Educational inequalities in cause-specific mortality in middle-aged and older men and women in eight western European populations

Smoking and the potential for reduction of inequalities in mortality in Europe

Socioeconomic inequalities in health and mortality remain a widely recognized problem. Countries with smaller inequalities in smoking have smaller inequalities in mortality, and smoking plays an important part in the explanation of inequalities in some countries. We identify the potential for reducing inequalities in all-cause and smoking-related mortality in 19 European populations, by applying different scenarios of smoking exposure. Smoking prevalence information and mortality data come from 19 European populations. Prevalence rates are mostly taken from National Health Surveys conducted around the year 2000. Mortality rates are based on country-specific longitudinal or cross-sectional datasets. Relative risks come from the Cancer Prevention Study II. Besides all-cause mortality we analyze several smoking-related cancers and chronic obstructive pulmonary disease/asthma. We use a newly-developed tool to quantify the changes in population health potentially resulting from modifying the population distribution of exposure to smoking. This tool is based on the epidemiological measure of the population attributable fraction, and estimates the impact of scenario-based distributions of smoking on educational inequalities in mortality. The potential reduction of relative inequality in all-cause mortality between those with high and low education amounts up to 26 % for men and 32 % for women. More than half of the relative inequality may be reduced for some causes of death, often in countries of Northern Europe and in Britain. Patterns of potential reduction in inequality differ by country or region and sex, suggesting that the priority given to smoking as an entry-point for tackling health inequalities should differ between countries.

Social and spatial patterns of obesity diffusion over three decades in a Norwegian county population: the HUNT Study

Background

In order to develop effective preventive strategies, knowledge of trends in socioeconomic and geographical differences in risk factor levels is important. The objective of this study was to examine social and spatial patterns of obesity diffusion in a Norwegian population during three decades.

Methods

Data on adults aged 30–69 years from three cross-sectional health surveys eleven years apart in the Nord-Trøndelag Health Study, Norway, HUNT1 (1984–1986), HUNT2 (1995–1997) and HUNT3 (2006–2008) were utilized. Body mass index (BMI) was used as a measure of obesity. Height and weight were measured clinically. Age standardized prevalences, absolute prevalence differences and ratios, prevalence odds ratios for BMI and the Relative Index of Inequality (RII) were calculated. Multilevel statistical models were fitted for analysing geographical patterns.

Results

The prevalence of obesity was systematically higher in groups with lower socio-economic status and increased successively in all groups in the population during the three decades. The relative socioeconomic inequalities in obesity measured by level of education did not change substantially in the period. In HUNT1 (1984–86) obesity was most prevalent among low educated women (14.1%) and in HUNT3 (2006–08) among low educated men (30.4%). The RII for men changed from 2.60 to 1.91 and 2.36 in HUNT1, HUNT2 and HUNT3. In women the RIIs were 1.71, 2.28 and 2.30 correspondingly. However, the absolute obesity prevalence inequalities increased, and a geographical diffusion from central to distal districts was observed from HUNT2 to HUNT3.

Conclusions

The prevalence of obesity increased in all socioeconomic groups in this Norwegian adult county population from the 1980ies up to present time. The data did not suggest increasing relative inequalities, but increasing absolute socioeconomic differences and a geographical diffusion towards rural districts. Public health preventive strategies should be oriented to counteract the obesity epidemic in the population.

Occupational class differences in body mass index and weight gain in Japan and Finland

Background

Occupational class differences in body mass index (BMI) have been systematically reported in developed countries, but the studies have mainly focused on white populations consuming a Westernized diet. We compared occupational class differences in BMI and BMI change in Japan and Finland.

Methods

The baseline surveys were conducted during 1998–1999 among Japanese (n = 4080) and during 2000–2002 among Finnish (n = 8685) public-sector employees. Follow-up surveys were conducted among those still employed, in 2003 (n = 3213) and 2007 (n = 7086), respectively. Occupational class and various explanatory factors were surveyed in the baseline questionnaires. Linear regression models were used for data analysis.

Results

BMI was higher at baseline and BMI gain was more rapid in Finland than in Japan. In Finland, baseline BMI was lowest among men and women in the highest occupational class and progressively increased to the lowest occupational class; no gradient was found in Japan (country interaction effect, P = 0.020 for men and P < 0.0001 for women). Adjustment for confounding factors reflecting work conditions and health behavior increased the occupational class gradient among Finnish men and women, whereas factors related to social life had no effect. No statistically significant difference in BMI gain was found between occupational classes.

Conclusions

The occupational class gradient in BMI was strong among Finnish employees but absent among Japanese employees. This suggests that occupational class inequalities in obesity are not inevitable, even in high-income societies.

The modifying influence of country development on the effect of individual educational attainment on self-rated health

OBJECTIVES

We investigated how much the Human Development Index (HDI), a global measure of development, modifies the effect of education on self-reported health.

METHODS

We analyzed cross-sectional World Health Survey data on 217,642 individuals from 49 countries, collected in 2002 to 2005, with random-intercept multilevel linear regression models.

RESULTS

We observed greater positive associations between educational levels and self-reported good health with increasing HDI. The magnitude of this effect modification of the education-health relation tended to increase with educational attainment. For example, before adjustment for effect modification, at comparable HDI, on average, finishing primary school was associated with better general health (b = 1.49; 95% confidence interval [CI] = 1.18, 1.80). With adjustment for effect modification by HDI, the impact became 4.63 (95% CI = 3.63, 5.62) for every 0.1 increase in HDI. Among those who completed high school, these associations were, respectively, 5.59 (95% CI = 5.20, 5.98) and 9.95 (95% CI = 8.89, 11.00).

CONCLUSIONS

The health benefits of educational attainment are greater in countries with greater human development. Health inequalities attributable to education are, therefore, larger in more developed countries.

