Indicators of socioeconomic position (part 1)

Measuring walking within and outside the neighborhood in Chinese elders: reliability and validity

Background

Walking is a preferred, prevalent and recommended activity for aging populations and is influenced by the neighborhood built environment. To study this influence it is necessary to differentiate whether walking occurs within or outside of the neighborhood. The Neighborhood Physical Activity Questionnaire (NPAQ) collects information on setting-specific physical activity, including walking, inside and outside one's neighborhood. While the NPAQ has shown to be a reliable measure in adults, its reliability in older adults is unknown. Additionally its validity and the influence of type of neighborhood on reliability and validity have yet to be explored.

Methods

The NPAQ walking component was adapted for Chinese speaking elders (NWQ-CS). Ninety-six Chinese elders, stratified by social economic status and neighborhood walkability, wore an accelerometer and completed a log of walks for 7 days. Following the collection of valid data the NWQ-CS was interviewer-administered. Fourteen to 20 days (average of 17 days) later the NWQ-CS was re-administered. Test-retest reliability and validity of the NWQ-CS were assessed.

Results

Reliability and validity estimates did not differ with type of neighborhood. NWQ-CS measures of walking showed moderate to excellent reliability. Reliability was generally higher for estimates of weekly frequency than minutes of walking. Total weekly minutes of walking were moderately related to all accelerometry measures. Moderate-to-strong associations were found between the NWQ-CS and log-of-walks variables. The NWQ-CS yielded statistically significantly lower mean values of total walking, weekly minutes of walking for transportation and weekly frequency of walking for transportation outside the neighborhood than the log-of-walks.

Conclusions

The NWQ-CS showed measurement invariance across types of neighborhoods. It is a valid measure of walking for recreation and frequency of walking for transport. However, it may systematically underestimate the duration of walking for transport in samples that engage in high levels of this type of walking.

Explanations of educational differences in major depression and generalised anxiety disorder in the Irish population

BACKGROUND

Social inequalities in mental disorders have been described, but studies that explain these inequalities are lacking, especially those using diagnostic interviews. This study investigates the contribution of various explanatory factors to the association between educational level and major depression and generalised anxiety disorder in Irish men and women.

METHODS

The study population comprised a national random sample of 5771 women and 4207 men aged 18 or more in Ireland (SLÁN 2007 survey). Major depression and generalised anxiety disorder were measured using a standardised diagnostic interview (CIDI-SF). Four groups of explanatory factors were explored: material, psychosocial, and behavioural factors, and chronic disease.

RESULTS

For both genders, low educational level increased the risk of both mental disorders. Material factors, especially no private health insurance, but also no car, housing tenure, insufficient food budget, and unemployment (for men), made the highest contribution (stronger for men than for women) in explaining the association between education and both mental disorders. Psychosocial (especially formal social participation, social support and marital status) and behavioural factors (smoking and physical activity for both genders, and alcohol and drug use for men) and chronic disease made low independent contributions in explaining the association between education and both mental disorders.

LIMITATIONS

Given the cross-sectional study design, no causal conclusion could be drawn.

CONCLUSIONS

Targeting various material, psychosocial, and behavioural factors, as well as chronic diseases may help to reduce educational differences in depression and anxiety in the general population.

Socioeconomic status and risk of psychological distress and depression in the Stockholm Public Health Cohort: a population-based study

BACKGROUND

There is limited evidence whether the association between low socioeconomic status and risk of common mental disorders varies with symptom severity, type of socioeconomic indicator or gender.

METHODS

A population-based survey was conducted among a random sample of Stockholm County residents aged 18-84 years in 2002. Respondents were reassessed via a follow-up questionnaire in 2007. Participants in both surveys (n = 23794) were categorized according to socioeconomic status at baseline and followed up for onset of psychological distress (according to the twelve-item general health questionnaire) and depression (according to health data registers). Logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Occupational class was not associated with risk of psychological distress, regardless of severity or gender. Occupational class was strongly associated with onset of depression in men (OR 3.0 [95% CI 1.5-5.9], comparing unskilled manual workers with higher non-manual workers) but not women. Income was associated with risk of onset of all outcomes, and risks increased with symptom severity. Belonging to the highest household income category was particularly protective of depression in women. Education was unrelated to either outcome in men and women overall.

LIMITATIONS

Retention rate at follow-up was 76% and depression was ascertained via health service use.

CONCLUSION

Low socioeconomic position is associated with onset of depression but not mild distress. Attributes of occupational class and household income may be respectively more relevant for the development of depression in men and women.

Associations with early-life socio-economic position in adult DNA methylation

BACKGROUND

Disadvantaged socio-economic position (SEP) in childhood is associated with increased adult mortality and morbidity. We aimed to establish whether childhood SEP was associated with differential methylation of adult DNA.

METHODS

Forty adult males from the 1958 British Birth Cohort Study were selected from SEP extremes in both early childhood and mid-adulthood. We performed genome-wide methylation analysis on blood DNA taken at 45 years using MeDIP (methylated DNA immunoprecipitation). We mapped in triplicate the methylation state of promoters of approximately 20,000 genes and 400 microRNAs. Probe methylation scores were averaged across triplicates and differential methylation between groups of individuals was determined. Differentially methylated promoter sites of selected genes were validated using pyrosequencing of bisulfite-converted DNA.

RESULTS

Variably methylated probes (9112 from n = 223,359 on the microarray) corresponded to 6176 gene promoters with at least one variable probe. Unsupervised hierarchical clustering of probes obtained from the 500 most variable promoters revealed a cluster enriched with high SEP individuals confirming that SEP differences contribute to overall epigenetic variation. Methylation levels for 1252 gene promoters were associated with childhood SEP vs 545 promoters for adulthood SEP. Functionally, associations with childhood SEP appear in promoters of genes enriched in key cell signalling pathways. The differentially methylated promoters associated with SEP cluster in megabase-sized regions of the genome.

CONCLUSIONS

Adult blood DNA methylation profiles show more associations with childhood SEP than adult SEP. Organization of these associations across the genome suggests a well-defined epigenetic pattern linked to early socio-economic environment.

Distinct impact of education and income on habitual exercise: a cross-sectional analysis in a rural city in Japan

Education and income are important socioeconomic indicators that reflect different aspects of social hierarchy. However, only a few studies have explicitly examined how different the relationship between education and health behaviour is from that between income and health behaviour. According to the human capital theory of health investment, education would reflect knowledge assets that allow an efficient investment in health, while income would relate to the value of healthy days and/or the time cost of health investment. Since time cost and the relative price of health would differ across age strata, we examined the significance of effect modification by age strata to distinguish the effects of education on habitual exercise from the effects of income. A cross-sectional survey was conducted using a self-administered questionnaire in a rural city in northern Japan in January 2007 (n = 3385). Logistic regression analyses were conducted to assess the association of educational attainment and household income with habitual exercise. Interaction terms of these socioeconomic indicators with age strata (<60 years versus ≥60 years) were included to test the distinctive association across age, followed by a stratified analysis. As theoretically predicted, higher income was significantly associated with habitual exercise among those aged 25-59 years, while the association was null or negative among those aged 60 and above. Education was significantly associated with habitual exercise regardless of the age groups. These results suggest that the effects of socioeconomic factors on health behaviours vary according to which socioeconomic indicators are analysed, and which age group is selected. We conclude that studies on the socioeconomic disparity of health behaviours should carefully choose socioeconomic indicators to explain specific health behaviours to reveal underlying mechanisms and provide relevant policy implications, based on explicit behavioural models.

