Widening socioeconomic inequalities in mortality in six Western European countries

Socioeconomic differences in suicide mortality by sex in Finland in 1971—2000: A register-based study of trends, levels, and life expectancy differences

Aim: Suicide is a common cause of death in many Western countries and it has been predicted to become even more common worldwide. The authors analysed socioeconomic differences and trends in Finnish suicide mortality, and assessed the relevance to public health by calculating socioeconomic differences in years of life expectancy lost attributable to suicide. Data and methods: Census records were used, linked with the death records of men and women aged 25 years and over in 1971—2000 in Finland. Results: Suicide among male and female manual workers was 2.3 and 1.3 times higher respectively than among upper non-manual workers. The differences were largest among those in their thirties. Because of the decline in suicide among upper non-manual workers and a slower decrease or even an increase among other socioeconomic groups, the relative mortality differences increased somewhat during 1970—90, then decreased in the 1990s but remained higher than in the 1970s. In 1991—2000 the suicide-related life expectancy gap between the upper non-manual and manual male workers was 0.6 years, and this difference contributed 10% to the total difference in years of life expectancy lost between these socioeconomic groups. Conclusion: Large and persistent socioeconomic differences were found in suicide mortality and suicide was an important component of the socioeconomic difference in total mortality. Reducing these differences could significantly improve equity in health and reduce the burden of excess mortality.

Subclinical coronary atherosclerosis is more pronounced in men and women with lower socio-economic status: associations in a population-based study Coronary atherosclerosis and social status

Background

Social inequalities of manifest coronary heart diseases are well documented in modern societies. Less evidence is available on subclinical atherosclerotic disease despite the opportunity to investigate processes underlying this association. Therefore, we examined the relationship between coronary artery calcification as a sign of subclinical coronary atherosclerosis, socio-economic status and established cardiovascular risk factors in a healthy population.

Design

Cross-sectional.

Methods

In a population-based sample of 4487 men and women coronary artery calcification was assessed by electron beam computed tomography quantified by the Agatston score. Socio-economic status was assessed by two indicators, education and income. First, we investigated associations between the social measures and calcification. Second, we assessed the influence of cardiovascular risk factors on this association.

Results

After adjustment for age, men with 10 and less years of formal education had a 70% increase in calcification score compared with men with high education. The respective increase for women was 80%. For income the association was weaker (among men 20% higher for the lowest compared with the highest quartile; and among women 50% higher, respectively). Consecutive adjustment for cardiovascular risk factors significantly attenuated the observed association of socio-economic status with calcification.

Conclusions

Social inequalities in coronary heart diseases seem to influence signs of subclinical coronary atherosclerosis as measured by coronary artery calcification. Importantly, cumulation of major cardiovascular risk factors in lower socio-economic groups accounted for a substantial part of this association.

Did the English strategy reduce inequalities in health? A difference-in-difference analysis comparing England with three other European countries

BACKGROUND

Between 1997 and 2010, the English government pursued an ambitious programme to reduce health inequalities, the explicit and sustained commitment of which was historically and internationally unique. Previous evaluations have produced mixed results. None of these evaluations have, however, compared the trends in health inequalities within England with those in other European countries. We carried out an innovative analysis to assess whether changes in trends in health inequalities observed in England after the implementation of its programme, have been more favourable than those in other countries without such a programme.

METHODS

Data were obtained from nationally representative surveys carried out in England, Finland, the Netherlands and Italy for years around 1990, 2000 and 2010. A modified difference-in-difference approach was used to assess whether trends in health inequalities in 2000-2010 were more favourable as compared to the period 1990-2000 in England, and the changes in trends in inequalities after 2000 in England were then compared to those in the three comparison countries. Health outcomes were self-assessed health, long-standing health problems, smoking status and obesity. Education was used as indicator of socioeconomic position.

RESULTS

After the implementation of the English strategy, more favourable trends in some health indicators were observed among low-educated people, but trends in health inequalities in 2000-2010 in England were not more favourable than those observed in the period 1990-2000. For most health indicators, changes in trends of health inequalities after 2000 in England were also not significantly different from those seen in the other countries.

CONCLUSIONS

In this rigorous analysis comparing trends in health inequalities in England both over time and between countries, we could not detect a favourable effect of the English strategy. Our analysis illustrates the usefulness of a modified difference-in-difference approach for assessing the impact of policies on population-level health inequalities.

The spatial structure of chronic morbidity: evidence from UK census returns

Background

Disease prevalence models have been widely used to estimate health, lifestyle and disability characteristics for small geographical units when other data are not available. Yet, knowledge is often lacking about how to make informed decisions around the specification of such models, especially regarding spatial assumptions placed on their covariance structure. This paper is concerned with understanding processes of spatial dependency in unexplained variation in chronic morbidity.

Methods

2011 UK census data on limiting long-term illness (LLTI) is used to look at the spatial structure in chronic morbidity across England and Wales. The variance and spatial clustering of the odds of LLTI across local authority districts (LADs) and middle layer super output areas are measured across 40 demographic cross-classifications. A series of adjacency matrices based on distance, contiguity and migration flows are tested to examine the spatial structure in LLTI. Odds are then modelled using a logistic mixed model to examine the association with district-level covariates and their predictive power.

Results

The odds of chronic illness are more dispersed than local age characteristics, mortality, hospitalisation rates and chance alone would suggest. Of all adjacency matrices, the three-nearest neighbour method is identified as the best fitting. Migration flows can also be used to construct spatial weights matrices which uncover non-negligible autocorrelation. Once the most important characteristics observable at the LAD-level are taken into account, substantial spatial autocorrelation remains which can be modelled explicitly to improve disease prevalence predictions.

Conclusions

Systematic investigation of spatial structures and dependency is important to develop model-based estimation tools in chronic disease mapping. Spatial structures reflecting migration interactions are easy to develop and capture autocorrelation in LLTI. Patterns of spatial dependency in the geographical distribution of LLTI are not comparable across ethnic groups. Ethnic stratification of local health information is needed and there is potential to further address complexity in prevalence models by improving access to disaggregated data.

Electronic supplementary material

The online version of this article (doi:10.1186/s12942-016-0057-5) contains supplementary material, which is available to authorized users.

Socioeconomic gradient in health in Canada: Is the gap widening or narrowing?

BACKGROUND

Notwithstanding a general improvement in health status, the socioeconomic gradient in health remains a public health challenge worldwide.

OBJECTIVE

Using longitudinal data from the National Population Health Survey (NPHS, n=17,276), we examined trends in socioeconomic gradients in two health indicators, viz. the Health Utility Index (HUI) and the Frailty Index (FI), among Canadian adults (25 years and older) between 1998/9-2010/11.

METHODS

The relative and slope indices of inequality (RII and SII, respectively) were employed to summarize income- and education-based inequality in the FI and the HUI in Canada as whole, and in five regions: the Atlantic provinces, Quebec, Ontario, the Prairies and British Columbia.

RESULTS

We found that education- and income-related inequalities in health were present in all five regions of Canada. The estimated RIIs and SIIs suggested that education-related inequalities in the FI and the HUI increased among women. The results also revealed that relative and absolute income-related inequalities in the HUI increased in Canada, especially among women. Both absolute and relative inequalities indicated that income-related inequalities in the HUI increased in Quebec and in the Prairies over time.

CONCLUSION

Persistent and growing socioeconomic inequalities in health in Canada over the past one and half decades should warrant more attention. The mechanisms underlying socioeconomic-related inequalities in Canada are less clear. Therefore, further studies are required to identify effective polices to reduce the socioeconomic gradient in health in Canada.

The impact of increasing income inequalities on educational inequalities in mortality - An analysis of six European countries

Background

Over the past decades, both health inequalities and income inequalities have been increasing in many European countries, but it is unknown whether and how these trends are related. We test the hypothesis that trends in health inequalities and trends in income inequalities are related, i.e. that countries with a stronger increase in income inequalities have also experienced a stronger increase in health inequalities.