Particulate air pollution and health inequalities: a Europe-wide ecological analysis

Background

Environmental disparities may underlie the unequal distribution of health across socioeconomic groups. However, this assertion has not been tested across a range of countries: an important knowledge gap for a transboundary health issue such as air pollution. We consider whether populations of low-income European regions were a) exposed to disproportionately high levels of particulate air pollution (PM₁₀) and/or b) disproportionately susceptible to pollution-related mortality effects.

Methods

Europe-wide gridded PM₁₀ and population distribution data were used to calculate population-weighted average PM₁₀ concentrations for 268 sub-national regions (NUTS level 2 regions) for the period 2004–2008. The data were mapped, and patterning by mean household income was assessed statistically. Ordinary least squares regression was used to model the association between PM₁₀ and cause-specific mortality, after adjusting for regional-level household income and smoking rates.

Results

Air quality improved for most regions between 2004 and 2008, although large differences between Eastern and Western regions persisted. Across Europe, PM₁₀ was correlated with low household income but this association primarily reflected East–West inequalities and was not found when Eastern or Western Europe regions were considered separately. Notably, some of the most polluted regions in Western Europe were also among the richest. PM₁₀ was more strongly associated with plausibly-related mortality outcomes in Eastern than Western Europe, presumably because of higher ambient concentrations. Populations of lower-income regions appeared more susceptible to the effects of PM₁₀, but only for circulatory disease mortality in Eastern Europe and male respiratory mortality in Western Europe.

Conclusions

Income-related inequalities in exposure to ambient PM₁₀ may contribute to Europe-wide mortality inequalities, and to those in Eastern but not Western European regions. We found some evidence that lower-income regions were more susceptible to the health effects of PM₁₀.

Education and the gender gaps in health and mortality

The positive associations between education and health and survival are well established, but whether the strength of these associations depends on gender is not. Is the beneficial influence of education on survival and on self-rated health conditioned by gender in the same way, in opposite ways, or not at all? Because women are otherwise disadvantaged in socioeconomic resources that are inputs to health, their health and survival may depend more on education than will men's. To test this hypothesis, we use data from the National Health Interview Survey-Linked Mortality Files (NHIS-LMF). We find that education's beneficial influence on feeling healthy and on survival are conditional on gender, but in opposite ways. Education has a larger effect on women's self-rated health than on men's, but a larger effect on men's mortality. To further examine the mortality results, we examine specific causes of death. We find that the conditional effect is largest for deaths from lung cancer, respiratory disease, stroke, homicide, suicide, and accidents. Because women report worse health but men's mortality is higher, education closes the gender gap in both health and mortality.

Inequality in 30-day mortality and the wait for surgery after hip fracture: the impact of the regional health care evaluation program in Lazio (Italy)

OBJECTIVE

INTERVENTIONS

that address inequalities in health care are a priority for public health research. We evaluated the impact of the Regional Health Care Evaluation Program in the Lazio region, which systematically calculates and publicly releases hospital performance data, on socioeconomic differences in the quality of healthcare for hip fracture.

DESIGN

Retrospective cohort study.

SETTING

and participants We identified, in the hospital information system, elderly patients hospitalized for hip fracture between 01 January 2006 and 31 December 2007 (period 1) and between 01 January 2009 and 30 November 2010 (period 2).

MAIN OUTCOME MEASURES

We used multivariate regression models to test the association between socioeconomic position index (SEP, level I well-off to level III disadvantaged) and outcomes: mortality within 30 days of hospital arrival, median waiting time for surgery and proportion of interventions within 48 h.

RESULTS

We studied 11 581 admissions. Lower SEP was associated with a higher risk of 30-day mortality in period 1 (relative risk (RR) = 1.42, P = 0.027), but not in period 2. Disadvantaged people were less likely to undergo intervention within 48 h than well-off persons in period 1 (level II: RR = 0.72, P < 0.001; level III: RR = 0.46, P < 0.001) and period 2 (level II: RR = 0.88, P = 0.037; level III: RR = 0.63, P < 0.001). We observed a higher probability of undergoing intervention within 48 h in period 2 compared with the period 1 for each socioeconomic level.

CONCLUSION

This study suggests that a systematic evaluation of health outcome approach, including public disclosure of results, could reduce socioeconomic differences in healthcare through a general improvement in the quality of care.

Impact of unlinked deaths and coding changes on mortality trends in the Swiss National Cohort

BACKGROUND

Results of epidemiological studies linking census with mortality records may be affected by unlinked deaths and changes in cause of death classification. We examined these issues in the Swiss National Cohort (SNC).

METHODS

The SNC is a longitudinal study of the entire Swiss population, based on the 1990 (6.8 million persons) and 2000 (7.3 million persons) censuses. Among 1,053,393 deaths recorded 1991-2007 5.4% could not be linked using stringent probabilistic linkage. We included the unlinked deaths using pragmatic linkages and compared mortality rates for selected causes with official mortality rates. We also examined the impact of the 1995 change in cause of death coding from version 8 (with some additional rules) to version 10 of the International Classification of Diseases (ICD), using Poisson regression models with restricted cubic splines. Finally, we compared results from Cox models including and excluding unlinked deaths of the association of education, marital status, and nationality with selected causes of death.

RESULTS

SNC mortality rates underestimated all cause mortality by 9.6% (range 2.4%-17.9%) in the 85+ population. Underestimation was less pronounced in years nearer the censuses and in the 75-84 age group. After including 99.7% of unlinked deaths, annual all cause SNC mortality rates were reflecting official rates (relative difference between -1.4% and +1.8%). In the 85+ population the rates for prostate and breast cancer dropped, by 16% and 21% respectively, between 1994 and 1995 coincident with the change in cause of death coding policy. For suicide in males almost no change was observed. Hazard ratios were only negligibly affected by including the unlinked deaths. A sudden decrease in breast (21% less, 95% confidence interval: 12%-28%) and prostate (16% less, 95% confidence interval: 7%-23%) cancer mortality rates in the 85+ population coincided with the 1995 change in cause of death coding policy.