Childhood socio-economic status and the onset, persistence, and severity of DSM-IV mental disorders in a US national sample

Although significant associations between childhood socio-economic status (SES) and adult mental disorders have been widely documented, SES has been defined using several different indicators often considered alone. Little research has examined the relative importance of these different indicators in accounting for the overall associations of childhood SES with adult outcomes. Nor has previous research distinguished associations of childhood SES with first onsets of mental disorders in childhood, adolescence, and adulthood from those with persistence of these disorders into adulthood in accounting for the overall associations between childhood SES and adult mental disorders. Disaggregated data of this sort are presented here for the associations of childhood SES with a wide range of adult DSM-IV mental disorders in the US National Comorbidity Survey Replication (NCS-R), a nationally-representative sample of 5692 adults. Childhood SES was assessed retrospectively with information about parental education and occupation and childhood family financial adversity. Associations of these indicators with first onset of 20 DSM-IV disorders that included anxiety, mood, behavioral, and substance disorders at different life-course stages (childhood, adolescence, early adulthood, and mid-later adulthood) and the persistence/severity of these disorders were examined using discrete-time survival analysis. Lifetime disorders and their ages-of-onset were assessed retrospectively with the WHO Composite International Diagnostic Interview. Different aspects of childhood SES predicted onset, persistence, and severity of mental disorders. Childhood financial hardship predicted onset of all classes of disorders at every life-course stage with odds-ratios (ORs) of 1.7-2.3. Childhood financial hardship was unrelated, in comparison, to disorder persistence or severity. Low parental education, although unrelated to disorder onset, significantly predicted disorder persistence and severity, whereas parental occupation was unrelated to onset, persistence, or severity. Some, but not all, of these associations were explained by other co-occurring childhood adversities. These specifications have important implications for mental health interventions targeting low-SES children.

Socioeconomic determinants of disability in Chile

BACKGROUND

Disability is a worldwide public health priority. A shift from a biomedical perspective of dysfunction to a broader social understanding of disability has been proposed. Among many different social factors described in the past, socioeconomic position remains as a key multidimensional determinant of health. The study goal was to analyze the relationship between disability and different domains of socioeconomic position in Chile.

METHODS

Cross-sectional analysis of an anonymized population-based survey conducted in Chile in 2006. Any disability (dichotomous variable) and 6 different types of disability were analyzed on the bases of their relationship with income quintiles, occupational status, educational level, and material living standards (quality of the housing, overcrowding rate and sanitary conditions). Confounding and interaction effects were explored using R statistical program.

RESULTS

Income, education, occupation, and material measures of socioeconomic position, along with some sociodemographic characteristics of the population, were independently associated with the chance of being disabled in Chile. Interestingly, classic measures of socioeconomic position (income, education, and occupation) were consistently associated with any disability in Chile, whereas material living conditions were partially confounded by these classic measures. In addition to this, each type of disability showed a particular pattern of related social determinants, which also varied by age group.

CONCLUSIONS

This study contributed to the understanding of disability in Chile and how different domains of socioeconomic position might be associated with this prevalent condition. Disability remains a complex multidimensional public health problem in Chile that requires the inclusion of a wide range of risk factors, of which socioeconomic position is particularly relevant.

Parental education as a predictor of offspring behavioural and physiological cardiovascular disease risk factors

BACKGROUND

Childhood socio-economic disadvantage has been shown to be associated with an elevated rate of cardiovascular disease (CVD) events in adulthood. The objective of this study is to examine associations between mothers' and fathers' education and offspring CVD risk factors.

METHODS

The Oslo Youth Study (n = 498) was initiated in 1979. Children (age 11-15 years) attending six schools and their parents were included. Information on education was collected for parents and participants. Participants were followed through 2006 (age 40 years). Information about physical activity, diet, smoking, binge drinking, body mass index (BMI), s-cholesterol, s-triglycerides and blood pressure was collected in 1981, 1991 and 2006.

RESULTS

Fathers' education was inversely associated with participants' BMI at 15 and 25 years, cholesterol at 25 and 40 years, triglycerides at 25 years and systolic blood pressure at 15 and 25 years (regression coefficients -0.18 to -0.11; P < 0.05 for all). The effects were weakened after adjusting for participants' own education. Maternal education showed no association with these risk factors. After controlling for participants' own education, associations between parental education and behavioural risk factors in adulthood were few.

CONCLUSION

Any impact of parental education on offspring CVD risk factors seemed to be mediated via subject's own education. Parental education offered little predictive capacity for offspring CVD risk factors.

[Internal migration in Spain in the 20th century: a new focus for the study of social inequalities in health]

OBJECTIVE

Catalonia and the Basque Country received substantial immigration quotas from the rest of Spain during the twentieth century. This study aimed to analyze inequalities in health by birthplace (the population born in the same region or other autonomous regions) in these two geographical areas.

METHODS

We conducted a cross-sectional study in the non-institutionalized population aged 50 to 79 years, with data from the health surveys of Catalonia 2006 (n=5,483) and the Basque Country 2007 (n=3,424). We used log-binomial models to estimate the prevalence ratios (PR) of poor self-rated health by birthplace, stratified by sex and social class, and successively adjusted for age, social class and educational attainment.

RESULTS

Immigrants from other autonomous regions had poorer self-rated health than the native-born population, both in the Basque Country (age-adjusted PR in men 1.30, 95% CI 1.11-1.54; women 1.42, 95% CI 1.25-1.62,) and in Catalonia (PR in men 1.41, 95% CI 1.26-1.62; PR in women 1.25, 95% CI 1.16-1.35). PRs were reduced but remained significant after adjustment for social class and educational attainment and stratification by manual or non-manual social class.

CONCLUSIONS

In both communities there are health inequalities that are detrimental to the immigrant population from the rest of Spain, which constitutes approximately half of the population in the studied age cohorts. Future studies should explore the persistence of these inequalities in other health indicators and their reproduction in second generations, and identify entry points for preventive policies.

Socio-economic differences in exposure to television food advertisements in the UK: a cross-sectional study of advertisements broadcast in one television region

Objective

To document socio-economic differences in exposure to food advertising, including advertisements for foods high in fat, salt and sugar (HFSS) as defined by the UK Food Standards Agency's Nutrient Profiling Model.

Design

A cross-sectional survey. Information (including product advertised and viewing figures) on all advertisements broadcast in one UK region over one week (6–12 July 2009) was obtained. Food advertisements were identified and linked to nutritional information on the content of advertised foods.

Setting

UK Tyne-Tees television region.

Subjects

Data were sourced from a UK-wide television viewing panel.

Results

Eleven per cent of advertising seen was for food and 63 % of food advertising seen was for HFSS foods. The proportion of all advertising seen that was for food was smaller among viewers in the least v. most affluent social grade (OR = 0·98, 99 % CI 0·95, 1·00). There was no difference in the proportion of food advertising seen that was for HFSS food between viewers in the most and least affluent social grades. Total exposure to both all food advertising and HFSS food advertising was 2·1 times greater among the least v. the most affluent viewers.