Methods

We collected trend data on all-cause and cause-specific mortality, as well as on the household income of people aged 35–79, for Belgium, Denmark, England & Wales, France, Slovenia, and Switzerland. We calculated absolute and relative differences in mortality and income between low- and high-educated people for several time points in the 1990s and 2000s. We used fixed-effects panel regression models to see if changes in income inequality predicted changes in mortality inequality.

Results

The general trend in income inequality between high- and low-educated people in the six countries is increasing, while the mortality differences between educational groups show diverse trends, with absolute differences mostly decreasing and relative differences increasing in some countries but not in others. We found no association between trends in income inequalities and trends in inequalities in all-cause mortality, and trends in mortality inequalities did not improve when adjusted for rising income inequalities. This result held for absolute as well as for relative inequalities. A cause-specific analysis revealed some association between income inequality and mortality inequality for deaths from external causes, and to some extent also from cardiovascular diseases, but without statistical significance.

Conclusions

We find no support for the hypothesis that increasing income inequality explains increasing health inequalities. Possible explanations are that other factors are more important mediators of the effect of education on health, or more simply that income is not an important determinant of mortality in this European context of high-income countries. This study contributes to the discussion on income inequality as entry point to tackle health inequalities. More research is needed to test the common and plausible assumption that increasing income inequality leads to more health inequality, and that one needs to act against the former to avoid the latter.

Electronic supplementary material

The online version of this article (doi:10.1186/s12939-016-0390-0) contains supplementary material, which is available to authorized users.

Migrant integration policies and health inequalities in Europe

BACKGROUND

Research on socio-economic determinants of migrant health inequalities has produced a large body of evidence. There is lack of evidence on the influence of structural factors on lives of fragile groups, frequently exposed to health inequalities. The role of poor socio-economic status and country level structural factors, such as migrant integration policies, in explaining migrant health inequalities is unclear. The objective of this paper is to examine the role of migrant socio-economic status and the impact of migrant integration policies on health inequalities during the recent economic crisis in Europe.

METHODS

Using the 2012 wave of Eurostat EU-SILC data for a set of 23 European countries, we estimate multilevel mixed-effects ordered logit models for self-assessed poor health (SAH) and self-reported limiting long-standing illnesses (LLS), and multilevel mixed-effects logit models for self-reported chronic illness (SC). We estimate two-level models with individuals nested within countries, allowing for both individual socio-economic determinants of health and country-level characteristics (healthy life years expectancy, proportion of health care expenditure over the GDP, and problems in migrant integration policies, derived from the Migrant Integration Policy Index (MIPEX).

RESULTS

Being a non-European citizen or born outside Europe does not increase the odds of reporting poor health conditions, in accordance with the "healthy migrant effect". However, the country context in terms of problems in migrant integration policies influences negatively all of the three measures of health (self-reported health status, limiting long-standing illnesses, and self-reported chronic illness) in foreign people living in European countries, and partially offsets the "healthy migrant effect".

CONCLUSIONS

Policies for migrant integration can reduce migrant health disparities.

Absolute and relative educational inequalities in depression in Europe

OBJECTIVES

To investigate (1) the size of absolute and relative educational inequalities in depression, (2) their variation between European countries, and (3) their relationship with underlying prevalence rates.

METHODS

Analyses are based on the European Social Survey, rounds three and six (N = 57,419). Depression is measured using the shortened Centre of Epidemiologic Studies Depression Scale. Education is coded by use of the International Standard Classification of Education. Country-specific logistic regressions are applied.

RESULTS

Results point to an elevated risk of depressive symptoms among the lower educated. The cross-national patterns differ between absolute and relative measurements. For men, large relative inequalities are found for countries including Denmark and Sweden, but are accompanied by small absolute inequalities. For women, large relative and absolute inequalities are found in Belgium, Bulgaria, and Hungary. Results point to an empirical association between inequalities and the underlying prevalence rates. However, the strength of the association is only moderate.

DISCUSSIONS

This research stresses the importance of including both measurements for comparative research and suggests the inclusion of the level of population health in research into inequalities in health.

EDUCATIONAL INEQUALITIES IN REPEAT ABORTION: A LONGITUDINAL REGISTER STUDY IN FINLAND 1975-2010

The proportion of repeat abortions among all abortions has increased over the last decades in Finland. This study examined the association of education with the likelihood of repeat abortion, and the change in this association over time using reliable longitudinal data. A unique set of register data from three birth cohorts were followed from age 20 to 45, including about 22,000 cases of repeat abortion, and analysed using discrete-time event-history models. Low education was found to be associated with a higher likelihood of repeat abortion. Women with low education had abortions sooner after the preceding abortion, and were more often single, younger and had larger families at the time of abortion than more highly educated women. The educational differences were more significant for later than earlier cohorts. The results show a lack of appropriate contraceptive use, possibly due to lack of knowledge of, or access to, services. There is a need to improve access to family planning services, and contraceptives should be provided free of charge. Register data overcome the common problems of under-reporting of abortion and attrition ensuring the results are reliable, unique and of interest internationally.

Contribution of smoking to socioeconomic inequalities in mortality: a study of 14 European countries, 1990-2004

BACKGROUND

Smoking contributes to socioeconomic inequalities in mortality, but the extent to which this contribution has changed over time and driven widening or narrowing inequalities in total mortality remains unknown. We studied socioeconomic inequalities in smoking-attributable mortality and their contribution to inequalities in total mortality in 1990-1994 and 2000-2004 in 14 European countries.

METHODS

We collected, harmonised and standardised population-wide data on all-cause and lung-cancer mortality by age, gender, educational and occupational level in 14 European populations in 1990-1994 and 2000-2004. Smoking-attributable mortality was indirectly estimated using the Preston-Glei-Wilmoth method.

RESULTS

In 2000-2004, smoking-attributable mortality was higher in lower socioeconomic groups in all countries among men, and in all countries except Spain, Italy and Slovenia, among women, and the contribution of smoking to socioeconomic inequalities in mortality varied between 19% and 55% among men, and between -1% and 56% among women. Since 1990-1994, absolute inequalities in smoking-attributable mortality and the contribution of smoking to inequalities in total mortality have decreased in most countries among men, but increased among women.

CONCLUSIONS

In many European countries, smoking has become less important as a determinant of socioeconomic inequalities in mortality among men, but not among women. Inequalities in smoking remain one of the most important entry points for reducing inequalities in mortality.

Health inequalities in the Netherlands: trends in quality-adjusted life expectancy (QALE) by educational level

BACKGROUND

Quality-adjusted life expectancy (QALE) has been proposed as a summary measure of population health because it encompasses multiple health domains as well as length of life. However, trends in QALE by education or other socio-economic measure have not yet been reported. This study investigates changes in QALE stratified by educational level for the Dutch population in the period 2001-2011.

METHODS

Using data from multiple sources, we estimated mortality rates and health-related quality of life (HRQoL) as functions of age, gender, calendar year and educational level. Subsequently, predictions from these regressions were combined for calculating QALE at ages 25 and 65. QALE changes were decomposed into effects of mortality and HRQoL.

RESULTS

In 2001-2011, QALE increased for men and women at all educational levels, the largest increases being for highly educated resulting in a widening gap by education. In 2001, at age 25, the absolute QALE difference between the low and the highly educated was 7.4 healthy years (36.7 vs. 44.1) for men and 6.3 healthy years (39.5 vs. 45.8) for women. By 2011, the QALE difference increased to 8.1 healthy years (38.8 vs. 46.9) for men and to 7.1 healthy years (41.3 vs. 48.4) for women. Similar results were observed at age 65. Although the gap was largely attributable to widening inequalities in mortality, widening inequalities in HRQoL were also substantial.

CONCLUSIONS

In the Netherlands, population health as measured by QALE has improved, but QALE inequalities have widened more than inequalities in life expectancy alone.

Socioeconomic status and substance use among Swiss young men: a population-based cross-sectional study

BACKGROUND

Socioeconomic status (SES) is often inversely related to health outcomes and is likely to play a role in the use of psychoactive substances among young individuals, although little consensus exists on the association between SES and substance use. The purpose of the study was to determine the association of three SES indicators (perceived family income, education level of participants, and parental education level) with past year use of alcohol, tobacco, cannabis, other illicit drugs and non-medical use of prescription drugs (NMPD) among Swiss young men.

