Pathways between socioeconomic determinants of health

Socioeconomic circumstances and common mental disorders among Finnish and British public sector employees: evidence from the Helsinki Health Study and the Whitehall II Study

BACKGROUND

Common mental disorders do not always show as consistent socioeconomic gradients as severe mental disorders and physical health. This inconsistency may be due to the multitude of socioeconomic measures used and the populations and national contexts studied. We examine the associations between various socioeconomic circumstances and common mental disorders among middle-aged Finnish and British public sector employees.

METHODS

We used survey data from the Finnish Helsinki Health Study (n = 6028) and the British Whitehall II Study (n = 3116). Common mental disorders were measured by GHQ-12. The socioeconomic indicators were parental education, childhood economic difficulties, own education, occupational class, household income, housing tenure and current economic difficulties. Logistic regression analysis was the main statistical method used.

RESULTS

Childhood and current economic difficulties were strongly associated with common mental disorders among men and women in both the Helsinki and the London cohort. The more conventional indicators of socioeconomic circumstances showed weak or inconsistent associations. Differences between the two cohorts and two genders were small.

CONCLUSIONS

Our findings emphasize the importance of past and present economic circumstances to common mental disorders across different countries and genders. Overall, our results suggest that among employee populations, the socioeconomic patterning of common mental disorders may differ from that of other domains of health.

Social determinants of the health of urban populations: methodologic considerations

A full understanding of the role of the urban environment in shaping the health of populations requires consideration of different features of the urban environment that may influence population health. The social environment is key to understanding the way in which cities affect the health of populations. Social determinants of health (SDH) are important, generally, yet can have different effects in different settings from urban to rural, between countries, between cities, and within cities. Failure to acknowledge, and more importantly, to understand the role of SDH in health and access to health and social services will hamper any effort to improve the health of the population. In this paper, we will briefly summarize a few key SDH and their measurement. We will also consider methodologic tools and some methodologic challenges. The concepts presented here are broadly applicable to a variety of settings: developed and developing countries, slum areas, inner cities, middle income neighborhoods, and even higher income neighborhoods. However, our focus will be on some of the more vulnerable urban populations who are most profoundly affected by SDH.

Differences in self-reported health among Asians, Latinos, and non-Hispanic whites: the role of language and nativity

PURPOSE

Self-reported overall health (SROH) is often used to compare the health status of multi-ethnic populations in the United States. SROH may not be comparable across cultural groups. We assessed if differences in SROH between non-Hispanic whites (NHW), Latinos, and Asians were explained primarily by differences in socioeconomic status (SES) or language and nativity.

METHODS

We used cross-sectional data on 36,660 NHW, 9399 Latinos, 1298 Chinese, 944 Filipinos, 803 Koreans, 857 Vietnamese, and 1036 "other Asians" from the 2001 California Health Interview Survey.

RESULTS

Compared with NHW, all ethnic groups were less likely to report "excellent" or "very good" health. Latinos, Chinese, Filipinos, Koreans, and Vietnamese were also more likely to report "fair" or "poor" health. Adjusting for SES attenuated these differences for Latinos but did not explain the effect of being Asian on SROH. Among all ethnicities, individuals with limited English proficiency had worse SROH than individuals who were English-proficient.

CONCLUSIONS

Differences in SROH between Asians and NHW do not appear to be mediated by SES and may be due to different perceptions of health that are rooted in culture and language. There remains a need for health status measures less susceptible to cultural bias in Asian and Latino populations.

Giving everyone the health of the educated: an examination of whether social change would save more lives than medical advances

OBJECTIVES

Social determinants of health, such as inadequate education, contribute greatly to mortality rates. We examined whether correcting the social conditions that account for excess deaths among individuals with inadequate education might save more lives than medical advances (e.g., new drugs and devices).

METHODS

Using US vital statistics data for 1996 through 2002, we applied indirect standardization techniques to estimate the maximum number of averted deaths attributable to medical advances and the number of deaths that would have been averted if mortality rates among adults with lesser education had been the same as those among college-educated adults.

RESULTS

Medical advances averted a maximum of 178193 deaths during the study period. Correcting disparities in education-associated mortality rates would have saved 1369335 lives during the same period, a ratio of 8:1.

CONCLUSIONS

Higher mortality rates among individuals with inadequate education reflect a complex causal pathway and the influence of confounding variables. Formidable efforts at social change would be necessary to eliminate disparities, but the changes would save more lives than would society's current heavy investment in medical advances. Spending large sums of money on such advances at the expense of social change may be jeopardizing public health.