Conclusions

While the least affluent viewers saw relatively fewer food advertisements, their absolute exposure to all food and HFSS food advertisements was higher than that of the most affluent viewers. Current UK restrictions prohibit advertisements for HFSS foods during programmes with a high proportion of child viewers. Extending these to all programming may reduce socio-economic inequalities in exposure to these advertisements and in diet and obesity.

Using matched areas to explore international differences in population health

In this paper, we develop and test a method for examining the influence of national level contextual influences on population health. Acknowledging calls for the use of experimental study designs to explore contextual influences on health, we develop a study design in which sets of local areas from Britain and Belgium became akin to two 'treatment' groups; one exposed to British society and culture and the other exposed to Belgian society and culture. The areas are matched on the basis of showing very strong similarities in economic, demographic and historical characteristics. Data describing these characteristics are obtained from national census data. A principal component analysis of these variables permits areas in Britain and Belgium with similar scores on the resulting components to be matched into pairs. A sequence of logistic regression models identifies between-country difference in the risk of reporting poor health. Our final model compares the risk of reporting poor health among Belgians and people from Britain living in similar local contexts, adjusting for any residual differences in individual level characteristics. We compare results from this new method with those from more conventional approaches. All approaches show that residence in Britain is associated with a substantial and significantly higher risk of reporting poor health for both men and women, after adjustment for both individual and local contextual influences. We then critically reflect on our method and on the context-composition framework for research into area variation in health. We conclude that whilst our approach succeeded in applying the idea of comparable groups with different exposures to an observational, international comparison, it also brought associated questions about external validity and the extent to which a sample of matched areas captures a 'national' context.

Cardiovascular disease by diabetes status in five ethnic minority groups compared to ethnic Norwegians

Background

The population in Norway has become multi-ethnic due to migration from Asia and Africa over the recent decades. The aim of the present study was to explore differences in the self-reported prevalence of cardiovascular disease (CVD) and associated risk factors by diabetes status in five ethnic minority groups compared to ethnic Norwegians.

Methods

Pooled data from three population-based cross-sectional studies conducted in Oslo between 2000 and 2002 was used. Of 54,473 invited individuals 24,749 (45.4%) participated. The participants self-reported health status, underwent a clinical examination and blood samples were drawn. A total of 17,854 individuals aged 30 to 61 years born in Norway, Sri-Lanka, Pakistan, Iran, Vietnam or Turkey were included in the study. Chi-square tests, one-way ANOVAs, ANCOVAs, multiple and logistic regression were used.

Results

Age- and gender-standardized prevalence of self-reported CVD varied between 5.8% and 8.2% for the ethnic minority groups, compared to 2.9% among ethnic Norwegians (p < 0.001). Prevalence of self-reported diabetes varied from 3.0% to 15.0% for the ethnic minority groups versus 1.8% for ethnic Norwegians (p < 0.001). Among individuals without diabetes, the CVD prevalence was 6.0% versus 2.6% for ethnic minorities and Norwegians, respectively (p < 0.001). Corresponding CVD prevalence rates among individuals with diabetes were 15.3% vs. 12.6% (p = 0.364). For individuals without diabetes, the odds ratio (OR) for CVD in the ethnic minority groups remained significantly higher (range 1.5-2.6) than ethnic Norwegians (p < 0.05), after adjustment for age, gender, education, employment, and body height, except for Turkish individuals. Regardless of diabetes status, obesity and physical inactivity were prevalent in the majority of ethnic minority groups, whereas systolic- and diastolic- blood pressures were higher in Norwegians. In nearly all ethnic groups, individuals with diabetes had higher triglycerides, waist-to-hip ratio (WHR), and body mass index compared to individuals without diabetes. Age, diabetes, hypertension, hypercholesterolemia, and WHR were significant predictors of CVD in both ethnic Norwegians and ethnic minorities, but significant ethnic differences were found for age, diabetes, and hypercholesterolemia.

Conclusions

Ethnic differences in the prevalence of CVD were prominent for individuals without diabetes. Primary CVD prevention including identification of undiagnosed diabetes should be prioritized for ethnic minorities without known diabetes.

Preventive Control of Breast and Cervical Cancer in Immigrant and Native Women in Spain: The Role of Country of Origin and Social Class

The study describes the periodic use of cervical and breast cancer screening by women residing in Spain, according to their country of origin, and analyzes whether the observed associations are modified by social class. A cross-sectional design was used, with the study population consisting of women residing in Spain in 2006, ages 25–65 years (N = 10,093) and 40–69 years (N = 6,674) in the cervical and breast cancer screening groups, respectively. The information source was Spain's National Health Survey of 2006. The dependent variables were: undergoing periodic cervical cancer screening (every 5 years or less) and breast cancer screening (every 2 years or less). The independent variables were: country of origin, social class, health care coverage, cohabitation, and age. A descriptive analysis was carried out, and robust Poisson regression models were fitted. Women from low-income countries underwent fewer periodic screening exams for cervical cancer and breast cancer. Independent of country of origin, women from the manual classes underwent fewer screening exams than those from the non-manual classes. In the 50–69 years age group, it was mainly women from the manual classes from low-income countries who underwent fewer periodic mammograms. Having only public health care coverage and not cohabiting with a partner were also associated with lower prevalences of use.

Inequality in self-rated health among immigrants, their descendants and ethnic Danes: examining the role of socioeconomic position

OBJECTIVES

We investigated inequalities in self-rated health between immigrants, their descendants, and ethnic Danes and explored mediation by socioeconomic position and interactions between country of origin and socioeconomic position.

METHODS

Cross-sectional survey data on self-rated health from 4,985 individuals aged 18-66 years including immigrants from seven non-Western countries, their descendants, and ethnic Danes was linked to registry-based data on education, employment status, and income as indicators of socioeconomic position. Using multiple logistic regression analysis, we estimated the association between country of origin and self-rated health.

RESULTS

Immigrants reported poorer health compared with ethnic Danes [age-adjusted odds ratio (OR) = 2.0-7.3 for men; 2.1-10.5 for women, dependent on country of origin] as well as their descendants (OR = 1.6-3.8 for men; 1.5-2.0 for women). Adjustment for socioeconomic position attenuated this association. Stratified analysis indicated that the effect of socioeconomic position on self-rated health varied across the groups.

CONCLUSION

Policies addressing inequalities in health between immigrants, their descendants, and ethnic Danes should target underlying socioeconomic inequalities. Further research of the effects of socioeconomic position on health among immigrants and descendants is needed.

Maternal body mass index and the risk of fetal and infant death: a cohort study from the North of England

BACKGROUND

Early pregnancy obesity (body mass index, BMI, ≥ 30 kg/m(2)) carries significant health implications. This cohort study investigates the association between early pregnancy BMI and the risk of fetal and infant death in pregnancies not affected by congenital anomalies or pre-gestational diabetes.

METHODS

Data on singleton pregnancies delivered during 2003-2005 at five hospitals were linked with data from three regional registers: the Northern Perinatal Mortality Survey, the Northern Diabetes in Pregnancy Survey and the Northern Congenital Abnormality Survey. Logistic regression models were used to determine the crude and adjusted odds ratios (aOR) of a spontaneous fetal death (≥ 20 weeks gestation) and infant death (aged up to 1 year), among underweight (BMI <18.5 kg/m(2)), overweight (BMI 25-29.9 kg/m(2)) and obese women compared with women of recommended BMI (18.5-24.9 kg/m(2)).