METHODS

Population-based cross-sectional study of 5,702 men at mean age twenty. Associations between SES indicators and substance use were assessed with regression models adjusted for age and linguistic region.

RESULTS

Participants with average or below average perceived family income were less likely to report any use of alcohol (OR = O.75) but more likely to use tobacco daily (OR = 1.31) and cannabis weekly (OR = 1.27) compared to those with perceived above average family income. Participants whose parents had only achieved obligatory education were less likely to engage in any use of alcohol (OR = 0.30), monthly risky single occasion drinking (RSOD, defined as 6 or more drinks per occasion) (OR = 0.48), any use of cannabis (OR = 0.53) and other illicit drugs (OR = 0.58), whereas those whose parents had only achieved secondary education were less at risk of engaging in cannabis (OR = 0.66 for any use and OR = 0.77 for more than once a week use) and other illicit drugs (OR = 0.74) use, compared to those whose parents had achieved tertiary education. Compared to participants who completed secondary or tertiary education, those who completed only obligatory education reported a higher risk of tobacco (OR = 1.18 for any use, OR = 1.31 for daily use), cannabis (OR = 1.23 for any use, OR = 1.37 for more than once a week use), and other illicit drugs (OR = 1.48) use. No association was found between NMPD and the studied SES variables.

CONCLUSION

The relationship between SES and substance use was complex in this sample. Higher socioeconomic status was associated with more alcohol and other illicit drugs use, while lower socioeconomic status was related to more tobacco use. Education level and perceived family income may have different impacts on substance use and may vary by substance.

Socioeconomic differentials in mortality by cause of death in the Republic of Ireland, 1984-2008

CONTEXT/PROBLEM

Comparative analysis of relative and absolute mortality differentials between socioeconomic groups are now available. These show consistently increasing relative increases in mortality differentials but complex trends in absolute mortality differentials.

OBJECTIVE

This paper provides an analysis of relative and absolute trends in mortality by cause of death and socioeconomic group (SEG) from 1984 to 2008 among men and active women aged 30-64 years in Ireland and compares these results with recent European and US studies to give an overview of trends.

METHODS

This paper uses mortality data from the Irish Central Statistics Office from 1984 to 2008 to calculate standardized death rates by age, sex, socioeconomic status and cause of death showing trends in SEG inequalities in mortality in Ireland. These show which specific causes of death are driving all-cause mortality trends.

RESULTS

SEG differentials in all-cause mortality among men and women have been increasing since the 1980s. Some of this increase reflects larger falls in cardiovascular causes among advantaged groups, but the trend is largely accounted for by increasing inequalities in mortality in digestive, neoplasm and external causes of deaths.

CONCLUSIONS

These findings are in line with international findings that show that socioeconomic differentials in digestive, neoplasm and external cause deaths are driving general socioeconomic differentials in all-cause mortality. External cause deaths may have been influenced by levels of economic activity, particularly in construction, during the economic boom among manual workers. Furthermore, deaths from digestive diseases during the 1990s and 2000s may well be the result of increases in liver disease associated with excessive alcohol consumption.

Forecasting differences in life expectancy by education

Forecasts of life expectancy (LE) have fuelled debates about the sustainability and dependability of pension and healthcare systems. Of relevance to these debates are inequalities in LE by education. In this paper, we present a method of forecasting LE for different educational groups within a population. As a basic framework we use the Li-Lee model that was developed to forecast mortality coherently for different groups. We adapted this model to distinguish between overall, sex-specific, and education-specific trends in mortality, and extrapolated these time trends in a flexible manner. We illustrate our method for the population aged 65 and over in the Netherlands, using several data sources and spanning different periods. The results suggest that LE is likely to increase for all educational groups, but that differences in LE between educational groups will widen. Sensitivity analyses illustrate the advantages of our proposed method.

Barriers to healthy eating in Switzerland: A nationwide study

BACKGROUND & AIMS

Several barriers can hinder healthy eating in the population. We aimed to assess the prevalence of self-reported barriers to healthy eating in Switzerland and examine their socioeconomic and demographic determinants.

METHODS

Using representative cross-sectional data from the Swiss Health Survey 2012, we assessed, separately by gender, the prevalence of ten barriers and their association with demographic and socioeconomic determinants; we used age- and multivariable-adjusted logistic regression and report the odds ratio for likelihood to identify each barrier according to each demographic and socioeconomic determinant.

RESULTS

The most prevalent barriers were "price" (43.2% in women, 35.8% in men), "daily habits, constraints" (39.8%, 37.5%), "fondness of good food" (38.8%, 51.0%), "time constraint" (34.8%, 29.0%) and "lack of willpower" (22.0%, 21.2%). Prevalence of most barriers decreased with age, increased for "fondness of good food" and remained constant for "price." After multivariable adjustment, obese participants were more likely to report "fondness of good food" [Odds ratio (95% confidence interval) for obese vs. normal weight women and men, respectively: 1.63 (1.38-1.91), 2.02 (1.72-2.38)]. Participants with lower education were more likely to report "fondness of good food" [mandatory vs. tertiary women and men, respectively: 1.93 (1.62-2.39), 1.51 (1.26-1.81)], but less likely to report "lack of willpower" [0.45 (0.38-0.55), 0.40 (0.33-0.49)] and "time constraint" [0.61 (0.51-0.73), 0.78 (0.63-0.96)]. Participants with lower income were more likely to report "price" [lowest vs. highest quartile for women and men, respectively, 1.65 (1.43-1.90), 1.47 (1.26-1.71)] but less likely to report "lack of willpower" [0.71 (0.61-0.82), 0.40 (0.33-0.49)]. Smoking, living situation, nationality and living area showed little or no association.

CONCLUSION

Several barriers to healthy eating were highly prevalent regardless of gender; the most important determinants were age, obesity, education, and income, with different effects per barrier. This requires multifaceted interventions to tackle several barriers simultaneously.

Relationship between Statin Utilization and Socioeconomic Deprivation in Hungary

The risk of premature mortality caused by cardiovascular diseases (CVDs) is approximately three times higher in the Central Eastern European region than in high income European countries, which suggests a lack and/or ineffectiveness of preventive interventions against CVDs. The aim of the present study was to provide data on the relationship between premature CVD mortality, statin utilization as a preventive medication and socioeconomic deprivation at the district level in Hungary. As a conceptually new approach, the prescription of statins, the prescription redemption and the ratio between redemption and prescription rates were also investigated. The number of prescriptions for statins and the number of redeemed statin prescriptions were obtained from the National Health Insurance Fund Administration of Hungary for each primary healthcare practice for the entire year of 2012. The data were aggregated at the district level. To define the frequency of prescription and of redemption, the denominator was the number of the 40+-year-old population adjusted by the rates of 60+-year-old population of the district. The standardized mortality rates, frequency of statin prescriptions, redeemed statin prescriptions, and ratios for compliance in relation to the national average were mapped using the “disease mapping” option, and their association with deprivation (tertile of deprivation index as a district-based categorical covariate) was defined using the risk analysis capabilities within the Rapid Inquiry Facility. The risk analysis showed a significant positive association between deprivation and the relative risk of premature cardiovascular mortality, and a reverse J-shaped association between the relative frequency of statin prescriptions and deprivation. Districts with the highest deprivation showed a low relative frequency of statin prescriptions; however, significantly higher primary compliance (redemption) was observed in districts with the highest deprivation. Our data clearly indicate that insufficient statin utilization is strongly linked to the so-called physician-factor, i.e., a statin prescription. Consequently, statin treatment is poor and represents a significant barrier to reducing mortality, particularly among people living in highly deprived areas of the country.