Socioeconomic position and the risk of gastric and oesophageal cancer in the European Prospective Investigation into Cancer and Nutrition (EPIC-EURGAST)

OBJECTIVES

To evaluate the association of socioeconomic position with adenocarcinoma of the oesophagus and stomach.

METHODS

The European Prospective Investigation into Cancer and Nutrition (EPIC) cohort comprises about 520 000 participants mostly aged 35-70 years. Information on diet and lifestyle was collected at recruitment. After an average follow-up of 6.5 years, 268 cases with adenocarcinoma of the stomach and 56 of the oesophagus were confirmed. We examined the effect of socioeconomic position on cancer risk by means of educational data and a computed Relative Index of Inequality (RII). In a nested case-control study, adjustment for Helicobacter pylori (H. pylori) infection was performed.

RESULTS

Higher education was significantly associated with a reduced risk of gastric cancer [vs lowest level of education, hazard ratio (HR): 0.64, 95% Confidence intervals (CI): 0.43-0.98]. This effect was more pronounced for cancer of the cardia (HR: 0.42, 95% CI: 0.20-0.89) as compared to non-cardia gastric cancer (HR: 0.66, 95% CI: 0.36-1.22). Additionally, the inverse association of educational level and gastric cancer was stronger for cases with intestinal (extreme categories, HR: 0.13, 95% CI: 0.04-0.44) rather than diffuse histological subtype (extreme categories, HR: 0.71 95% CI: 0.37-1.40). In the nested case-control study, inverse but statistically non-significant associations were found after additional adjustment for H. pylori infection [highest vs lowest level of education: Odds ratio (OR) 0.53, 95% CI: 0.24-1.18]. Educational level was non-significantly, inversely associated with carcinoma of the oesophagus.

CONCLUSION

A higher socioeconomic position was associated with a reduced risk of gastric adenocarcinoma, which was strongest for cardia cancer or intestinal histological subtype, suggesting different risk profiles according to educational level. These effects appear to be explained only partially by established risk factors.

Multiple socio-economic circumstances and healthy food habits

OBJECTIVE

To examine associations between seven indicators of socio-economic circumstances and healthy food habits, while taking into account assumed temporal order between these socio-economic indicators.

DESIGN AND SETTING

Data were derived from cross-sectional postal questionnaires in 2000-2002. Socio-economic circumstances were assessed by parental education, childhood economic difficulties, own education, occupational class, household income, home ownership and current economic difficulties. Healthy food habits were measured by an index consisting of consumption of fresh vegetables, fruit or berries, rye bread, fish and choosing vegetable fats on bread and oil in cooking. Sequential logistic regression models were used, adjusting for age and marital status.

PARTICIPANTS

Employees of the City of Helsinki, Finland (n=8960, aged 40-60 years).

RESULTS

Healthy food habits were reported by 28% of women and by 17% of men. Own education, occupational class, household income, home ownership and current economic difficulties were associated with healthy food habits. These associations were attenuated but mainly remained after mutual adjustments for the socio-economic indicators. Among women, a pathway was found suggesting that part of the effects of education on food habits were mediated through occupational class.

CONCLUSIONS

Employees in higher and lower socio-economic positions differ in their food habits, and those in lower positions and economically disadvantaged are less likely to report healthy food habits. Health promotion programmes and food policies should encourage healthier food choices among those in lower socio-economic positions and among those with economic difficulties in particular.

Provincial income inequality and self-reported health status in China during 1991-7

BACKGROUND

The relationship between income inequality and health has been widely explored. Today there is some evidence suggesting that good health is inversely related to income inequality. After the economic reforms initiated in the early 1980s, China experienced one of the fastest-growing income inequalities in the world. The state of China in the 1990s is focussed on and possible effects of provincial income inequality on individual health status are explored.

METHODS

A multilevel regression model is used to analyse the data collected in 1991, 1993 and 1997 from nine provinces included in the China Health and Nutrition Survey. The effects of provincial Gini coefficients on self-rated health in each year are evaluated by two logistic regressions estimating the odds ratios of reporting poor or fair health. The patterns of this effect are compared among the survey years and also among different demographic groups.

RESULTS

The analyses show an independent effect of income inequality on self-reported health after adjusting for individual and household variables. Furthermore, the effect of income distribution is not attenuated when household income and provincial gross domestic product per capita are included in the model. The results show that there is an increased risk of about 10-15% on average for fair or poor health for people living in provinces with greater income inequalities compared with provinces with modest income inequalities.