RESULTS

Obese women were at significantly increased risks of both fetal death [aOR = 2.32 (95% confidence interval: 1.64-3.28), P< 0.001] and infant death [aOR = 1.97 (1.13-3.45), P= 0.02]. Continuous analyses revealed a V-shaped relationship between BMI and the risk of fetal and infant death, with a minimum risk at 23 kg/m(2), and significantly increased risk thereafter for both fetal death [aOR, per unit = 1.07 (1.05-1.10), P< 0.001] and infant death [aOR, per unit = 1.06 (1.02-1.10), P= 0.007]. No significant excess risks, however, were identified for either maternal underweight [fetal death: aOR = 0.98 (0.42-2.25), P= 0.96; infant death: aOR = 1.89 (0.73-4.88), P= 0.19] or maternal overweight [fetal death: aOR = 1.34 (0.94-1.89), P= 0.10; infant death: aOR = 1.35 (0.79-2.32), P= 0.27] as categories. Except for higher rates of pre-eclampsia among stillbirths, no specific cause of death could explain the increased odds of fetal and infant death among the obese.

CONCLUSIONS

Early pregnancy obesity is significantly associated with fetal and infant death, independent of the known relationships with congenital anomalies and maternal pre-gestational diabetes.

Does socioeconomic inequality in health persist among older people living in resource-poor urban slums?

Using self-reported health that assesses functionality or disability status, this paper investigates whether there are any differences in health status among older people living in a deprived area of Nairobi, Kenya. Data from a cross-sectional survey of 2,037 men and women aged 50 years and older are used to examine the association between socioeconomic position and self-reported health status across 6 health domains. Education, occupation, a wealth index, and main source of livelihood are used to assess the presence of a socioeconomic gradient in health. All the indicators showed the expected negative association with health across some, but not all, of the disability domains. Nonetheless, differences based on occupation, the most commonly used indicators to examine health inequalities, were not statistically significant. Primary level of education was a significant factor for women but not for men; conversely, wealth status was associated with lower disability for both men and women. Older people dependent on their own sources of livelihood were also less likely to report a disability. The results suggest the need for further research to identify an appropriate socioeconomic classification that is sensitive in identifying poverty and deprivation among older people living in slums.

Health differentials in the older population of England: an empirical comparison of the materialist, lifestyle and psychosocial hypotheses

BACKGROUND

In developed countries with old age structures most deaths occur at older ages and older people account for the majority of those in poor health, which suggests a particular need to investigate health inequalities in the older population.

METHODS

We empirically compared the materialist, psychosocial and lifestyle/behavioural theoretical mechanisms of explanation for socio-economic variation in health using data from two waves of the English Longitudinal Study of Ageing (ELSA), a nationally representative multi-purpose sample of the population aged 50 and over living in England. Three dimensions of health were examined: somatic health, depression and well-being.

RESULTS

The materialist and lifestyle/behavioural paths had the most prominent mediating role in the association between socio-economic position and health in the older population, whereas the psychosocial pathway was less influential and exerted most of its influence on depression and well-being, with part of its effect being due to the availability of material resources.

CONCLUSIONS

From a policy perspective there is therefore an indication that population interventions to reduce health differentials and thus improve the overall health of the older population should focus on material circumstances and population based interventions to promote healthy lifestyles.

Social inequalities in road traffic deaths at age 16-20 years among all 611,654 Norwegians born between 1967 and 1976: a multilevel analysis

Background

Road traffic injury is a major cause of death among youths.

Aims

To estimate mortality differences in family socioeconomic position (SEP) and municipal disadvantage level.

Methods

Data on all Norwegians born in 1967–76, gathered from national registries, were linked by a unique national identification number. The 611 654 participants were followed-up for 5 years from age 16 years. Parental education level, father's income level, and proportion of high-income earners in the municipality served as SEP indicators. Associations between SEP and road traffic deaths were analysed by multilevel Poisson regression.

Results

Road traffic deaths (n=676, rate 22.2 per 100 000 person-years) constituted a major cause of death, of which 91.9% were motor vehicle occupants. SEP distributions differed according to gender and type of motor vehicle crash (collision, non-collision). There was an inverse relationship between municipal proportions of high-income earners and mortality (population attributable fraction (PAF) 0.43, 95% CI 0.30 to 0.53) in all categories of gender-specific crash types. Family SEP gradients were not found except for male non-collision deaths, where increasing mortality was found in association with decreasing parental education level (PAF 0.94, 95% CI 0.59 to 0.99) and increasing paternal income (PAF 0.25, 95% CI 0.06 to 0.40).

Conclusion

The different SEP patterns for road traffic deaths across gender and motor vehicle crash type illustrate that heterogeneity of social inequalities in health can be found even within narrow age bands and for similar causes of death.

Socio-economic differences in weight-control behaviours and barriers to weight control

Objective

To examine socio-economic differences in weight-control behaviours (WCB) and barriers to weight control.

Design

A cross-sectional study.

Setting

Data were obtained by means of a postal questionnaire.

Subjects

A total of 1013 men and women aged 45–60 years residing in Brisbane, Australia (69·8 % response rate).

Results

Binary and multinomial logistic regression analyses were performed, adjusted for age, gender and BMI. Socio-economically disadvantaged groups were less likely to engage in weight control (OR for lowest income quartile = 0·60, 95 % CI 0·39, 0·94); among those who engaged in weight control, the disadvantaged group had a likelihood of 0·52 (95 % CI 0·30, 0·90) of adopting exercise strategies, including moderate (OR = 0·56, 95 % CI 0·33, 0·96) and vigorous (OR = 0·47, 95 % CI 0·25, 0·89) physical activities, compared with their more-advantaged counterparts. However, lower socio-economic groups were more likely to decrease their sitting time to control their weight compared with their advantaged counterparts (OR for secondary school or lower education = 1·78, 95 % CI 1·11, 2·84). They were also more likely to believe that losing weight was expensive, not of high priority, required a lot of cooking skills and involved eating differently from others in the household.

Conclusions

Marked socio-economic inequalities existed with regard to engaging in WCB, the type of weight-control strategies used and the perceived barriers to weight control; these differences are consistent with socio-economic gradients in weight status. These factors may need to be included in health promotion strategies that address socio-economic inequalities in weight status, as well as inequalities in weight-related health outcomes.

Extra burden of psychosomatic complaints among adolescents suffering from chronic conditions

OBJECTIVE

To determine whether there are differences in health perception and health care use among adolescents with psychosomatic symptoms (PS), with chronic conditions (CCs), and with both conditions compared with healthy controls.

METHODS

By using the SMASH02 database, 4 groups were created: youths with PS but no CCs (N = 1010); youths with CCs but no PS (N = 497); youths with both psychosomatic symptoms and chronic conditions (PSCC, N = 213); and youths with neither PS nor CC (control, N = 5709). We used χ(2) tests and analysis of variance to compare each variable between the 4 groups. In a second step, all health and health care use variables were included in a multinomial regression analysis controlling for significant (p < .05) background variables and using the control group as the reference.

RESULTS

Overall, PS and PSCC youths were significantly more likely to rate their health as poor, to be depressed, and to have consulted several times their primary health care provider or a mental health professional than their healthy peers. With the exception of being depressed, PSCC adolescents reported worse health perception and higher health care use than CC and PS.