CONCLUSIONS

Unlinked deaths bias analyses of absolute mortality rates downwards but have little effect on relative mortality. To describe time trends of cause-specific mortality in the SNC, accounting for the unlinked deaths and for the possible effect of change in death certificate coding was necessary.

A cross-sectional study on socioeconomic status and health-related quality of life among elderly Chinese

OBJECTIVES

To examine the association between socioeconomic status (SES) and health-related quality of life (HRQOL) in a sample of elderly Chinese people in Hong Kong.

STUDY DESIGN

Cross-sectional study.

SETTING

18 elderly health centers in Hong Kong.

PARTICIPANTS

This study was based on a cohort aged 65 years or above who were enrolled in the Elderly Health Services from 1998 to 2005 in Hong Kong. Initially, 3324 individuals were randomly sampled from the baseline database. In the end, 2441 successful cases were obtained for the telephone survey. After excluding cases with missing SES or HRQOL information and the cases whose questionnaires were answered by their family members, 2347 individuals were included in the final analysis.

RESULTS

Elderly Chinese with less subjective economic hardship reported much better self-rated health (SRH) (OR 1.57-4.70, all p<0.01)< and higher Medical Outcomes Study short form (SF)12 scores (β 2.56-10.26, all p<0.01) than those with economic hardship. Male individuals in the highest education and occupation subgroup reported better HRQOL comparing with the baseline subgroup (OR for SRH 1.91-3.26, p<0.01; β 2.63-4.96, p<0.05). Two economic indicators, income and expenditure, only showed significant positive associations with physical SF12 scores for men (β 2.91-5.42, all p<0.05). Housing tenure was associated with SRH (OR 1.34 for men and 1.27 for women, p<0.05) but not SF12 scores.

CONCLUSIONS

Economic hardship showed the strongest association with HRQOL among all SES indicators. Educational level, occupational level and economic indicators tended to associate with physical HRQOL only among elderly Chinese men. More attention should be placed on subjective SES indicators when investigating influences on HRQOL among elderly Chinese people.

The Association Between Individual Income and Remaining Life Expectancy at the Age of 65 in the Netherlands

This article quantifies the association between individual income and remaining life expectancy at the statutory retirement age (65) in the Netherlands. For this purpose, we estimate a mortality risk model using a large administrative data set that covers the 1996–2007 period. Besides age and marital status, the model includes as covariates individual and spouse’s income as well as a random individual specific effect. It thus allows for dynamic selection based on both observed and unobserved characteristics. We find that conditional on marital status, individual income is about equally strong and negatively associated with mortality risk for men and women and that spouse’s income is only weakly associated with mortality risk for women. For both men and women, we quantify remaining life expectancy at age 65 for low-income individuals as approximately 2.5 years less than that for high-income individuals.

Educational inequalities in patient-centred care: patients' preferences and experiences

Background

Educational attainment is strongly related to specific health outcomes. The pathway in which individual patient-provider interactions contribute to (re)producing these inequalities has yet to be studied. In this article, the focus is on differences between less and more highly educated patients in their preferences for and experiences with patient-centred care., e.g. shared decision making, receiving understandable explanations and being able to ask questions.

Methods

Data are derived from several Consumer Quality-index (CQ-index) studies. The CQ-index is a family of standardized instruments which are used in the Netherlands to measure quality of care from the patient’s perspective.

Results

The educational level of patients is directly related to the degree of importance patients attribute to specific aspects of patient-centred care. It has a minor influence on the experienced level of shared decision making, but not on experiences regarding other aspects of patient-centred care.

Conclusions

All patients regard patient-centred care as important and report positive experiences. However, there is a discrepancy between patient preferences for patient-centred care on one hand and the care received on the other. Less educated patients might receive ‘too much’, and more highly educated patients ‘too little’ in the domains of communication, information and shared decision making.

Social determinants and osteoarthritis outcomes

Osteoarthritis (OA) is one of the most frequently occurring musculoskeletal diseases, posing a significant public health problem due to its impact on pain and disability. Traditional risk factors fail to account for all of the risk observed for OA outcomes. In recent years, our view of disease causation has broadened to include health risks that are created by an individual's socioeconomic circumstances. Early research into social determinants has focused on social position and explored factors related to the individual such as education, income and occupation. Results from these investigations suggest that low education attainment and nonprofessional occupation are associated with poorer arthritis outcomes. More recently, research has expanded to examine how one's neighborhood socioeconomic environment may be relevant to OA outcomes. This narrative review proposes a framework to help guide our understanding of how social context may interact with pathophysiological processes and individual-level variables to influence health outcomes in those living with OA.

Utilization of supportive and palliative care services among oncology outpatients at one academic cancer center: determinants of use and barriers to access

Abstract Background: Cancer causes significant symptom burden and diminished quality of life. Despite the expansion of supportive and palliative care services (SPCS), little is known about rates of utilization and barriers to access to these services among oncology outpatients.

METHODS

We performed a cross-sectional survey in three outpatient medical oncology clinics. Patients with a diagnosis of breast, lung, or gastrointestinal (GI) cancer and a Karnofsky score of ≥60 were included. Patients reported their use of SPCS and any perceived barriers. Multivariable logistic regression was used to identify factors associated with SPCS use.