CONCLUSIONS

In China, societal income inequality appears to be an important determinant of population health during 1991-7.

Self-rated life expectancy and lifetime socio-economic position: cross-sectional analysis of the British household panel survey

BACKGROUND

The association between mortality risk and socio-economic position (SEP) across the lifecourse is established. This study investigates whether people's own ratings of their life expectancy are also associated with lifetime SEP. Health behaviour messages, which often emphasize the long-term benefits of behavioural change, may be received differently depending on people's perceptions of their life chances.

METHODS

Cross-sectional analysis of 4780 adults aged 25-64 interviewed in the British Household Panel Survey in 2001.

RESULTS

Just under a quarter of respondents did not think it likely they would live to 75 or older. People in lower SEPs were more likely to be pessimistic about their life expectancy. This applied across a number of socio-economic measures (father's social class, educational achievement, own social class, and household income). Eight socio-economic lifecourse pathways were compared. In comparison to those following the most advantaged pathway, those experiencing sustained socio-economic disadvantage were most likely to be pessimistic about their longevity, but those experiencing sustained upward mobility did not differ. Comparisons with measures of self-rated general health and limiting illness suggest that self-rated life expectancy is at least partially independent of current health status.

CONCLUSIONS

This study shows that people's own perceptions of their life expectancy are associated with lifetime SEP. Self-rated life expectancy, in part, appears to reflect something over and above current health status and smoking behaviour. Given its ease of collection, it would be informative to include self-rated life expectancy in future studies.

Mortality after acute myocardial infarction according to income and education

OBJECTIVE

To study how income and educational level influence mortality after acute myocardial infarction (AMI).

DESIGN AND SETTING

Prospective analysis using individual level linkage of registries in Denmark.

PARTICIPANTS

All patients 30-74 years old hospitalised for the first time with AMI in Denmark in 1995-2002.

MAIN OUTCOME MEASURES

Relative risk (RR) of 30 day mortality and long term mortality (31 days until 31 December 2003) associated with income (adjusted for education) or educational level (adjusted for income) and further adjusted for sex, age, civil status, and comorbidity.

RESULTS

The study identified 21 391 patients 30-64 years old and 16 169 patients 65-74 years old. The 30 day mortality was 7.0% among patients 30-64 years old and 15.9% among those 65-74 years old. Among patients surviving the first 30 days, the long term mortality was 9.9% and 28.3%, respectively. The adjusted RR of 30 day mortality and long term mortality among younger patients with low compared with high income was 1.54 (95% confidence interval 1.36 to 1.79) and 1.65 (1.45 to 1.85), respectively. The RR of 30 day and long term mortality among younger patients with low compared with high education was 1.24 (1.03 to 1.50) and 1.33 (1.11 to 1.59), respectively. The RR of 30 day and long term mortality among older patients with low compared with high income was 1.27 (1.15 to 1.41) and 1.38 (1.27 to 1.50), respectively. Older high and low education patients did not differ in mortality.

CONCLUSION

This study shows that both educational level and income substantially and independently affect mortality after AMI, indicating that each indicator has specific effects on mortality and that these indicators are not interchangeable.

Decreasing prevalence of disability in activities of daily living, functional limitations and poor self-rated health: a 6-year follow-up study in Spain

BACKGROUND AND AIMS

Forecasting functional status in elderly populations is uncertain. Our aim is to provide evidence of population trends of Activities of Daily Living (ADL) disability, functional limitations and self-rated health.

METHODS

Data come from a longitudinal study of aging in Leganés (Spain), collected in 1993, 1995, 1997 and 1999, on a representative sample of 1560 community dwelling people over 65. Response rate at baseline was 82%. ADL disability was defined as needing help in at least one of the following: walking across a small room, taking a shower, toileting, getting out of bed, getting up from a chair, using the toilet, dressing and eating. Functional limitations were based on questions of difficulty with upper and lower limbs. Self-rated health was assessed with a single question. ADL disability, functional limitations and self-rated health were regressed on age, survey year, sex and education.

RESULTS

There are significant declines in ADL disability, functional limitations and poor self-rated health at every age and up to very advanced ages. Over 90, the ADL disability trend may be reversed, with the emergence of a very old and disabled population. Women and people with little education have a higher prevalence of disability, functional limitations and poor health, when compared with men and those with higher education.