CONCLUSIONS

Although PS youths do not define PS as a CC, it should be considered as one. Moreover, having PS represents an additional burden to chronically ill adolescents. Health professionals dealing with adolescents must be aware of the deleterious health effects that PS can have on adolescents and have this diagnosis in mind to better target the treatment and improve their management.

Effects of childhood socioeconomic position on subjective health and health behaviours in adulthood: how much is mediated by adult socioeconomic position?

BACKGROUND

Adult socioeconomic position (SEP) is one of the most frequently hypothesised indirect pathways between childhood SEP and adult health. However, few studies that explore the indirect associations between childhood SEP and adult health systematically investigate the mediating role of multiple individual measures of adult SEP for different health outcomes. We examine the potential mediating role of individual measures of adult SEP in the associations of childhood SEP with self-rated health, self-reported mental health, current smoking status and binge drinking in adulthood.

METHODS

Data came from 10,010 adults aged 25-64 years at Wave 3 of the Survey of Family, Income and Employment in New Zealand. The associations between childhood SEP (assessed using retrospective information on parental occupation) and self-rated health, self-reported psychological distress, current smoking status and binge drinking were determined using logistic regression. Models were adjusted individually for the mediating effects of education, household income, labour market activity and area deprivation.

RESULTS

Respondents from a lower childhood SEP had a greater odds of being a current smoker (OR 1.70 95% CI 1.42-2.03), reporting poorer health (OR 1.82 95% CI 1.39-2.38) or higher psychological distress (OR 1.60 95% CI 1.20-2.14) compared to those from a higher childhood SEP. Two-thirds to three quarters of the association of childhood SEP with current smoking (78%), and psychological distress (66%) and over half the association with poor self-rated health (55%) was explained by educational attainment. Other adult socioeconomic measures had much smaller mediating effects.

CONCLUSIONS

This study suggests that the association between childhood SEP and self-rated health, psychological distress and current smoking in adulthood is largely explained through an indirect socioeconomic pathway involving education. However, household income, area deprivation and labour market activity are still likely to be important as they are intermediaries in turn, in the socioeconomic pathway between education and health.

Area-based socioeconomic status and mood disorders: cross-sectional evidence from a cohort of randomly selected adult women

OBJECTIVE

Data suggest there are established socio-economic disparities associated with mental health although most research has focused on individual-level indicators of socio-economic position. The aim of this study was to investigate the association between mood disorders and area-based socio-economic status (SES), and whether both ends of the SES continuum experienced increased odds for a mood disorder.

METHODS

Using a clinical interview (SCID-I/NP), psychiatric history was ascertained in a population-based sample of 1095 women (20-93 years) from the Barwon Statistical Division, south-eastern Australia. SES was determined by cross-referencing residential addresses with Australian Bureau of Statistics 2006 census data for the region and categorised into three groupings of low, mid, and upper SES. The Index of Economic Resources (IER), Index of Education and Occupation (IEO), and Index of Relative Socioeconomic Advantage/Disadvantage (IRSAD) were utilised. Lifestyle factors were self-reported.

RESULTS

For IER, the low SES group had a 2.0-fold increased odds of a current mood disorder compared to the mid group, after adjustment for physical activity and current anxiety (OR=2.0, 95% CI 1.0-4.1, p=0.05). This pattern was similarly observed for IEO (OR=1.8, 95% CI 0.9-3.7, p=0.1) and IRSAD (OR=1.6 95% CI 0.8-3.4, p=0.2). Those within the upper SES group showed a non-significant increase in the odds of a current mood disorder compared to the mid-group; IER (OR=1.4, 95% CI 0.8-2.5, p=0.3), IEO (OR=1.2, 95% CI 0.07-2.3, p=0.5) and IRSAD (OR=1.2, 95% CI 0.7-2.1, p=0.6).

CONCLUSIONS

Women in the low SES category were most likely to have a mood disorder. Furthermore, being in an upper SES group may not be protective against mood disorders.

The socioeconomic determinants of cancer

This paper provides a synthesis on socioeconomic inequalities in cancer incidence, mortality and survival across countries and within countries, with particular focus on the Italian context; the paper also describes the underlying mechanisms documented for cancer incidence, and reports some remarks on policies to tackle inequalities.From a worldwide perspective, the burden of cancer appears to be particularly increasing in developing countries, where many cancers with a poor prognosis (liver, stomach and oesophagus) are much more common than in richer countries. As in the case of incidence and mortality, also in cancer survival we observe a great variability across countries. Different studies have suggested a possible impact of health care on the social gradients in cancer survival, even in countries with a National Health System providing equitable access to care.In developed countries, there is increasing awareness of social inequalities as an important public health issue; as a consequence, there is a variety of strategies and policies being implemented throughout Europe. However, recent reviews emphasize that present knowledge on effectiveness of policies and interventions on health inequalities is not sufficient to offer a robust and evidence-based guide to the choice and design of interventions, and that more evaluation studies are needed.The large disparities in health that we can measure within and between countries represent a challenge to the world; social health inequalities are avoidable, and their reduction therefore represents an achievable goal and an ethical imperative.

Pathways and mechanisms in adolescence contribute to adult health inequalities

AIMS

This paper presents a model that encompasses pathways and mechanisms working over adolescence that contribute to adult health inequalities. We review evidence on the four mechanisms: socially differential exposure, tracking, socially differential tracking, and socially differential vulnerability.

METHODS

We conducted literature searches in English-language peer-reviewed journals using PubMed (from 1966 to May 2009) and PsycINFO, and combined these with hand-searches of reference lists, journals, and authors of particular relevance.

RESULTS

Most health indicators are socially patterned in adolescence and track into adulthood, with higher risks of adverse outcomes among individuals from lower socioeconomic positions. Adolescent health behaviours track into adulthood. Smoking, physical activity, and especially fruit and vegetable intake are socially patterned, while evidence for social patterning of alcohol use is less consistent. Relational dimensions like lone parenthood and bullying are socially patterned and track over time, and there are indications of a socially differential vulnerability to the effects of these types of relational strain. Very little research has investigated the social patterning of the above indicators over time or studied social vulnerability of these indicators from adolescence to adulthood. However, all four mechanisms seem to be active in establishing social differences in adult educational attainment.

CONCLUSIONS

We find the Adolescent Pathway Model useful for providing an overview of what elements and mechanisms in adolescence may be of special importance for adult health inequalities. There is a lack of knowledge of how social patterns of health, health behaviours, and social relations in adolescence transfer into adulthood and to what extent they reflect themselves in adult health.

Socioeconomic status and risk of acute myocardial infarction. Population-based case-control study

INTRODUCTION AND OBJECTIVES

Socioeconomic status is associated with cardiovascular mortality. The aims of this study were to investigate the association between socioeconomic status and its various indicators and the risk of acute myocardial infarction (AMI), and to determine whether any association found is independent of the presence of cardiovascular risk factors (CVRFs).

METHODS

Study cases were matched with controls by age, sex and year of recruitment. Cases were recruited from a hospital register and controls from cross-sectional studies of the general population. The socioeconomic status was determined from educational level and social class, as indicated by occupation. Self-reported data were collected on the presence of CVRFs.