RESULTS

Among 313 participants, (50.5%) had not used SPCS since cancer diagnosis. The most common services used were nutrition (26.5%), psychiatric/psychological counseling (29.7%), and physical therapy (15.1%). Pain/palliative care and cancer rehabilitation consultations were used by 8.5% and 4.1% of participants, respectively. In multivariate analysis, graduate education was associated with greater SPCS use (adjusted odds ratio [AOR] 2.14, 95% confidence interval [CI] 1.08-4.26) compared with those with high school or less, whereas having lung cancer was associated with less SPCS use (AOR 0.48, 95% CI 0.24-0.96) when compared with those having breast cancer. The biggest reported barriers to using SPCS were a lack of awareness (22.4%) and lack of physician referral (23%).

CONCLUSIONS

Approximately half of these patients had not accessed SPCS since cancer diagnosis and cite lack of awareness and physician nonreferral as barriers. Further research is needed to understand patients' needs and beliefs regarding SPCS, and how to integrate SPCS into conventional treatments to improve cancer care.

Changes in contribution of causes of death to socioeconomic mortality inequalities in Korean adults

Objectives

This study aimed to analyze long-term trends in the contribution of each cause of death to socioeconomic inequalities in all-cause mortality among Korean adults.

Methods

Data were collected from death certificates between 1990 and 2004 and from censuses in 1990, 1995, and 2000. Age-standardized death rates by gender were produced according to education as the socioeconomic position indicator, and the slope index of inequality was calculated to evaluate the contribution of each cause of death to socioeconomic inequalities in all-cause mortality.

Results

Among adults aged 25-44, accidental injuries with transport accidents, suicide, liver disease and cerebrovascular disease made relatively large contributions to socioeconomic inequalities in all-cause mortality, while, among adults aged 45-64, liver disease, cerebrovascular disease, transport accidents, liver cancer, and lung cancer did so. Ischemic heart disease, a very important contributor to socioeconomic mortality inequality in North America and Western Europe, showed a very low contribution (less than 3%) in both genders of Koreans.

Conclusions

Considering the contributions of different causes of death to absolute mortality inequalities, establishing effective strategies to reduce socioeconomic inequalities in mortality is warranted.

The effectiveness of a motivational interviewing primary-care based intervention on physical activity and predictors of change in a disadvantaged community

Little research exists on the impact of behavior change interventions in disadvantaged communities. We conducted a prospective study to explore the effectiveness of motivational interviewing on physical activity change within a deprived community and the social- psychological and motivational predictors of change in physical activity including stage of change, self-efficacy, social support, and variables from self-determination theory and the theory of planned behavior. Five motivational interviewing counsellors recruited 207 patients and offered motivational interviewing sessions to support physical activity behavior change. At 6-months there were significant improvements in physical activity, stage of change, and social support. A dose-response relationship was evident; those who attended 2 or more consultations increased their total physical activity, stage of change and family social support more than those who attended just one. Hierarchical regression analyses indicated that number of sessions and change in stage of change predicted 28.4% of the variance in change in total physical activity and, with social support from friends, 21.0% of the variance in change walking time. Change in perceived behavioral control and attitudes, friend social support, and number of sessions predicted 16.8% of the variance in change in vigorous physical activity. Motivational interviewing is an effective approach for promoting physical activity amongst lower socio-economic status groups in the short term. The study demonstrates good translational efficacy, and contributes to a limited number of physical activity interventions targeting low income groups in the UK.

The contribution of educational inequalities to lifespan variation

Background

Studies of socioeconomic inequalities in mortality consistently point to higher death rates in lower socioeconomic groups. Yet how these between-group differences relate to the total variation in mortality risk between individuals is unknown.

Methods

We used data assembled and harmonized as part of the Eurothine project, which includes census-based mortality data from 11 European countries. We matched this to national data from the Human Mortality Database and constructed life tables by gender and educational level. We measured variation in age at death using Theil's entropy index, and decomposed this measure into its between- and within-group components.

Results

The least-educated groups lived between three and 15 years fewer than the highest-educated groups, the latter having a more similar age at death in all countries. Differences between educational groups contributed between 0.6% and 2.7% to total variation in age at death between individuals in Western European countries and between 1.2% and 10.9% in Central and Eastern European countries. Variation in age at death is larger and differs more between countries among the least-educated groups.

Conclusions

At the individual level, many known and unknown factors are causing enormous variation in age at death, socioeconomic position being only one of them. Reducing variations in age at death among less-educated people by providing protection to the vulnerable may help to reduce inequalities in mortality between socioeconomic groups.

Prognostic impact of education level of patients with advanced non-small cell lung cancer enrolled in clinical trials

BACKGROUND

Socioeconomic status can potentially affect prognosis of cancer patients. Our aim was to describe potential differences in demographic and clinical characteristics, treatment, and survival by education level in patients with advanced non-small cell lung cancer (NSCLC) enrolled in clinical trials of first-line treatment.

METHODS

Individual data of Italian patients with advanced NSCLC (stage IV, or IIIB with supraclavicular nodes or malignant pleural effusion), ECOG performance status (PS) 0-2, enrolled in four phase III randomized trials conducted between 1996 and 2005 were pooled. Information about education was available for 1680 of 1709 patients (98.3%). Patients were divided in two groups according to education level: high (patients with at least high school diploma) or low (those with less than high school diploma). Survival analyses were stratified by treatment arm within trial.

RESULTS

There were 312 (19%) and 1368 (81%) patients with high and low education, respectively. Education level was significantly different among birth cohorts, with a time-trend toward higher education level. Patients with high education were significantly younger (median age 65 vs. 70), were less frequently unfit at diagnosis (ECOG PS2 5% vs. 16%), and their tumor type was more frequently adenocarcinoma (47% vs. 37%). Number of treatment cycles received was not significantly different between education groups. Median survival was 9.4 and 7.6 months in high and low education, respectively (p=0.012). At multivariable analysis, female sex, better PS and high education level (Hazard Ratio 0.85, 95%CI 0.73-0.99, p=0.03) were independently associated with longer survival.