Inequality in mortality by occupation related to economic crisis from 1980 to 2010 among working-age Japanese males

The mortality rate for Japanese males aged 30–59 years in managerial and professional spiked in 2000 and remains worse than that of other occupations possibly associated with the economic downturn of the 1990s and the global economic stagnation after 2008. The present study aimed to assess temporal occupation-specific mortality trends from 1980 to 2010 for Japanese males aged 30–59 years for major causes of death. We obtained data from the Occupation-specific Vital Statistics. We calculated age-standardized mortality rates for the four leading causes of death (all cancers, suicide, ischaemic heart disease, and cerebrovascular disease). We used a generalized estimating equation model to determine specific effects of the economic downturn after 2000. The age-standardized mortality rate for the total working-age population steadily declined up to 2010 in all major causes of death except suicide. Managers had a higher risk of mortality in all leading causes of death compared with before 1995. Mortality rates among unemployed people steadily decreased for all cancers and ischaemic heart disease. Economic downturn may have caused the prolonged increase in suicide mortality. Unemployed people did not experience any change in mortality due to suicide and cerebrovascular disease and saw a decline in cancer and ischemic heart disease mortality, perhaps because the basic properties of Japan’s social welfare system were maintained even during economic recession.

Trends in Socioeconomic Inequalities in Body Mass Index, Underweight and Obesity among English Children, 2007-2008 to 2011-2012

Background

Socioeconomic inequalities in childhood obesity have been reported in most developed countries, with obesity more common in deprived groups. Whether inequalities are found in the prevalence of underweight, the rest of the body mass index (BMI) distribution, or have changed across time is not clear.

Methods and Findings

The sample comprised 5,027,128 children on entry (4 to 5 years old) and leaving (10 to 11 years) state primary (elementary) school who participated in the National Child Measurement Programme (England, United Kingdom). We used area-level deprivation (Indices of Multiple Deprivation at the lower super output area) as a measure of socioeconomic deprivation. From 2007–2008 to 2011–2012 inequalities in obesity between the most compared to least deprived group increased (from 7.21% to 8.30%; p<0.001), whereas inequalities in the prevalence of underweight (1.50% to 1.21%; p = 0.15) were stable during this period. There were no differences by age group or by sex, but a three-way interaction suggested inequalities in obesity had increased at a faster rate for 10 to 11 year old girls, than 4 to 5 year old boys, (2.03% vs 0.07%; p<0.001 for interaction). Investigating inequalities across the distribution of zBMI showed increases in mean zBMI (0.18 to 0.23, p<0.001) could be attributed to increases in inequalities between the 50^th and 75^th centiles of BMI. Using the 2011 to 2012 population attributable risk estimates, if inequalities were halved, 14.04% (95% CI 14.00% to 14.07%) of childhood obesity could be avoided.

Conclusions

Socioeconomic inequalities in childhood obesity and zBMI increased in England between 2007–2008 and 2011–2012. Inequalities in the prevalence of underweight did not change. Traditional methods of examining inequalities only at the clinical thresholds of overweight and obesity may have led the magnitude of inequalities in childhood BMI to be underestimated.

Free establishment of primary health care providers: effects on geographical equity

BACKGROUND

A reform in 2010 in Swedish primary care made it possible for private primary care providers to establish themselves freely in the country. In the former, publicly planned system, location was strictly regulated by local authorities. The goal of the new reform was to increase access and quality of health care. Critical arguments were raised that the reform could have detrimental effects on equity if the new primary health care providers chose to establish foremost in socioeconomically prosperous areas. The aim of this study is to examine how the primary care choice reform has affected geographical equity by analysing patterns of establishment on the part of new private providers.

METHODS

The basis of the design was to analyse socio-economic data on individuals who reside in the same electoral areas in which the 1411 primary health care centres in Sweden are established. Since the primary health care centres are located within 21 different county councils with different reimbursement schemes, we controlled for possible cluster effects utilizing generalized estimating equations modelling. The empirical material used in the analysis is a cross-sectional data set containing socio-economic data of the geographical areas in which all primary health care centres are established.

RESULTS

When controlling for the effects of the county council regulation, primary health care centres established after the primary care choice reform were found to be located in areas with significantly fewer older adults living alone as well as fewer single parents - groups which generally have lower socio-economic status and high health care needs. However, no significant effects were observed for other socio-economic variables such as mean income, percentage of immigrants, education, unemployment, and children <5 years.

CONCLUSIONS

The primary care choice reform seems to have had some negative effects on geographical equity, even though these seem relatively minor.

The Health Effects of Income Inequality: Averages and Disparities

Much research has investigated the association of income inequality with average life expectancy, usually finding negative correlations that are not very robust. A smaller body of work has investigated socioeconomic disparities in life expectancy, which have widened in many countries since 1980. These two lines of work should be seen as complementary because changes in average life expectancy are unlikely to affect all socioeconomic groups equally. Although most theories imply long and variable lags between changes in income inequality and changes in health, empirical evidence is confined largely to short-term effects. Rising income inequality can affect individuals in two ways. Direct effects change individuals' own income. Indirect effects change other people's income, which can then change a society's politics, customs, and ideals, altering the behavior even of those whose own income remains unchanged. Indirect effects can thus change both average health and the slope of the relationship between individual income and health.

The Added Value of Medical Testing in Underwriting Life Insurance

Background

In present-day life-insurance medical underwriting practice the risk assessment starts with a standard health declaration (SHD). Indication for additional medical screening depends predominantly on age and amount of insured capital. From a medical perspective it is questionable whether there is an association between the level of insured capital and medical risk in terms of mortality. The aim of the study is to examine the prognostic value of parameters from the health declaration and application form on extra mortality based on results from additional medical testing.

Methods

A history register-based cohort study was conducted including about 15.000 application files accepted between 2007 and 2010. Blood pressure, lipids, cotinine and glucose levels were used as dependent variables in logistic regression models. Resampling validation was applied using 250 bootstrap samples to calculate area under the curves (AUC’s). The AUC was used to discriminate between persons with and without at least 25% extra mortality.

Results

BMI and the overall assessment of the health declaration by an insurance physician or medical underwriter showed the strongest discrimination in multivariable analysis. Including all variables at minimum cut-off levels resulted in an AUC of 0.710 while by using a model with BMI, the assessment of the health declaration and gender, the AUC was 0.708. Including all variables at maximum cut-off levels lead to an AUC of 0.743 while a model with BMI, the assessment of the health declaration and age resulted in an AUC of 0.741.

Conclusions

The outcome of this study shows that BMI and the overall assessment of the health declaration were the dominant variables to discriminate between applicants for life-insurance with and without at least 25 percent extra mortality. The variable insured capital set by insurers as factor for additional medical testing could not be established in this study population. The indication for additional medical testing at underwriting life-insurance can possibly be done on limited variables instead of the obligatory medical testing based on age and the amount of insured capital.

Cause-specific mortality in Finnish ferrochromium and stainless steel production workers

Background

Although stainless steel has been produced for more than a hundred years, exposure-related mortality data for production workers are limited.

Aims

To describe cause-specific mortality in Finnish ferrochromium and stainless steel workers.

Methods

We studied Finnish stainless steel production chain workers employed between 1967 and 2004, from chromite mining to cold rolling of stainless steel, divided into sub-cohorts by production units with specific exposure patterns. We obtained causes of death for the years 1971–2012 from Statistics Finland. We calculated standardized mortality ratios (SMRs) as ratios of observed and expected numbers of deaths based on population mortality rates of the same region.

Results

Among 8088 workers studied, overall mortality was significantly decreased (SMR 0.77; 95% confidence interval [CI] 0.70–0.84), largely due to low mortality from diseases of the circulatory system (SMR 0.71; 95% CI 0.61–0.81). In chromite mine, stainless steel melting shop and metallurgical laboratory workers, the SMR for circulatory disease was below 0.4 (SMR 0.33; 95% CI 0.07–0.95, SMR 0.22; 95% CI 0.05–0.65 and SMR 0.16; 95% CI 0.00–0.90, respectively). Mortality from accidents (SMR 0.84; 95% CI 0.67–1.04) and suicides (SMR 0.72; 95% CI 0.56–0.91) was also lower than in the reference population.