RESULTS

The study included 1369 cases and controls. Both educational level and social class influenced AMI risk. Among non-manual workers, there was an inverse linear relationship between educational level and AMI risk independent of CVRFs: compared with university educated individuals, the odds ratio (OR) for an AMI among those with a high school education was 1.63 (95% confidence interval [CI], 1.16-2.3), and among those with an elementary school education, 3.88 (95% CI, 2.79-5.39). No association between educational level and AMI risk was observed in manual workers. However, the AMI risk was higher in manual workers than non-manual university educated workers: in those with an elementary school education, the increased risk (OR=2.09; 95% CI, 1.59-2.75) was independent of CVRFs.

CONCLUSIONS

An association was found between socioeconomic status and AMI risk. The AMI risk was greatest in individuals with only an elementary school education, irrespective of CVRFs and social class, as indicated by occupation.

Type 2 diabetes incidence and socio-economic position: a systematic review and meta-analysis

BACKGROUND

We conducted a systematic review and meta-analysis, the first to our knowledge, summarizing and quantifying the published evidence on associations between type 2 diabetes incidence and socio-economic position (SEP) (measured by educational level, occupation and income) worldwide and when sub-divided into high-, middle- and low-income countries.

METHODS

Relevant case-control and cohort studies published between 1966 and January 2010 were searched in PubMed and EMBASE using the keywords: diabetes vs educational level, occupation or income. All identified citations were screened by one author, and two authors independently evaluated and extracted data from relevant publications. Risk estimates from individual studies were pooled using random-effects models quantifying the associations.

RESULTS

Out of 5120 citations, 23 studies, including 41 measures of association, were found to be relevant. Compared with high educational level, occupation and income, low levels of these determinants were associated with an overall increased risk of type 2 diabetes; [relative risk (RR) = 1.41, 95% confidence interval (CI): 1.28-1.51], (RR = 1.31, 95% CI: 1.09-1.57) and (RR = 1.40, 95% CI: 1.04-1.88), respectively. The increased risks were independent of the income levels of countries, although based on limited data in middle- and low-income countries.

CONCLUSIONS

The risk of getting type 2 diabetes was associated with low SEP in high-, middle- and low-income countries and overall. The strength of the associations was consistent in high-income countries, whereas there is a strong need for further investigation in middle- and low-income countries.

Life-course socioeconomic position and type 2 diabetes mellitus: The Framingham Offspring Study

Evidence is lacking on whether the duration and timing of low socioeconomic position (SEP) across a person's life course may be associated with incidence of type 2 diabetes mellitus (T2D). The authors' objectives were to investigate associations between cumulative SEP and the incidence of T2D in the Framingham Offspring Study (n = 1,893; 52% women; mean baseline age = 34 years). Pooled logistic regression analyses demonstrated that age-adjusted cumulative SEP was associated with T2D in women (for low vs. high cumulative SEP, odds ratio (OR) = 1.92, 95% confidence interval (CI): 1.08, 3.42). Age-adjusted analyses for young-adulthood SEP (7.85 for ≤12 vs. >16 years of education, OR = 2.84, 95% CI: 1.03), active professional life SEP (for laborer vs. professional/executive/supervisory/technical occupations, OR = 2.40, 95% CI: 1.05, 5.47), and social-mobility frameworks (for declining life-course SEP, OR = 2.99, 95% CI: 1.39, 6.44; for stable low vs. stable high life-course SEP, OR = 1.85, 95% CI: 1.02, 3.35) all demonstrated associations between low SEP and T2D incidence in women. No association was observed between childhood SEP and T2D in women for father's education (some high school or less vs. any postsecondary education, OR = 1.26, 95% CI: 0.72, 2.22). In men, there was little evidence of associations between life-course SEP and T2D incidence. These findings suggest that cumulative SEP is inversely associated with incidence of T2D in women, and that this association may be primarily due to the women's educational levels and occupations.

Ethnic differences in diabetes-related mortality in the Brussels-Capital Region (2001-05): the role of socioeconomic position

OBJECTIVES

To examine if and to what extent ethnic differences in diabetes-related mortality are associated with differences in education and housing status.

METHODS

The data consist of a cohort study linking the 2001 census to emigration and mortality data for the period 2001-05. The study population comprises all Belgian and North African inhabitants of the Brussels-Capital Region (BCR) aged 25-74. Age-standardized mortality rates (ASMRs) (direct standardization) and mortality rate ratios (MRRS) (Poisson regression) are computed.

RESULTS

North Africans have a higher diabetes-related mortality compared to Belgians. The ASMRs for North African and Belgian women are 54.8 (95% confidence interval (CI) 31.5-78.2) and 23.8 (95% CI 20.3-27.3), respectively. These differences in diabetes-related mortality largely disappear when differences in education are taken into account. The MRRs for North African versus Belgian origin drop from 1.62 (95% CI 1.11-2.37) to 1.19 (95% CI 0.73-1.93) in men and from 3.35 (95% CI 2.08-5.41) to 1.88 (95% CI 0.95-3.69) in women.

CONCLUSIONS

Differences in education play an important part in the excess diabetes-related mortality among North Africans in the BCR.

Socioeconomic position and breast reconstruction in Danish women

Few studies have been conducted on the socioeconomic position of women undergoing breast reconstruction, and none have been conducted in the Danish population. We investigated the association between educational level and breast reconstruction in a nationwide cohort of Danish women with breast cancer.

MATERIAL AND METHODS

From nationwide registers, 13 379 women aged 30-80 years who had been treated by mastectomy for breast cancer in Denmark in 1999-2006 were identified and followed up through November 2009. Multivariate logistic regression models were used to investigate the simultaneous influence of educational level on the likelihood of having immediate or delayed (up to three years after mastectomy) breast reconstruction, with adjustment for age, breast cancer characteristics, comorbidity, socioeconomic variables and availability of plastic surgery services at each woman's affiliated hospital.

RESULTS

The odds ratios (ORs) for both immediate and delayed breast reconstruction increased significantly with level of education. Being affiliated to a hospital with a plastic surgery department increased the likelihood of both immediate (adjusted OR, 4.02; 95% confidence interval [CI], 2.81-5.75) and delayed breast reconstruction (adjusted OR, 1.41; 95% CI, 1.26-1.66). There was no association between education and breast reconstruction among 30-44 year old women, regardless of type of breast reconstruction; however, medium or higher education was significantly associated with a fourfold increase in the OR for immediate breast reconstruction in women aged 45-59 years and a more than twofold increase in the OR for delayed breast reconstruction in women aged 60-80 years compared to women with short education.

CONCLUSION

Increasing education was associated with increasing odds for having immediate or delayed breast reconstruction, but only in the older age groups. The offer of breast reconstruction appears to be unequally distributed in Denmark, and living in an area where the hospital has a plastic surgery department significantly increased the odds for having breast reconstruction.

Assessing access barriers to tuberculosis care with the tool to Estimate Patients' Costs: pilot results from two districts in Kenya

Background

The poor face geographical, socio-cultural and health system barriers in accessing tuberculosis care. These may cause delays to timely diagnosis and treatment resulting in more advanced disease and continued transmission of TB. By addressing barriers and reasons for delay, costs incurred by TB patients can be effectively reduced. A Tool to Estimate Patients' Costs has been developed. It can assist TB control programs in assessing such barriers. This study presents the Tool and results of its pilot in Kenya.

Methods

The Tool was adapted to the local setting, translated into Kiswahili and pretested. Nine public health facilities in two districts in Eastern Province were purposively sampled. Responses gathered from TB patients above 15 years of age with at least one month of treatment completed and signed informed consent were double entered and analyzed. Follow-up interviews with key informants on district and national level were conducted to assess the impact of the pilot and to explore potential interventions.