CONCLUSIONS

In Italian patients enrolled in four randomized trials of first-line chemotherapy for advanced NSCLC, high education was significantly more frequent among younger patients, and was associated with lower proportion of PS2 patients. Education level did not significantly affect number of chemotherapy cycles received. Overall survival was longer in patients with high education, after adjustment for PS and other prognostic factors. The exact underlying mechanisms of the independent prognostic role of education level are substantially unknown, but lead-time bias (anticipation in diagnosis and time to inclusion in the trial), differences in adherence to care outside the trial procedures, differences in comorbidities and life-style factors may all contribute.

Mortality among adults: gender and socioeconomic differences in a Brazilian city

Background

Population groups living in deprived areas are more exposed to several risk factors for diseases and injuries and die prematurely when compared with their better-off counterparts. The strength and patterning of the relationships between socioeconomic status and mortality differ depending on age, gender, and diseases or injuries. The objective of this study was to identify the magnitude of social differences in mortality among adult residents in a city of one million people in Southeastern Brazil in 2004-2008.

Methods

Forty-nine health care unit areas were classified into three homogeneous strata using 2000 Census small-area socioeconomic indicators. Mortality rates by age group, sex, and cause of death were calculated for each socioeconomic stratum. Mortality rate ratios (RR) and 95% confidence intervals were estimated for the low and middle socioeconomic strata compared with the high stratum.

Results

In general, age-specific mortality rates showed a social gradient of increasing risks of death with decreasing socioeconomic status. The highest mortality rate ratios between low and high strata were observed in the 30-39 age group for males (RR = 1.74, 95% CI 1.59-1.89), and females (RR = 1.90, 95% CI 1.65-2.15). Concerning specific diseases and injuries, the greatest inequalities between low and high strata were found for homicides (RR = 2.44, 95% CI 2.27-2.61) and traffic accidents (RR = 1.64, 95% CI 1.45-1.83) among males. For women, the highest inequalities between the low and high strata were for chronic respiratory diseases (RR = 2.19, 95% CI 1.94-2.45) and acute myocardial infarction (RR = 1.93, 95% CI 1.79-2.07). Only breast cancer showed a reversed social gradient (RR = 0.70, 95% CI 0.48-0.92). Inequalities in circulatory and respiratory diseases mortality were greater among females than among males.

Conclusions

Substandard living conditions are related to unhealthy behaviors, as well as difficulties in accessing health care. Therefore, the Brazilian Health System (SUS) must ensure greater access to primary and hospital care, and develop programs that promote healthier lifestyles among vulnerable groups to reduce social inequalities in mortality. Moreover, because deaths from external causes are concentrated in poor areas, cooperative and coordinated intersectoral actions should be taken to combat the deadly violence cycle.

Hypertension prevalence, awareness, treatment and control, and associated factors: results from a national survey, jordan

The study examined prevalence, awareness, treatment and control of hypertension (HTN), and associated factors and to evaluate the trend in hypertension between 2009 (period 2) and 1994-1998 (period 1). A national sample of 4117 adults aged 25 years and older was selected. Prevalence rate of HTN (SBP ≥ 140 or DBP ≥ 90 or on antihypertensive therapy) was 32.3% and was higher than the 29.4% prevalence rate reported in period 1. Prevalence rate was significantly higher among males, older age groups, least educated, obese, and diabetics than their counterparts. The rate of awareness among hypertensives was 56.1% and was higher than the 38.8% rate reported form period 1 data. Awareness was positively associated with age, smoking, and diabetes for both men and women, and with level of education and body mass index for men. Rate of treatment for HTN among aware patients was 63.3% and was significantly higher than the 52.8% rate reported in period1. Control rate of HTN among treated hypertensives was 39.6%; significantly higher than the 27.9% control rate in period 1. Control of HTN was positively associated with age but only for women. In conclusion, HTN is still on the rise in Jordan, and levels of awareness and control are below the optimal levels.

Incidence and lifetime risk of dementia and Alzheimer's disease in a Southern European population

OBJECTIVE

To calculate both the incidence rates and the lifetime risk (LTR) of dementia and Alzheimer's disease (AD).

METHODS

A two-phase case-finding procedure was implemented in a cohort of 4057 cognitively intact individuals 55+ years of age living in Zaragoza, Spain, and followed-up at 2.5 and 4.5 years. Age- and sex-specific incidence rates were calculated. A mortality-adjusted, multivariate model was used to document LTRs.

RESULTS

The incidence rate of dementia continued to rise after the age of 90 years, but was slightly lower than in North and West European studies. Only a tendency for an increased LTR with age was observed. Thus, LTR was 19.7% for a 65-year-old woman and 20.4% at the age of 85 years, the corresponding figures for AD being 16.7% and 17.6%. The LTR of AD was higher in women and was about twice as high among illiterate individuals when compared with individuals with higher educational levels.

CONCLUSIONS

The incidence rate of dementia in this Southern European city was slightly lower than in previous studies in North-West Europe. LTR of dementia and AD seems to be slightly increased with age. The association of illiteracy with higher LTR of AD is intriguing.

Inequalities in utilisation of general practitioner and specialist services in 9 European countries

Background

The aim of this study is to describe the magnitude of educational inequalities in utilisation of general practitioner (GP) and specialist services in 9 European countries. In addition to West European countries, we have included 3 Eastern European countries: Hungary, Estonia and Latvia. To cover the gap in knowledge we pay a special attention to the magnitude of inequalities among patients with chronic conditions.