Conclusions

Working in the Finnish ferrochromium and stainless steel industry appears not to be associated with increased mortality.

Variations in vascular mortality trends, 2001-2010, among 1.3 million women with different lifestyle risk factors for the disease

AIMS

Vascular disease mortality has declined rapidly in most Western countries, against a background of improved treatments and falling prevalence of smoking, but rising obesity. We examined whether this decline differed by lifestyle risk factors for vascular disease.

METHODS AND RESULTS

During 2001-2010, there were 9241 vascular disease deaths in a prospective study of 1.3 million women in middle age, about one-quarter of all UK women in the eligible age range (50-64 years in 1996-2001). We estimated percentage declines in mortality from coronary heart disease, cerebrovascular disease and other vascular diseases, overall and by age, smoking, alcohol consumption, adiposity, physical activity, socioeconomic status and age at leaving school. Over 10 years, coronary heart disease mortality fell by half (52%), cerebrovascular disease mortality by two-fifths (42%) and other vascular disease mortality by one-fifth (22%). Lean women experienced greater declines in coronary heart disease mortality than overweight or obese women (70%, 48% and 26%, respectively; P < 0.001 for heterogeneity) and women in the highest and middle thirds of socioeconomic status experienced greater declines in other (non-coronary, non-cerebrovascular) vascular disease mortality than women in the lowest third (41% and 42% and -9%, respectively; P = 0.001). After accounting for multiple testing, there were no other significant differences in vascular mortality trends by any lifestyle risk factor, including by smoking status.

CONCLUSION

Vascular disease mortality trends varied in this cohort by adiposity and socioeconomic status, but not by smoking status or other lifestyle risk factors. Prevention and treatment of vascular disease appear not to have been equally effective in all subgroups of UK women.

Population health and status of epidemiology in Western European, Balkan and Baltic countries

BACKGROUND

This article is part of a series commissioned by the International Epidemiological Association, aimed at describing population health and epidemiological resources in the six World Health Organization (WHO) regions. It covers 32 of the 53 WHO European countries, namely the Western European countries, the Balkan countries and the Baltic countries.

METHODS

The burdens of mortality and morbidity and the patterns of risk factors and inequalities have been reviewed in order to identify health priorities and challenges. Literature and internet searches were conducted to stock-take epidemiological teaching, research activities, funding and scientific productivity.

FINDINGS

These countries have among the highest life expectancies worldwide. However, within- and between-country inequalities persist, which are largely due to inequalities in distribution of main health determinants. There is a long tradition of epidemiological research and teaching in most countries, in particular in the Western European countries. Cross-national networks and collaborations are increasing through the support of the European Union which fosters procedures to standardize educational systems across Europe and provides funding for epidemiological research through framework programmes. The number of Medline-indexed epidemiological research publications per year led by Western European countries has been increasing. The countries accounts for nearly a third of the global epidemiological publication.

CONCLUSIONS

Although population health has improved considerably overall, persistent within- and between-country inequalities continue to challenge national and European health institutions. More research, policy and action on the social determinants of health are required in the region. Epidemiological training, research and workforce in the Baltic and Balkan countries should be strengthened. European epidemiologists can play pivotal roles and must influence legislation concerning production and access to high-quality data.

Health-Risk Behaviour in Deprived Neighbourhoods Compared with Non-Deprived Neighbourhoods: A Systematic Literature Review of Quantitative Observational Studies

BACKGROUND

There has been increasing interest in neighbourhoods' influence on individuals' health-risk behaviours, such as smoking, alcohol consumption, physical activity and diet. The aim of this review was to systematically review recent studies on health-risk behaviour among adults who live in deprived neighbourhoods compared with those who live in non-deprived neighbourhoods and to summarise what kind of operationalisations of neighbourhood deprivation that were used in the studies.

METHODS

PRISMA guidelines for systematic reviews were followed. Systematic searches were performed in PubMed, Embase, Web of Science and Sociological Abstracts using relevant search terms, Boolean operators, and truncation, and reference lists were scanned. Quantitative observational studies that examined health-risk behaviour in deprived neighbourhoods compared with non-deprived neighbourhoods were eligible for inclusion.

RESULTS

The inclusion criteria were met by 22 studies. The available literature showed a positive association between smoking and physical inactivity and living in deprived neighbourhoods compared with non-deprived neighbourhoods. In regard to low fruit and vegetable consumption and alcohol consumption, the results were ambiguous, and no clear differences were found. Numerous different operationalisations of neighbourhood deprivation were used in the studies.

CONCLUSION

Substantial evidence indicates that future health interventions in deprived neighbourhoods should focus on smoking and physical inactivity. We suggest that alcohol interventions should be population based rather than based on the specific needs of deprived neighbourhoods. More research is needed on fruit and vegetable consumption. In future studies, the lack of a uniform operationalisation of neighbourhood deprivation must be addressed.

Socio-economic mortality inequalities in Lithuania during 2001-2009: the record linkage study

OBJECTIVES

To present socio-economic inequalities in mortality and their trends in Lithuania using routinely collected data and record linkage for the years 2001-2009, as related to educational level, occupation, economic activity, marital status and household size.

STUDY DESIGN

Retrospective cohort study.

METHODS

Record linkage was performed using personal identification number between three data sources: 2001 population census, national mortality register for years 2001-2009 and population register, including individuals of age 30 years and older. The linked data set consisted of 2,061,481 records, including 338,652 death cases. Age-standardized mortality rates were calculated for socio-economic groups and compared in terms of rate differences (RD) and rate ratios (RR).

RESULTS

Significant mortality inequalities were found for all socio-economic variables. Both among males and females the highest RR were observed for the occupation (males--3.4, females--2.8) and economic activity status (males--2.7, females--3.1). RR were the highest in mid-ages and declined with ageing. RD increased with the increase in total mortality during 2005-2007, while decline in inequalities was observed in later years.

CONCLUSIONS

Lower education, manual occupations, unemployed, economically inactive and unmarried groups of population appeared in the most unfavourable position in terms of mortality and contributed most to the mortality increase in Lithuania throughout 2005-2007.

Johan Mackenbach, awarded an honorary doctorate for his work on health inequalities, in a discussion of burning issues in tackling health inequalities

On 20 March 2015, Professor Johan Mackenbach of the Erasmus University Medical Centre was awarded a doctorate honoris causa by the Catholic University (Université Catholique) of Louvain, Belgium, for his outstanding contribution to the analysis of health inequalities in Europe and to the development of policies intended to address them. In this context, a debate took place between Professor Mackenbach, Professor Maniquet, a well-being economist, and a representative of the Federal Health Ministry (Mr. Brieuc Vandamme). They were asked to debate on three topics. (1) socio-economic inequalities in health are not smaller in countries with universal welfare policies; (2) Policies needs to target either absolute inequalities or relative inequalities; (3) The focus of policies should either address the social determinants of health or concentrate on access to health care. The results of the debate by the three speakers highlighted the fact that welfare systems have not been able to tackle diseases of affluence. Targets for health policies should be set according to opportunity cost: health care is increasingly costly and a focus on health inequalities above all other inequalities runs the risk of taking a dogmatic approach to well-being. Health is only one dimension of well-being and policies to address inequality need to balance preferences between several dimensions of well-being. Finally, policymakers may not have that much choice when it comes to reducing inequality: all effective policies should be implemented. For example, Belgium and other European countries should not leave aside health protection policies that are evidence-based, in particular taxes on tobacco and alcohol. In his final contribution, Professor Mackenbach reminded the audience that politics is medicine on a larger scale and stated that policymakers should make more use of research into public health.

Socioeconomic Disparities in Alcohol-Related Mortality in Sweden, 1991-2006: A Register-Based Follow-Up Study

AIM

To examine whether apparent stability of overall alcohol-related mortality in Sweden during a period when traditionally strict alcohol policies went through a series of liberalizations and overall alcohol mortality remained stable, concealed a heterogeneity across socioeconomic groups (defined by educational level); and whether an increase occurred in the contribution of alcohol-related mortality to overall mortality differentials.