Results

A total of 208 patients were interviewed in September 2008. TB patients in both districts have a substantial burden of direct (out of pocket; USD 55.8) and indirect (opportunity; USD 294.2) costs due to TB. Inability to work is a major cause of increased poverty. Results confirm a 'medical poverty trap' situation in the two districts: expenditures increased while incomes decreased. Subsequently, TB treatment services were decentralized to fifteen more facilities and other health programs were approached for nutritional support of TB patients and sputum sample transport. On the national level, a TB and poverty sub-committee was convened to develop a comprehensive pro-poor approach.

Conclusions

The Tool to Estimate Patients' Costs proved to be a valuable instrument to assess the costs incurred by TB patients, socioeconomic situations, health-seeking behavior patterns, concurrent illnesses such as HIV, and social and gender-related impacts. The Tool helps to identify and tackle bottlenecks in access to TB care, especially for the poor. Reducing delays in diagnosis, decentralization of services, fully integrated TB/HIV care and expansion of health insurance coverage would alleviate patients' economic constraints due to TB.

Socioeconomic position and lifestyle in relation to breast cancer incidence among postmenopausal women: a prospective cohort study, Denmark, 1993-2006

BACKGROUND

In Denmark, the incidence of breast cancer is higher among women with higher socioeconomic position. We investigated whether differences in exposure to certain risk factors contribute to this gradient, as measured from education, income and occupation.

METHODS

We conducted a cohort study of 23,111 postmenopausal women aged 50-65 years who were enrolled in the prospective Danish 'Diet, Cancer and Health' study between 1993 and 1995. At baseline, all women filled in a questionnaire on lifestyle and food frequency. The results were analysed in Cox proportional hazard models.

RESULTS

Part of the association with socioeconomic position is due to the potential mediators reproductive pattern, use of hormone replacement therapy and alcohol consumption. After simultaneous adjustment for these factors, the hazard ratios were 1.06 (95% confidence interval [CI], 0.88-1.27) for women with higher education and 1.07 (95% CI, 0.85-1.34) for women with higher income. The HR ratio for women working as higher officials when compared with unskilled workers was 1.23 (0.96-1.59).

CONCLUSION

The results support the hypothesis that the higher incidence of breast cancer among socially advantaged women is mediated partly by differences in exposure to reproductive factors, hormone replacement therapy and alcohol.

Repeated exposure to socioeconomic disadvantage and health selection as life course pathways to mid-life depressive and anxiety disorders

BACKGROUND

Socioeconomic position (SEP) in childhood and adulthood influences the risk of adult psychiatric disorder. This paper investigates first how cumulative childhood manual SEP influences the risk for mid-life depressive and anxiety disorders and secondly the effects of health selection based on psychological disorder in childhood and psychological distress in early adulthood on mid-life social position.

METHODS

9,377 participants of the 1958 Birth Cohort were followed up at 45 years with the Revised Clinical Interview Schedule to measure depressive and anxiety disorders. SEP was measured by Registrar General Social Class in childhood (ages 7, 11 and 16 years) and adulthood (ages 23, 33 and 42 years). Internalising and externalising disorders were also measured in childhood.

RESULTS

Cumulative manual SEP in childhood was weakly associated with increased risk of mid-life disorder. Childhood internalising and externalising disorders were associated with less upward social mobility and manual adult social position. Psychological disorder on three occasions in childhood was associated with manual adult occupational status (OR = 3.33, 95% CI 2.63-4.21) even after adjusting for childhood SEP and malaise score at 42 years.

CONCLUSIONS

Both social causation and health selection contribute to the association of childhood socioeconomic disadvantage and mid-life depressive and anxiety disorders. Tackling accumulation of disadvantage and understanding and treating childhood psychological disorders and their educational and occupational consequences could reduce the risk of mid-life psychiatric disorders.

Motives to quit smoking and reasons to relapse differ by socioeconomic status

OBJECTIVE

To investigate motives, strategies and experiences to quit smoking and reasons to relapse as a function of socioeconomic status.

METHODS

A population-based study, Inter99, Denmark. Two thousand six hundred twenty-one daily smokers with a previous quit attempt completed questionnaires at baseline. Cross-sectional baseline-data (1999-2001) were analysed in adjusted regression analyses.

RESULTS

Consistent findings across the three indicators of socioeconomic status (employment, school education, higher education/vocational training): smokers with low socioeconomic status were significantly more likely than smokers with high socioeconomic status to report that they wanted to quit because smoking was too expensive (OR: 1.85 (1.4-2.4), for school education) or because they had health related problems (OR: 1.75 (1.4-2.2)). When looking at previous quit attempts, smokers with low socioeconomic status were significantly more likely to report that it had been a bad experience (OR: 1.41 (1.1-1.8)) and that they had relapsed because they were more nervous/restless/depressed (OR: 1.43 (1.1-1.8)).

CONCLUSIONS

This study shows that smokers with low socioeconomic status have other motives to quit and other reasons to relapse than smokers with high socioeconomic status. Future tobacco prevention efforts aimed at smokers with low socioeconomic status should maybe focus on current advantages of quitting smoking, using high cost of smoking and health advantages of quitting as motivating factors and by including components of mental health as relapse prevention.

Factors affecting survival of women diagnosed with breast cancer in El-Minia Governorate, Egypt

OBJECTIVES

This study was conducted to determine breast cancer survival time and the association between breast cancer survival and socio-demographic and pathologic factors among women, in El-Minia, Egypt. While there has been much researches regarding prognostic factors for breast cancer but the majority of these studies were from developed countries. El-Minia has a population of approximately 4 million. To date, no research has been performed to determine breast cancer survival and the factors affecting it in El-minia.

METHODS

This retrospective study used data obtained from the cancer registry in the National Institute of Oncology in El-Minia and included 1207 women diagnosed with first primary breast cancer between 1(st) January 2005 and 31(st) December 2009 and followed to 30(th) June 2010. The association between survival and sociodemographic and pathological factors and distant metastasis at diagnosis, and treatment options was investigated using unifactorial chi-square test and multi-factorial (Cox regression) analyses. Kaplan-Meier analysis was used to compare survival time among different groups.

RESULTS

Median survival time was 83.8 ± 3.2. Cox regression showed that high vs low educational level (Hazard ratio (HR)= 0.35, 95% CI; 0.27-0.46), metastases to bone (HR = 3.22, 95% CI: 1.71-6.05), metastases to lung (HR= 2.314, 95% CI: 1.225-4.373), tumor size (≤ 2 cm vs ≥ 5 cm: HR = 1.4, 95% CI: 1.1-1.8) and number of involved nodes (1 vs > 10 HR = 5.21, 95%CI: 3.1-9.01) were significantly related to survival.

CONCLUSIONS

The results showed the need to develop screening programs and standardized treatment regimens in a tax-funded health care system.