Methods

Data on the use of GP and specialist services were derived from national health surveys of Belgium, Estonia, France, Germany, Hungary, Ireland, Latvia, the Netherlands and Norway. For each country and education level we calculated the absolute prevalence and relative inequalities in utilisation of GP and specialist services. In order to account for the need for care, the results were adjusted by the measure of self-assessed health.

Results

People with lower education used GP services equally often in most countries (except Belgium and Germany) compared with those with a higher level of education. At the same time people with a higher education used specialist care services significantly more often in all countries, except in the Netherlands. The general pattern of educational inequalities in utilisation of specialist care was similar for both men and women. Inequalities in utilisation of specialist care were equally large in Eastern European and in Western European countries, except for Latvia where the inequalities were somewhat larger. Similarly, large inequalities were found in the utilisation of specialist care among patients with chronic diseases, diabetes, and hypertension.

Conclusions

We found large inequalities in the utilisation of specialist care. These inequalities were not compensated by utilisation of GP services. Of particular concern is the presence of inequalities among patients with a high need for specialist care, such as those with chronic diseases.

Poverty, hunger, education, and residential status impact survival in HIV

Despite combination antiretroviral therapy (ART), HIV infected people have higher mortality than non-infected. Lower socioeconomic status (SES) predicts higher mortality in many chronic illnesses but data in people with HIV is limited. We evaluated 878 HIV infected individuals followed from 1995 to 2005. Cox proportional hazards for all-cause mortality were estimated for SES measures and other factors. Mixed effects analyses examined how SES impacts factors predicting death. The 200 who died were older, had lower CD4 counts, and higher viral loads (VL). Age, transmission category, education, albumin, CD4 counts, VL, hunger, and poverty predicted death in univariate analyses; age, CD4 counts, albumin, VL, and poverty in the multivariable model. Mixed models showed associations between (1) CD4 counts with education and hunger; (2) albumin with education, homelessness, and poverty; and (3) VL with education and hunger. SES contributes to mortality in HIV infected persons directly and indirectly, and should be a target of health policy in this population.

Height gain during early childhood is an important predictor of schooling and mathematics ability outcomes

AIM

To examine the association between height gain at different stages of early childhood and schooling and cognitive outcomes in 12-year-old Malawian children.

METHODS

A prospective cohort study looking at the growth and development of 325 rural Malawian children. Main outcome measures were highest school grade completed, number of times repeating grades and percentage of correctly answered mathematical questions at 12 years of age. Height-for-age at 1 month and conditional height gain for 6, 18 and 60 months were used as predictors. Ordinal logistic and linear regression analyses were used to estimate the association and adjust for confounder.

RESULTS

The conditional height gain during 18-60 months was positively associated with mathematics test results (p=0.003) and negatively associated with number of times repeating grades (p=0.011). It was not significantly associated with highest grade completed (p=0.194) if those who never attended school were included as having completed zero grade, but was positively (p=0.049) associated with this outcome among those who ever attended school.

CONCLUSION

Height gain during the 18-60 months period of age was related to schooling and mathematics ability at age 12 years. The importance of promoting catch-up growth after the period when stunting is common should receive attention.

Could clinical decision rules relying on cardiovascular risk models increase psychosocial inequalities in health? Results from the PRIME cohort study

OBJECTIVE

Guidelines on cardiovascular prevention relying on common cardiovascular risk scoring could result in delayed drug therapy for patients with low psychosocial status because of underestimation of true cardiovascular risk. We aimed to assess the potential delay in drug therapy for subjects with adverse psychosocial factors.

METHOD

The study population consisted of 6185 French men from the PRIME (Prospective Epidemiological Study of Myocardial Infarction) cohort study (1991-2003). The number of extra years to reach a risk threshold for subjects without adverse psychosocial factor compared to subject with adverse psychosocial factor was estimated using a coronary risk model including biomedical factors and a psychosocial variable (education, occupation, living conditions or a depression score).

RESULTS

Coronary risk was significantly higher only for subjects with a high depression score (odds ratio=1.34; 95% confidence interval 1.04, 1.72) or low educational attainment (odds ratio=1.39; 95% confidence interval=1.07, 1.81). For a given risk threshold, subjects with high depression scores were 4.5 years (95% confidence interval=0.0, 15.4 years) younger than subjects with low depression scores. The age difference was 4.1 years (95% confidence interval=-0.5, 15.8 years) between subjects with low and high educational attainment.

CONCLUSION

Clinical decision rules relying on classic cardiovascular risk scoring could result in delayed drug therapy for patients with depression or low educational attainment.

Disability and satisfaction after rotator cuff decompression or repair: a sex and gender analysis

Background

Rotator-cuff pathology is the most common cause of pain and disability in the shoulder. Examining the combined effect of biological and societal factors on disability would potentially identify existing differences between men and women with rotator cuff pathology which would help to provide suggestions for better models of care. Purpose of this study was to determine the overall differences in disability between men and women and to examine the relationship between factors that represent sex (biological factors) and gender (non-biological factors) with disability and satisfaction with surgical outcome 6 months after rotator cuff surgery.

Methods

Patients with impingement syndrome and/or rotator cuff tear who underwent rotator cuff surgery completed the Western Ontario Rotator Cuff (WORC) index, the American Shoulder & Elbow Surgeons (ASES) assessment form, and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) outcome measures prior to surgery and 6 months post-operatively. They also rated their satisfaction with surgery at their follow-up appointment.

Results and Discussion

One hundred and seventy patients entered into the study (85 men and 85 women). One hundred and sixty patients (94%) completed the 6-month assessment. Women reported more disability both prior to and after surgery. Disability at 6 months was associated with pain-limited range of motion, participation limitation, age and strength. Satisfaction with surgery was associated with level of reported disability, expectations for improved pain, pain-limited range of motion and strength.