METHODS

Drawing on cause of death data linked to census records for the period 1991-2006, we computed annual age-standardized and sex-specific rates of alcohol-related mortality for groups with low, intermediate and high education.

RESULTS

Alcohol-related mortality was considerably higher in lower educational groups for both men and women. For men, the trends in alcohol-related mortality were roughly stable for all education groups, and there were no signs of increasing inequalities by education. For women, alcohol-related mortality increased significantly for the low-education group whereas the two higher education groups showed no significant time trends, thus resulting in a widened educational gap in alcohol mortality for women. Alcohol's contribution to the overall mortality differentials declined for men and was basically unchanged for women.

CONCLUSIONS

The findings provide only partial support to the hypothesis that the liberalizations of Swedish alcohol policy have been followed by a general increase in socioeconomic disparities in alcohol-related mortality.

Occupational class differences in suicide: evidence of changes over time and during the global financial crisis in Australia

BACKGROUND

Previous research showed an increase in Australian suicide rates during the Global Financial Crisis (GFC). There has been no research investigating whether suicide rates by occupational class changed during the GFC. The aim of this study was to investigate whether the GFC-associated increase in suicide rates in employed Australians may have masked changes by occupational class.

METHODS

Negative binomial regression models were used to investigate Rate Ratios (RRs) in suicide by occupational class. Years of the GFC (2007, 2008, 2009) were compared to the baseline years 2001-2006.

RESULTS

There were widening disparities between a number of the lower class occupations and the highest class occupations during the years 2007, 2008, and 2009 for males, but less evidence of differences for females.

CONCLUSIONS

Occupational disparities in suicide rates widened over the GFC period. There is a need for programs to be responsive to economic downturns, and to prioritise the occupational groups most affected.

Education and Mortality in the Rome Longitudinal Study

Background

A large body of evidence supports an inverse association between socioeconomic status and mortality. We analysed data from a large cohort of residents in Rome followed-up between 2001 and 2012 to assess the relationship between individual education and mortality. We distinguished five causes of death and investigated the role of age, gender, and birthplace.

Methods

From the Municipal Register we enrolled residents of Rome on October 21^st 2001 and collected information on educational level attained from the 2001 Census. We selected Italian citizens aged 30–74 years and followed-up their vital status until 2012 (n = 1,283,767), identifying the cause of death from the Regional Mortality Registry. We calculated hazard ratios (HRs) for overall and cause-specific mortality in relation to education. We used age, gender, and birthplace for adjusted or stratified analyses. We used the inverse probability weighting approach to account for right censoring due to emigration.

Results

We observed an inverse association between education (none vs. post-secondary+ level) and overall mortality (HRs(95%CIs): 2.1(1.98–2.17), males; 1.5(1.46–1.59), females) varying according to demographic characteristics. Cause-specific analysis also indicated an inverse association with education, in particular for respiratory, digestive or circulatory system related-mortality, and the youngest people seemed to be more vulnerable to low education.

Conclusion

Our results confirm the inverse association between education and overall or cause-specific mortality and show differentials particularly marked among young people compared to the elderly. The findings provide further evidence from the Mediterranean area, and may contribute to national and cross-country comparisons in Europe to understand the mechanisms generating socioeconomic differentials especially during the current recession period.

Sympathoneural and adrenomedullary responses to mental stress

This concept-based review provides historical perspectives and updates about sympathetic noradrenergic and sympathetic adrenergic responses to mental stress. The topic of this review has incited perennial debate, because of disagreements over definitions, controversial inferences, and limited availability of relevant measurement tools. The discussion begins appropriately with Cannon's "homeostasis" and his pioneering work in the area. This is followed by mental stress as a scientific idea and the relatively new notions of allostasis and allostatic load. Experimental models of mental stress in rodents and humans are discussed, with particular attention to ethical constraints in humans. Sections follow on sympathoneural responses to mental stress, reactivity of catecholamine systems, clinical pathophysiologic states, and the cardiovascular reactivity hypothesis. Future advancement of the field will require integrative approaches and coordinated efforts between physiologists and psychologists on this interdisciplinary topic.

Contribution of food prices and diet cost to socioeconomic disparities in diet quality and health: a systematic review and analysis

CONTEXT

It is well established in the literature that healthier diets cost more than unhealthy diets.

OBJECTIVE

The aim of this review was to examine the contribution of food prices and diet cost to socioeconomic inequalities in diet quality.

DATA SOURCES

A systematic literature search of the PubMed, Google Scholar, and Web of Science databases was performed.

STUDY SELECTION

Publications linking food prices, dietary quality, and socioeconomic status were selected.

DATA EXTRACTION

Where possible, review conclusions were illustrated using a French national database of commonly consumed foods and their mean retail prices.

DATA SYNTHESIS

Foods of lower nutritional value and lower-quality diets generally cost less per calorie and tended to be selected by groups of lower socioeconomic status. A number of nutrient-dense foods were available at low cost but were not always palatable or culturally acceptable to the low-income consumer. Acceptable healthier diets were uniformly associated with higher costs. Food budgets in poverty were insufficient to ensure optimum diets.

CONCLUSIONS

Socioeconomic disparities in diet quality may be explained by the higher cost of healthy diets. Identifying food patterns that are nutrient rich, affordable, and appealing should be a priority to fight social inequalities in nutrition and health.

A Widening Gap? Changes in Multiple Lifestyle Risk Behaviours by Socioeconomic Status in New South Wales, Australia, 2002-2012

Background

Socioeconomic inequalities in health outcomes have increased over the past few decades in some countries. However, the trends in inequalities related to multiple health risk behaviours have been infrequently reported. In this study, we examined the trends in individual health risk behaviours and a summary lifestyle risk index in New South Wales, Australia, and whether the absolute and relative inequalities in risk behaviours by socioeconomic positions have changed over time.

Methods

Using data from the annual New South Wales Adult Population Health Survey during the period of 2002–2012, we examined four individual risk behaviours (smoking, higher than recommended alcohol consumption, insufficient fruit and vegetable intake, and insufficient physical activity) and a combined lifestyle risk indicator. Socioeconomic inequalities were assessed based on educational attainment and postal area-level index of relative socio-economic disadvantage (IRSD), and were presented as prevalence difference for absolute inequalities and prevalence ratio for relative inequalities. Trend tests and survey logistic regression models examined whether the degree of absolute and relative inequalities between the most and least disadvantaged subgroups have changed over time.

Results

The prevalence of all individual risk behaviours and the summary lifestyle risk indicator declined from 2002 to 2012. Particularly, the prevalence of physical inactivity and smoking decreased from 52.6% and 22% in 2002 to 43.8% and 17.1% in 2012 (p for trend<0.001). However, a significant trend was observed for increasing absolute and relative inequalities in smoking, insufficient fruit and vegetable consumption, and the summary lifestyle risk indicator.

Conclusions

The overall improvement in health behaviours in New South Wales, Australia, co-occurred with a widening socioeconomic gap.

Implications

Governments should address health inequalities through risk factor surveillance and combined strategies of population-wide and targeted interventions.

Decreasing educational differences in mortality over 40 years: evidence from the Turin Longitudinal Study (Italy)

BACKGROUND

Recent studies suggest that inequalities in premature mortality have continued to rise over the last decade in most European countries, but not in southern European countries.

METHODS

In this study, we assess long-term trends (1971-2011) in absolute and relative educational inequalities in all-cause and cause-specific mortality in the Turin Longitudinal Study (Turin, Italy), a record-linkage study including all individuals resident in Turin in the 1971, 1981, 1991 and 2001 censuses, and aged 30-99 years (more than 2 million people). We examined mortality for all causes, cardiovascular disease (CVD), all cancers and specific cancers (lung, breast), as well as smoking and alcohol-related mortality.

