method. Data were collected through structured interviews and were analyzed using group comparisons, and psychometric properties were tested.

RESULTS

Women and men with type 2 diabetes demonstrated very similar experiences regarding their illness perception and no differences in self-management. Women perceived more negative consequences of the disease and more fluctuation in the symptoms than men, whereas men felt more confident about the treatment effectiveness than women. Furthermore, the translated instruments used in this study showed acceptable validity and reliability.

CONCLUSIONS

The Thai sociocultural context may influence people's perceptions and affect the self-care activities of Thai individuals, both women and men, with type 2 diabetes, causing differences from those found in the Western environment. Intervention programs that aim to improve the effectiveness of the self-management of Thai people with diabetes might consider a holistic and sex-related approach as well as incorporating Buddhist beliefs.

Factors associated with mental health consultation in South Korea

BACKGROUND

The aim of this study was to examine factors associated with the use of mental health consultation for depressive symptoms.

METHODS

We used data from the 2013 Community Health Survey, which included responses from 13,269 individuals who reported that they had experienced depressive symptoms for more than 2 weeks in Korea. We investigated associations between mental health consultation rates for depressive symptoms and sociodemographic, socioeconomic, and health-related factors. Logistic regression analysis was used to examine the significance of associations.

RESULTS

Among participants who report depressive symptoms, 16.0% (n = 2120) undergo mental health consultation. Respondents with a college education or over are more likely to undergo mental health consultation (odds ratio (OR) = 1.49; 95% CI: 1.21-1.84) than respondents with less education. Individuals aged 70 years or above are less likely to receive mental health consultation than those aged between 19 and 29 years. Females exhibit higher mental health consultation rates than males. Respondents who are divorced show greater odds of receiving mental health consultation than respondents who are married and cohabitate with their spouse.

CONCLUSIONS

This study indicates that rates of use of mental health consultation services are lower among older adults and men and higher among divorced people. Educational level shows a significant positive association with mental health consultation among Koreans. The results could have implications for mental health policy in many ways in Korea.

Fatalism and educational disparities in beliefs about the curability of advanced cancer

OBJECTIVE

Understanding socioeconomic disparities in the care of patients with incurable cancer is a high priority. We hypothesized that patients without a high school education are more likely to believe that they could be cured and we explored the role of fatalism.

METHODS

We studied 977 patients with advanced, incurable cancer. Two logistic regression analyses were conducted. Model One examined the effect of education on beliefs about curability. Model Two added fatalism.

RESULTS

The significant association between having less than a high school education and the belief that advanced cancer can be cured (OR=2.55; 95% CI: 1.09-5.96) in Model One was attenuated by 39% and rendered nonsignificant in Model Two. Fatalism was associated with the belief that advanced cancer can be cured. Whites were less likely to believe they could be cured than Blacks and Asians/Pacific Islanders. Beliefs about curability were not associated with income or insurance status.

CONCLUSIONS

People who do not complete high school are more likely to believe that their advanced cancer is curable, in part because they are more likely to hold fatalistic worldviews.

PRACTICE IMPLICATIONS

Interventions to help oncologists care for patients with fatalistic beliefs could mitigate socioeconomic disparities in end-of-life care.

Childhood Disadvantage, Psychosocial Resiliency, and Later Life Functioning: Linking Early-Life Circumstances to Recovery From Mobility Limitation

Objective: There is limited knowledge about whether childhood disadvantage, defined as economic and health disadvantage, influences recovery from functional impairment. Method: Using data from the Health and Retirement Study (2008-2010), this research explores whether childhood disadvantage shapes recovery from mobility limitation. In addition, this research examines whether measures of psychosocial resiliency such as mastery, optimism, and religiosity moderate the relationship between childhood disadvantage and recovery. Results: Childhood disadvantage appeared to shape recovery from mobility limitation in later life. Greater number of chronic childhood conditions and low maternal education decreased the odds of recovery. Mastery was a robust predictor of recovery and also a moderator of childhood disadvantage (i.e., moving for financial reasons) and recovery. Discussion: Findings suggest that mastery may be able to diminish the negative effects of financial hardship in childhood on recovery outcomes in later life.