Conclusions

The results of this study indicate that women with rotator cuff pathology suffer from higher levels of pre- and post-operative disability and sex and gender qualities contribute to these differences. Gender-sensitive approach will help to identify existing differences between men and women which will help to promote more effective and tailored care by health professionals.

The contribution of psychological distress to socio-economic differences in cause-specific mortality: a population-based follow-up of 28 years

BACKGROUND

Psychological factors associated with low social status have been proposed as one possible explanation for the socio-economic gradient in health. The aim of this study is to explore whether different indicators of psychological distress contribute to socio-economic differences in cause-specific mortality.

METHODS

The data source is a nationally representative, repeated cross-sectional survey, "Health Behaviour and Health among the Finnish Adult Population" (AVTK). The survey results were linked with socio-economic register data from Statistics Finland (from the years 1979-2002) and mortality follow-up data up to 2006 from the Finnish National Cause of Death Register. The data included 32,451 men and 35,420 women (response rate 73.5%). Self-reported measures of depression, insomnia and stress were used as indicators of psychological distress. Socio-economic factors included education, employment status and household income. Mortality data consisted of unnatural causes of death (suicide, accidents and violence, and alcohol-related mortality) and coronary heart disease (CHD) mortality. Adjusted hazard ratios were calculated using the Cox regression model.

RESULTS

In unnatural mortality, psychological distress accounted for some of the employment status (11-31%) and income level (4-16%) differences among both men and women, and for the differences related to the educational level (5-12%) among men; the educational level was associated statistically significantly with unnatural mortality only among men. Psychological distress had minor or no contribution to socio-economic differences in CHD mortality.

CONCLUSIONS

Psychological distress partly accounted for socio-economic disparities in unnatural mortality. Further studies are needed to explore the role and mechanisms of psychological distress associated with socio-economic differences in cause-specific mortality.

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.

Work ability in midlife as a predictor of mortality and disability in later life: a 28-year prospective follow-up study

BACKGROUND

Poor work ability correlates with increased morbidity and early retirement from the workforce, but the association in old age is not known. We investigated work ability in midlife among white-collar and blue-collar employees as a predictor of mortality and disability 28 years later.

METHODS

A total of 5971 occupationally active people aged 44-58 years participated in the Finnish Longitudinal Study of Municipal Employees (FLAME) in 1981. Perceived work ability relative to lifetime best was categorized as excellent, moderate or poor. In 2009, the ability to perform activities of daily living was assessed among 2879 respondents (71.0% of the survivors). Mortality data were available up to July 2009.

RESULTS

At the 28-year follow-up, 1918 of the 5971 participants had died and 1403 had some form of disability. Rates of death per 1000 person-years among white-collar men were 7.7 for those with excellent work ability, 14.7 for those with moderate work ability and 23.5 for those with poor work ability. Among blue-collar men, the corresponding rates were 15.5, 20.2 and 25.3. In women, rates ranged between 6.3 and 10.6 per 1000 person-years. The age-adjusted hazard ratios (HRs) for mortality were two to three times higher among blue-collar male employees with lower work ability than among white-collar male employees with excellent work ability in midlife (i.e., the reference group). The odds of death or disability at follow-up compared with white-collar workers with excellent work ability were highest among blue-collar employees with poor work ability in midlife (odds ratio [OR] 4.56, 95% confidence interval [CI] 2.82-7.37 for men; OR 3.37, 95% CI 2.28-4.98 for women). Among the survivors, similar but slightly lower risks of disability 28 years later were found.

INTERPRETATION

Perceived poor work ability in midlife was associated with accelerated deterioration in health and functioning and remains evident after 28 years of follow-up.

Socioeconomic factors, ethnicity and alcohol-related mortality in regions in Slovakia. What might a tree analysis add to our understanding?

Regional differences in alcohol-related mortality might reflect strong socioeconomic differences between regions. The present study examines the contribution of education, unemployment, income and minority proportion on regional differences in alcohol-related mortality for inhabitants aged 20-64 years. Linear regression analysis and a non-parametric regression tree analysis were used separately for males and females. The unemployment rate and low education appeared as important determinants of regional alcohol-related mortality, while the proportion of Roma and income were not significantly associated with alcohol-related mortality among males in Slovak districts. A district's unemployment rate was assumed to be the strongest predictor of the outcome measure.

Intelligence in youth and all-cause-mortality: systematic review with meta-analysis

BACKGROUND

A number of prospective cohort studies have examined the association between intelligence in childhood or youth and life expectancy in adulthood; however, the effect size of this association is yet to be quantified and previous reviews require updating.

METHODS

The systematic review included an electronic search of EMBASE, MEDLINE and PSYCHINFO databases. This yielded 16 unrelated studies that met inclusion criteria, comprising 22,453 deaths among 1,107,022 participants. Heterogeneity was assessed, and fixed effects models were applied to the aggregate data. Publication bias was evaluated, and sensitivity analyses were conducted.

RESULTS

A 1-standard deviation (SD) advantage in cognitive test scores was associated with a 24% (95% confidence interval 23-25) lower risk of death, during a 17- to 69-year follow-up. There was little evidence of publication bias (Egger's intercept = 0.10, P = 0.81), and the intelligence-mortality association was similar for men and women. Adjustment for childhood socio-economic status (SES) in the nine studies containing these data had almost no impact on this relationship, suggesting that this is not a confounder of the intelligence-mortality association. Controlling for adult SES in five studies and for education in six studies attenuated the intelligence-mortality hazard ratios by 34 and 54%, respectively.

CONCLUSIONS

Future investigations should address the extent to which attenuation of the intelligence-mortality link by adult SES indicators is due to mediation, over-adjustment and/or confounding. The explanation(s) for association between higher early-life intelligence and lower risk of adult mortality require further elucidation.