The contribution of risk factors to the higher incidence of invasive and in situ breast cancers in women with higher levels of education in the European prospective investigation into cancer and nutrition

The authors investigated the role of known risk factors in educational differences in breast cancer incidence. Analyses were based on the European Prospective Investigation Into Cancer and Nutrition and included 242,095 women, 433 cases of in situ breast cancer, and 4,469 cases of invasive breast cancer. Reproductive history (age at first full-term pregnancy and parity), exposure to endogenous and exogenous hormones, height, and health behaviors were accounted for in the analyses. Relative indices of inequality (RII) for education were estimated using Cox regression models. A higher risk of invasive breast cancer was found among women with higher levels of education (RII = 1.22, 95% confidence interval (CI): 1.09, 1.37). This association was not observed among nulliparous women (RII = 1.13, 95% CI: 0.84, 1.52). Inequalities in breast cancer incidence decreased substantially after adjusting for reproductive history (RII = 1.11, 95% CI: 0.98, 1.25), with most of the association being explained by age at first full-term pregnancy. Each other risk factor explained a small additional part of the inequalities in breast cancer incidence. Height accounted for most of the remaining differences in incidence. After adjusting for all known risk factors, the authors found no association between education level and risk of invasive breast cancer. Inequalities in incidence were more pronounced for in situ breast cancer, and those inequalities remained after adjustment for all known risk factors (RII = 1.61, 95% CI: 1.07, 2.41), especially among nulliparous women.

The Empathy Quotient: a cross-cultural comparison of the Italian version

INTRODUCTION

The Empathy Quotient (EQ) is a self-report questionnaire that was developed to measure the cognitive, affective, and behavioural aspects of empathy. We evaluated its cross-cultural validity in an Italian sample.

METHODS

A sample of 18- to 30-year-old undergraduate students of both sexes (N=256, males=118) were invited to fill in the Italian version of the EQ, as well as other measures of emotional competence and psychological distress. Results. The EQ had an excellent reliability (Cronbach's alpha=.79; test-retest at 1 month: Pearson's r=.85), and was normally distributed. Females scored higher than males, and more males (n=14, 11.9%) than females (n=4, 2.9%) scored lower than 30, the cutoff score that best differentiates autism spectrum conditions from controls. EQ was negatively related to the Toronto Alexithymia Scale (TAS) and positively related to the Marlowe-Crowne Social Desirability Scale (SDS). Principal component analysis retrieved the three-factor structure of the EQ. Lower emotional reactivity correlated with higher scores in measures of risk in both the schizophrenia-like (Peters et al. Delusions Inventory) and the bipolar (Hypomanic Personality Scale) spectra.

CONCLUSIONS

The Italian version of the EQ has good validity, with an acceptable replication of the original three-factor solution, yielding three subscales with high internal and test-retest reliability.

General and abdominal obesity in South Korea, 1998-2007: gender and socioeconomic differences

OBJECTIVE

To examine national trends in prevalence and socioeconomic inequalities in both general (measured by body mass index) and abdominal obesity (measured by waist circumference) by gender and socioeconomic position (SEP) indicators.

METHODS

Data were from four rounds of nationally representative cross-sectional surveys for Korean men and women aged 25-64 (6,286 in 1998, 4,839 in 2001, 4,181 in 2005, and 2,006 in 2007). We calculated age-adjusted prevalence rates of overweight and abdominal obesity by gender and SEP indicators (education, occupational class, employment status and income) and examined trends of prevalence and its inequalities.

RESULTS

Overweight and abdominal obesity has significantly increased in Korean men (P for linear trend <0.01), not in women. For men, high SEP was associated with overweight and abdominal obesity, but the magnitude of socioeconomic differences in obesity measures generally remained unchanged during the study period. Among women, low SEP was associated with overweight. Interestingly, increasing inequalities in abdominal obesity according to education and income were found in women.

CONCLUSIONS

Clear gender differences were noted in (1) time trends of overweight and abdominal obesity, (2) relationships between the obesity measures and various SEP indicators, and (3) linear time trends of socioeconomic differentials in obesity.

Socioeconomic status is not inversely associated with overweight in preschool children

OBJECTIVE

To assess whether socioeconomic inequalities were already present in preschool children.

STUDY DESIGN

We used data from 2954 Dutch children participating in a longitudinal birth cohort study. Indicators of socioeconomic status were mother's educational level and household income. Body mass index (BMI)-for-age standard deviation scores were derived from a national reference. Overweight was defined at 24 and 36 months according to age- and sex-specific cut-off points for BMI. Multivariable regression analyses were performed.

RESULTS

Relative to children from mothers with the highest educational level, mean BMI standard deviation scores was lower at age 24 months in children from mothers with the low, mid-low, and mid-high educational level, and in the mid-low group at 36 months (P < .001). Prevalence of overweight was lower in children from mothers with the mid-low educational level at age 24 and 36 months (adjusted odds ratio at 24 months: 0.61; 95% confidence interval: 0.43-0.87 and at 36 months: 0.65; 95% confidence interval: 0.44-0.96) but was not significantly different for the other educational levels. There were no significant differences in childhood overweight by income level.

CONCLUSIONS

The inverse association between socioeconomic status and childhood overweight presumably emerges after age 3 years. Before this age, the gradient may be the reverse.

Education level and oral health in Finnish adults: evidence from different lifecourse models

AIM

To assess the relationship between education level and several oral health outcomes in Finnish adults, using three conceptual lifecourse models.

MATERIALS AND METHODS

This study analysed data from 7112 subjects, aged 30 years or over, who participated in the nationally representative Finnish Health 2000 Survey. Parental and own education levels were the childhood and adulthood socioeconomic measures, respectively. Oral health was indicated by edentulousness, perceived oral health and levels of dental caries and periodontal disease. Three conceptual lifecourse models, namely critical period, accumulation and social trajectories, were separately tested in regression models.

RESULTS

In line with the critical period model, parental and own education levels were independently associated with oral health after mutual adjustment. There was also a graded linear relationship between the number of periods of socioeconomic disadvantage and oral health, corresponding to the accumulation model. Gradual declines in oral health were evident between social trajectories from persistently high to upwardly mobile, downwardly mobile and persistently low groups.

CONCLUSION

There was similar support for the lifecourse models of critical period, accumulation and social trajectories. They collectively contribute to a better understanding of oral health inequalities.

Occupational and behavioural factors in the explanation of social inequalities in premature and total mortality: a 12.5-year follow-up in the Lorhandicap study

The respective contribution of occupational and behavioural factors to social disparities in all-cause mortality has been studied very seldom. The objective of this study was to evaluate the role of occupational and behavioural factors in explaining social inequalities in premature and total mortality in the French working population. The study population consisted of a sample of 2,189 and 1,929 French working men and women, who responded to a self-administered questionnaire in mid-1996, and were followed up until the end of 2008. Mortality was derived from register-based information and linked to the baseline data. Socioeconomic status was measured using occupation. Occupational factors included biomechanical and physical exposures, temporary contract, psychological demands, and social support, and behavioural factors, smoking, alcohol abuse, and body mass index. Significant social differences were observed for premature and total mortality. Occupational factors reduced the hazard ratios of mortality for manual workers compared to managers/professionals by 72 and 41%, from 1.88 (95% CI: 1.17-3.01) to 1.25 (95% CI: 0.74-2.12) for premature mortality, and from 1.71 (95% CI: 1.18-2.47) to 1.42 (95% CI: 0.95-2.13) for total mortality. The biggest contributions were found for biomechanical and physical exposures, and job insecurity. The role of behavioural factors was very low. Occupational factors played a substantial role in explaining social disparities in mortality, especially for premature mortality and men. Improving working conditions amongst the lowest social groups may help to reduce social inequalities in mortality.