'Fundamental causes' of inequalities in mortality: an empirical test of the theory in 20 European populations

The 'fundamental causes' theory stipulates that when new opportunities for lowering mortality arise, higher socioeconomic groups will benefit more because of their greater material and non-material resources. We tested this theory using harmonised mortality data by educational level for 22 causes of death and 20 European populations from the period 1980-2010. Across all causes and populations, mortality on average declined by 2.49 per cent (95%CI: 2.04-2.92), 1.83% (1.37-2.30) and 1.34% (0.89-1.78) per annum among the high, mid and low educated, respectively. In 69 per cent of cases of declining mortality, mortality declined faster among the high than among the low educated. However, when mortality increased, less increase among the high educated was found in only 46 per cent of cases. Faster mortality decline among the high educated was more manifest for causes of death amenable to intervention than for non-amenable causes. The difference in mortality decline between education groups was not larger when income inequalities were greater. While our results provide support for the fundamental causes theory, our results suggest that other mechanisms than the theory implies also play a role.

Frailty is associated with socioeconomic and lifestyle factors in community-dwelling older subjects

BACKGROUND AND AIMS

This study assessed the association between frailty and sociodemographic, socioeconomic and lifestyle factors in community-dwelling older people.

METHODS

This was a cross-sectional survey in a population-based sample of 542 community-dwelling subjects aged 65 years and older living in a metropolitan area in Italy. Frailty was evaluated by means of the FRAIL scale proposed by the International Association of Nutrition and Aging. Basal and instrumental activities of daily living (ADL, IADL), physical activity, sociodemographic (age, gender, marital status and cohabitation), socioeconomic (education, economic conditions and occupational status) and lifestyle domains (cultural and technological fruition and social activation) were assessed through specific validated tools. Statistical analysis was performed through multinomial logistic regression.

RESULTS

Impairments in ADL and IADL were significantly associated with frailty, while moderate and high physical activity were inversely associated with frailty. Moreover, regarding both socioeconomic variables and lifestyle factors, more disadvantaged socioeconomic conditions and low levels of cultural fruition were significantly associated with frailty.

CONCLUSIONS

Socioeconomic and lifestyle factors, particularly cultural fruition, are associated with frailty independently from functional impairment and low physical activity. Cultural habits may therefore represent a new target of multimodal interventions against geriatric frailty.

Individual- and area-level characteristics associated with alcohol-related mortality among adult Lithuanian males: A multilevel analysis based on census-linked data

Background

Although excessive alcohol-related mortality in the post-Soviet countries remains the major public health threat, determinants of this phenomenon are still poorly understood.

Aims

We assess simultaneously individual- and area-level factors associated with an elevated risk of alcohol-related mortality among Lithuanian males aged 30–64.

Methods

Our analysis is based on a census-linked dataset containing information on individual- and area-level characteristics and death events which occurred between March 1^st, 2011 and December 31^st, 2013. We limit the analysis to a few causes of death which are directly linked to excessive alcohol consumption: accidental poisonings by alcohol (X45) and liver cirrhosis (K70 and K74). Multilevel Poisson regression models with random intercepts are applied to estimate mortality rate ratios (MRR).

Results

The selected individual-level characteristics are important predictors of alcohol-related mortality, whereas area-level variables show much less pronounced or insignificant effects. Compared to married men, never married (MRR = 1.9, CI:1.6–2.2), divorced (MRR = 2.6, CI:2.3–2.9), and widowed (MRR = 2.4, CI: 1.8–3.1) men are disadvantaged groups. Men who have the lowest level of educational attainment have the highest mortality risk (MRR = 1.7 CI:1.4–2.1). Being unemployed is associated with a five-fold risk of alcohol-related death (MRR = 5.1, CI: 4.4–5.9), even after adjusting for all other individual variables. Lithuanian males have an advantage over Russian (MRR = 1.3, CI:1.1–1.6) and Polish (MRR = 1.8, CI: 1.5–2.2) males. After adjusting for all individual characteristics, only two out of seven area-level variables—i.e., the share of ethnic minorities in the population and the election turnout—have statistically significant direct associations. These variables contribute to a higher risk of alcohol-related mortality at the individual level.

Conclusions

The huge and increasing socio-economic disparities in alcohol-related mortality indicate that recently implemented anti-alcohol measures in Lithuania should be reinforced by specific measures targeting the most disadvantaged population groups and geographical areas.