RESULTS

Overall mortality substantially decreased in all educational groups over the study period, although cancer rates only slightly declined. Absolute inequalities decreased for both genders (SII=962/694 in men/women in 1972-1976 and SII=531/259 in 2007-2011, p<0.01). Among men, absolute inequalities for CVD and alcohol-related causes declined (p<0.05), while remaining stable for other causes of death. Among women, declines in absolute inequalities were observed for CVD, smoking and alcohol-related causes and lung cancer (p<0.05). Relative inequalities in all-cause mortality remained stable for men and decreased for women (RII=1.92/2.03 in men/women in 1972-1976 and RII=2.15/1.32 in 2007-2011). Among men, relative inequalities increased for smoking-related causes, while among women they decreased for all cancers, CVD, smoking-related causes and lung cancer (p<0.05).

CONCLUSIONS

Absolute inequalities in mortality strongly declined over the study period in both genders. Relative educational inequalities in mortality were generally stable among men; while they tended to narrow among women. In general, this study supports the hypothesis that educational inequalities in mortality have decreased in southern European countries.

Exploring trends in and determinants of educational inequalities in self-rated health

AIMS

Educational inequalities in self-rated health (SRH) in European welfare countries are documented, but recent trends in these inequalities are less well understood. We examined educational inequalities in SRH in different age groups, and the contribution of selected material, behavioural and psychosocial determinants from 2000 to 2008.

METHODS

Data were derived from cross-sectional surveys conducted in 2000, 2004 and 2008 including 37,478, 34,876 and 32,982 respondents, respectively, aged 25-75 in mid-Sweden. Inequalities were analysed by age-standardized and age-stratified rate ratios of poor SRH and age-standardized prevalence of determinants, and contribution of determinants by age-adjusted logistic regression.

RESULTS

Relative educational inequalities in SRH increased among women from 2000 (rate ratio (RR) 1.70, 95% CI 1.55-1.85) to 2008 (RR 2.07, 95% CI 1.90-2.26), but were unchanged among men (RR 1.91-2.01). The increase among women was mainly due to growing inequalities in the age group 25-34 years. In 2008, significant age differences emerged with larger inequalities in the youngest compared with the oldest age group in both genders. All determinants were more prevalent in low educational groups; the most prominent were lack of a financial buffer, smoking and low optimism. Educational differences were unchanged over the years for most determinants. In all three surveys, examined determinants together explained a substantial part of the educational inequalities in SRH.

CONCLUSIONS

Increased relative educational health inequalities among women, and persisting inequalities among men, were paralleled by unchanged, large differences in material/structural, behavioural and psychosocial factors. Interventions to reduce these inequalities need to focus on early mid-life.

Self-reported health and socio-economic inequalities in England, 1996-2009: Repeated national cross-sectional study

Tackling social inequalities in health has been a priority for recent UK governments. We used repeated national cross-sectional data for 155,311 participants (aged ≥16 years) in the Health Survey of England to examine trends in socio-economic inequalities in self-reported health over a recent period of sustained policy focus by successive UK governments aimed at tackling social inequalities in health. Socio-economic related inequalities in self-reported health were estimated using the Registrar General's occupational classification (1996-2009), and for sensitivity analyses, the National Statistics Socio-Economic Classification (NS-SEC; 2001-2011). Multi-level regression was used to evaluate time trends in General Health Questionnaire (GHQ-12) scores and bad or very bad self-assessed health (SAH), as well as EQ-5D utility scores. The study found that the probability of reporting GHQ-12 scores ≥4 and ≥ 1 was higher in those from lower social classes, and decreased for all social classes between 1997 and 2009. For SAH, the probability of reporting bad or very bad health remained relatively constant for social class I (professional) [0.028 (95%CI: 0.026, 0.029) in 1996 compared to 0.028 (95%CI: 0.024, 0.032) in 2009], but increased in lower social classes, with the greatest increase observed amongst those in social class V (unskilled manual) [0.089 (95%CI: 0.085, 0.093) in 1996 compared to 0.155 (95%CI: 0.141, 0.168) in 2009]. EQ-5D utility scores were lower for those in lower social classes, but remained comparable across survey years. In sensitivity analyses using the NS-SEC, health outcomes improved from 2001 to 2011, with no evidence of widening socio-economic inequalities. Our findings suggest that socio-economic inequalities have persisted, with evidence of widening for some adverse self-reported health outcomes.

Socioeconomic status and risk of hemorrhage during warfarin therapy for atrial fibrillation: A population-based study

BACKGROUND

Among patients taking warfarin, lower socioeconomic status is associated with poorer control of anticoagulation. However, the extent to which socioeconomic status influences the risk of hemorrhage is unknown. We examined the extent to which socioeconomic status influences the risk of hemorrhage in older individuals newly commencing warfarin therapy for atrial fibrillation.

METHODS

We conducted a population-based cohort study of individuals 66 years or older with atrial fibrillation who commenced warfarin therapy between April 1, 1997, and November 30th 2011, in Ontario, Canada. We used neighborhood-level income quintiles as a measure of socioeconomic status. The primary outcome was an emergency department visit or hospitalization for hemorrhage, and the secondary outcome was fatal hemorrhage.

RESULTS

We studied 166,742 older patients with atrial fibrillation who commenced warfarin therapy. Of these, 16,371 (9.8%) were hospitalized for hemorrhage during a median follow-up of 369 (interquartile range 102-865) days. After multivariable adjustment using Cox proportional hazards regression, we found that those in the lowest-income quintile faced an increased risk of hospitalization for hemorrhage relative to those in the highest quintile (adjusted hazard ratio 1.18, 95% CI 1.12-1.23). Similarly, the risk of fatal hemorrhage (n = 1,802) was increased in the lowest-income relative to the highest-income quintile (adjusted hazard ratio 1.28, 95% CI 1.11-1.48).

CONCLUSIONS

Among older individuals receiving warfarin therapy for atrial fibrillation, lower socioeconomic status is a risk factor for hemorrhage and hemorrhage-related mortality. This factor should be carefully considered when initiating and monitoring warfarin therapy.

The Socioeconomic Differences in Alcohol-Related Harm and the Effects of Alcohol Prices on Them: A Summary of Evidence from Finland

AIMS

We make a case study of Finland to study the connections between socioeconomic status, alcohol use, related harm and possibilities for intervention by means of alcohol pricing.

METHODS

A review of Finnish studies on the topic.

RESULTS

The socioeconomic differences in severe alcohol-related harm were great, and in the past two decades, these differences have widened. Alcohol-related mortality has also strongly contributed to both the level and widening of socioeconomic differences in life expectancy. Both in 2004, when alcohol prices were abruptly cut, and in the longer term with more gradual changes in lowest prices of alcohol, the lowest socioeconomic groups were most affected in absolute-but not so clearly in relative-terms, particularly among men. However, these effects are sometimes weak, not fully consistent by gender and across different measures of harm.

CONCLUSIONS

The large and increasing socioeconomic differences in alcohol-related harm in Finland underline the importance of reducing these differences. The finding that particularly among men the impact of reduced alcohol prices on health has often in absolute terms been the greatest in the lower socioeconomic groups suggests that policies aimed at keeping the price of alcoholic beverages high may help to both minimize the overall level of alcohol-related health problems and to reduce absolute inequalities.

Socioeconomic inequality and mortality--a regional Danish cohort study

Background

Socioeconomic inequalities in mortality pose a serious impediment to enhance public health even in highly developed welfare states. This study aimed to improve the understanding of socioeconomic disparities in all-cause mortality by using a comprehensive approach including a range of behavioural, psychological, material and social determinants in the analysis.

Methods

Data from The North Denmark Region Health Survey 2007 among residents in Northern Jutland, Denmark, were linked with data from nationwide administrative registries to obtain information on death in a 5.8-year follow-up period (1^stFebruary 2007- 31^stDecember 2012). Socioeconomic position was assessed using educational status as a proxy. The study population was assigned to one of five groups according to highest achieved educational level. The sample size was 8,837 after participants with missing values or aged below 30 years were excluded. Cox regression models were used to assess the risk of death from all causes according to educational level, with a step-wise inclusion of explanatory covariates.