Self-reported cardiovascular risk factors in immigrants and Swiss nationals

OBJECTIVE

The purpose of this study was to investigate whether the prevalence of self-reported cardiovascular risk factors differs between immigrants and Swiss nationals.

DESIGN AND SAMPLE

This study is a secondary data analysis of the Swiss Health Survey 2002, a cross-sectional survey. In total, 19,249 individuals living in Switzerland were included.

MEASURES

The prevalence of hypertension, high cholesterol level, smoking, diabetes, overweight, low fruit and vegetable intake, and physical inactivity were calculated for major immigrant groups and Swiss nationals. Demographic data were used to control for age and socioeconomic status.

RESULTS

Major immigrant groups were people from Italy, Germany, former Yugoslavia, Spain, Portugal, France, and Turkey. Compared with Swiss women, women from former Yugoslavia were more likely to have hypertension, and women from Germany were more likely to have high cholesterol levels. Women from Italy, former Yugoslavia, Spain, Portugal, and Turkey were more likely to show physical inactivity and (except Turkish women) to be overweight. Men from these countries (except Spanish men) were more likely to be overweight than Swiss men.

CONCLUSIONS

Differences exist in the prevalence of modifiable cardiovascular risk factors between Swiss nationals and many of the immigrant groups. Age and socioeconomic status could only partly explain the differences.

To What Extent Do Age, Period, and Cohort Patterns Account for Time Trends and Social Inequalities in Smoking?

Aims: This paper evaluates nonconfounded and independent age, period, and cohort effects on time trends and social disparities in smoking behavior. Methods: Data from nine waves of the German Epidemiological Survey of Substance Abuse (ESA) conducted between 1980 and 2009 were used. A total of N = 73,782 individuals aged 18 and older were included in the analyses. Using cross-classified random-effects models, fixed effects of age (level 1) as well as random effects of periods and cohorts (level 2) on 30-day smoking prevalence and average number of cigarettes per day were estimated. Analyses were stratified by socioeconomic status (SES). Results: Independent of SES, positive and curvilinear age effects emerged. Prevalence and amount of smoking declined sharply over time and revealed an inversion of the social gradient in 2003. This was due to a stronger decrease of smoking in the highest SES group compared to the other groups. Cohort effects were nonlinear and inconsistent. Conclusion: The emergence of increasing social disparities in smoking implies the need to specifically address the situation of low-SES groups when developing tobacco control measures.

Healthy and unhealthy migrant effect on the mortality of immigrants from wealthy countries residing in Spain

This study attempts to identify the possible existence of a healthy migrant effect and an unhealthy migrant effect on the mortality of immigrants from wealthy countries who move to Spain. Immigrants aged 35-64 years from France, Germany, Great Britain and 16 other wealthy OECD countries who resided in Spain were compared with respect to: (1) mortality from cancer, cardiovascular disease, and all other diseases and (2) employment status, duration of residence, and educational level, in two geographic areas: the "preferred destination area"-the Mediterranean coast, Balearic Islands and Canary Islands-and the rest of Spain. In general, cancer mortality was lower and mortality from cardiovascular disease was higher in immigrants who resided in the preferred destination area than in their countries of origin and than in immigrants who resided in the rest of Spain. Immigrants in the preferred destination area had a higher percentage of retired persons, longer time of residence and a lower percentage of persons with university education. The largest differences between the two areas in cardiovascular and all-disease mortality and in the frequency of the aforementioned sociodemographic characteristics were observed in British immigrants and those from the 16 OECD countries. Possible explanations for these findings are suggested which are compatible with the presence of an unhealthy and/or healthy immigrant bias in the two areas.

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.

Do Measured and Unmeasured Family Factors Bias the Association Between Education and Self-Assessed Health?

The association between educational attainment and self-assessed health is well established but the mechanisms that explain this association are not fully understood yet. It is likely that part of the association is spurious because (genetic and non-genetic) characteristics of a person's family of origin simultaneously affect one's educational attainment and one's adult health. In order to obtain an unbiased estimate of the association between education and health, we have to control for all relevant family factors. In practice, however, it is impossible to measure all relevant family factors. Sibling models are particularly appropriate in this case, because they control for the total impact of family factors, even if not all relevant aspects can be measured. I use data on siblings from a US study (MIDUS) and Dutch study (NKPS) to assess the total family impact on self-assessed health and, more importantly, to assess whether there is a family bias in the association between educational attainment and self-assessed health. The results suggest that there is a substantial family effect; about 20% of the variation in self-assessed health between siblings can be ascribed to (measured and unmeasured) family factors. Measured family factors, such as parental education and father's occupation, could account only for a small part of the family effect. Furthermore, the results imply that it is unlikely that there is substantial bias due to family effects in the association between education and self-assessed health. This strengthens the conclusions from prior studies on the association between education and self-assessed health.

Determinants of health disparities between Italian regions

Background

Among European countries, Italy is one of the countries where regional health disparities contribute substantially to socioeconomic health disparities. In this paper, we report on regional differences in self-reported poor health and explore possible determinants at the individual and regional levels in Italy.

Methods

We use data from the "Indagine Multiscopo sulle Famiglie", a survey of aspects of everyday life in the Italian population, to estimate multilevel logistic regressions that model poor self-reported health as a function of individual and regional socioeconomic factors. Next we use the causal step approach to test if living conditions, healthcare characteristics, social isolation, and health behaviors at the regional level mediate the relationship between regional socioeconomic factors and self-rated health.

Results

We find that residents living in regions with more poverty, more unemployment, and more income inequality are more likely to report poor health and that poor living conditions and private share of healthcare expenditures at the regional level mediate socioeconomic disparities in self-rated health among Italian regions.

Conclusion

The implications are that regional contexts matter and that regional policies in Italy have the potential to reduce health disparities by implementing interventions aimed at improving living conditions and access to quality healthcare.