Results

Participants’ mean age at baseline was 54.1 years (SD 12.6); 3,999 were men (45.3%). In the follow-up period, 395 died (4.5%). With adjustment for age and gender, the risk of all-cause mortality was significantly higher in the two least-educated levels (HR = 1.5, 95%, CI = 1.2-1.8 and HR = 3.7, 95% CI = 2.4-5.9, respectively) compared to the middle educational level. After adjustment for the effect of subjective and objective health, similar results were obtained (HR = 1.4, 95% CI = 1.1-1.7 and HR = 3.5, 95% CI = 2.0-6.3, respectively). Further adjustment for the effect of behavioural, psychological, material and social determinants also failed to eliminate inequalities found among groups, the risk remaining significantly higher for the least educated levels (HR = 1.4, 95% CI = 1.1-1.9 and HR = 4.0, 95% CI = 2.3-6.8, respectively). In comparison with the middle level, the two highest educated levels remained statistically insignificant throughout the entire analysis.

Conclusion

Socioeconomic inequality influenced mortality substantially even when adjusted for a range of determinants that might explain the association. Further studies are needed to understand this important relationship.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1813-3) contains supplementary material, which is available to authorized users.

What is the association of smoking and alcohol use with the increase in social inequality in mortality in Denmark? A nationwide register-based study

OBJECTIVES

The aim of this paper is to estimate the impact of smoking and alcohol use on the increase in social inequality in mortality in Denmark in the period 1985-2009.

DESIGN

A nationwide register-based study.

SETTING

Denmark.

PARTICIPANTS

The whole Danish population aged 30 years or more in the period 1985-2009.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome is mortality rates in relation to educational attainments calculated with and without deaths related to smoking and alcohol use. An absolute measure of inequality in mortality is applied along with a result on the direct contribution from smoking and alcohol use on the absolute difference in mortality rates. The secondary outcome is life expectancy in relation to educational attainments.

RESULTS

Since 1985, Danish overall mortality rates have decreased. Alongside the improvement in mortality, the absolute difference in the mortality rate (per 100,000 persons) between the lowest and the highest educated quartile grew from 465 to 611 among men and from 250 to 386 among women. Smoking and alcohol use have caused 75% of the increase among men and 97% of the increase among women. Among men the increase was mainly caused by alcohol. In women the increase was mainly caused by smoking.

CONCLUSIONS

The main explanation for the increase in social inequality in mortality since the mid-1980s is smoking and alcohol use. A significant reduction in the social inequality in mortality can only happen if the prevention of smoking and alcohol use are targeted to the lower educated part of the Danish population.

Prospective register-based study of the impact of immigration on educational inequalities in mortality in Norway

Background

Differences in mortality with regard to socioeconomic status have widened in recent decades in many European countries, including Norway. A rapid upsurge of immigration to Norway has occurred since the 1990s. The article investigates the impact of immigration on educational mortality differences among adults in Norway.

Methods

Two linked register-based data sets are analyzed; the first consists of all registered inhabitants aged 20–69 in Norway January 1, 1993 (2.6 millions), and the second of all registered inhabitants aged 20–69 as of January 1, 2008 (2.8 millions). Deaths 1993–1996 and 2008–2011, respectively, immigrant status, and other background information are available in the data. Mortality is examined by Cox regression analyses and by estimations of age-adjusted deaths per 100,000 personyears.

Results

Both relative and absolute educational inequality in mortality increased from the 1993–1996 period to 2008–2011, but overall mortality levels went down during these years. Immigrants in general, and almost all the analyzed immigrant subcategories, had lower mortality than the native majority. This was due to comparatively low mortality among lower educated immigrants, while mortality among higher educated immigrants was similar to the mortality level of highly educated natives.

Conclusions

The widening of educational inequality in mortality during the 1990s and 2000s in Norway was not due to immigration. Immigration rather contributed to slightly lower overall mortality in the population and a less steep educational gradient in mortality.

Socioeconomic status and its association with the risk of developing hip fractures: a region-wide ecological study

PURPOSE

To determine the association between socioeconomic deprivation (SES) and hip fracture risk.

METHODS

Retrospective cohort study using a population-based database (primary care records) of over 5 million people. Eligibility: all living subjects registered during the period 2009-2012 and resident in an urban area.

MEASURES

a validated SES composite index (proportion of unemployed, temporary workers, manual workers, low educational attainment and low educational attainment among youngsters) estimated for each area based on census data.

OUTCOME

incident hip fracture rates as coded in medical records using ICD-10 codes.

STATISTICS

zero-inflated Poisson models fitted to study the association between SES quintiles and hip fracture risk, adjusted for age, sex, obesity, smoking and alcohol consumption.

RESULTS

Compared to the most deprived, wealthy areas had a higher hip fracture incidence (age- and sex-adjusted incidence 38.57 (37.14-40.00) compared to 34.33 (32.90-35.76) per 10,000 person-years). Similarly, most deprived areas had a crude and age- and sex-adjusted lower risk of hip fracture, RR of 0.71 (0.65-0.78) and RR of 0.90 (0.85-0.95), respectively, compared to wealthiest areas. The association was attenuated and no longer significant after adjustment for obesity: RR 0.96 (0.90-1.01). Further adjustment for smoking and high alcohol consumption did not make a difference.

CONCLUSION

Wealthiest areas have an almost 30% increased risk of hip fracture compared to the most deprived. Differences in age-sex composition and a higher prevalence of obesity in deprived areas could explain this higher risk.

The population attributable fraction of low education for mortality in South Korea with improvement in educational attainment and no improvement in mortality inequalities

Background

The educational attainment of Koreans has greatly increased, which was expected to reduce the magnitude of the population attributable fraction (PAF) of mortality associated with low education levels. However, increase in the relative risk (RR) of mortality among those with lower educational levels actually increased the PAF. The purpose of this study was to examine the change in the PAF of lower educational levels for mortality in Korea, where educational attainment has improved and is associated with the exacerbation of inequalities in mortality levels.

Methods

National census data were used to derive educational levels. The mortality-associated RR of lower educational levels was calculated by reference to national census and death certificate data from 1995, 2000, 2005, and 2010. PAFs were calculated for all-cause mortality, malignant neoplasms, cerebrovascular disease, heart disease, and suicide by gender and age group (30–44 and 45–59 years).

Results

The PAF of low educational level in terms of total mortality has decreased since 1995 in both genders. This trend was more prominent among those aged 30–44 years. However, the PAFs of suicide in younger females (30–44 years) and of cerebrovascular disease in older males (45–59 years) have increased. The RRs of all-cause mortality and those of the four leading causes of death in those with the lowest educational levels have increased, especially in females aged 30–44 years.

Conclusions

The consistent and sharp increase in the attainment of education has contributed to the reduction in the PAFs of lower education for mortality, despite the fact that mortality inequalities have not improved. Efforts to reduce health inequalities must promote healthy public policy and address public health policies.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1665-x) contains supplementary material, which is available to authorized users.

Self-rated health and mortality in different occupational classes and income groups in Nord-Trøndelag County, Norway

BACKGROUND

People with a lower socioeconomic position have a higher the prevalence of most self-rated health problems. In this article we ask whether this may be attributed to self-rated health not reflecting actual health, understood as mortality, in different socioeconomic groups.

MATERIAL AND METHOD

For the study we used data from the Nord-Trøndelag Health Study 1984-86 (HUNT1), in which the county's entire adult population aged 20 years and above were invited to participate. The association between self-rated health and mortality in different occupational classes and income groups was analysed. The analysis corrected for age, chronic disease, functional impairment and lifestyle factors.

RESULTS

The association between self-rated health and mortality was of the same order of magnitude for the occupational classes and income groups, but persons without work/income and with poor self-rated health stood out. Compared with persons in the highest socioeconomic class, unemployed men had a hazard ratio for death that was three times higher in the follow-up period. For women with no income, the ratio was twice as high. INTERPRETATION Self-rated health and mortality largely conform to the different socioeconomic strata. This supports the perception that socioeconomic differences in health are a reality and represent a significant challenge nationally. Our results also increase the credibility of findings from other studies that use self-reported health in surveys to measure differences and identify the mechanisms that create them.