CONCLUSIONS

Results suggest the postponement of severe disability onset in this Spanish population, leading to longer healthy life expectancy, and support the emergence of a very disabled population over 90 years of age.

Education, income, and occupational class cannot be used interchangeably in social epidemiology. Empirical evidence against a common practice

STUDY OBJECTIVE

Education, income, and occupational class are often used interchangeably in studies showing social inequalities in health. This procedure implies that all three characteristics measure the same underlying phenomena. This paper questions this practice. The study looked for any independent effects of education, income, and occupational class on four health outcomes: diabetes prevalence, myocardial infarction incidence and mortality, and finally all cause mortality in populations from Sweden and Germany.

DESIGN

Sweden: follow up of myocardial infarction mortality and all cause mortality in the entire population, based on census linkage to the Cause of Death Registry. Germany: follow up of myocardial infarction morbidity and all cause mortality in statutory health insurance data, plus analysis of prevalence data on diabetes. Multiple regression analyses were performed to calculate the effects of education, income, and occupational class before and after mutual adjustments.

SETTING AND PARTICIPANTS

Sweden (all residents aged 25-64) and Germany (Mettman district, Nordrhein-Westfalen, all insured persons aged 25-64).

MAIN RESULTS

Correlations between education, income, and occupational class were low to moderate. Which of these yielded the strongest effects on health depended on type of health outcome in question. For diabetes, education was the strongest predictor and for all cause mortality it was income. Myocardial infarction morbidity and mortality showed a more mixed picture. In mutually adjusted analyses each social dimension had an independent effect on each health outcome in both countries.

CONCLUSIONS

Education, income, and occupational class cannot be used interchangeably as indicators of a hypothetical latent social dimension. Although correlated, they measure different phenomena and tap into different causal mechanisms.

Diurnal salivary cortisol levels in postpartum mothers as a function of infant feeding choice and parity

Daily stress and sleep deprivation can influence the diurnal pattern of cortisol, which normally consists of high morning levels and a gradual decline throughout the day. While most individuals have consistent declining cortisol concentrations over days, others display either flat or inconsistent profiles. Postpartum mothers experience considerable home demands and sleep deprivation, yet, breastfeeding mothers perceive lower stress and reduced negative mood states compared to bottlefeeders. On the other hand, multiparity (having more than one child) is associated with reduced steepness in diurnal cortisol decline. Interestingly, no study to date has investigated the diurnal cortisol pattern and its stability across days in postpartum women as a function of their choice of infant feeding and parity. In this study, we measured salivary cortisol at four different time points during the day, on two non-consecutive days in first-time (primiparous) and second-time (multiparous) mothers at 5-20 weeks postpartum who were exclusively breastfeeding or bottlefeeding, and in non-postpartum mothers of young children (1-6 years). Among multiparous mothers, we found that cortisol levels in those who were bottlefeeding were higher than in breastfeeding mothers at both awakening and 1600 h. This effect remained significant after controlling for individual differences related to infant feeding choice, such as estradiol levels, education and income. No effect of infant feeding choice on cortisol concentrations was observed in primiparous mothers. While a consistent decline across days was common, some mothers presented a flat or inconsistent profile, a profile that was not associated with infant feeding choice or parity. Importantly, mothers with consistent declining profiles had the highest household income. Our findings suggest that although breastfeeding might promote a tighter regulation of diurnal basal cortisol secretion, in particular for multiparous mothers who are likely to be exposed to greater home demands and maternal responsibilities, some aspects of socioeconomic status such as income can also play a significant role in the stability of diurnal cortisol secretion across days.

Self-reported health in high and very high incomes

The objective of the present study was to investigate whether self-reported health (SRH), an overall health indicator, continues to improve as individual income increases to very high levels or whether there is a threshold above which this relationship changes direction. We used data from the 2003 US Current Population Survey, focusing on the upper income decile. We modelled the relationship between income and SRH before and after adjustment for other socio-demographic parameters that are known to influence SRH. In the unadjusted model, SRH increased with increasing income up to the threshold of $326,000, above which SRH declined. After adjustment for all major socio-demographic parameters (age, gender, race, education, and marital status), the adjusted curve showed monotonically increasing SRH with increasing income. Adjustment for each of these parameters separately revealed that the threshold effect was lost only after adjusting for education. There were more people with low levels of educational attainment among those receiving more than $500,000 per year, compared to other people in the upper income decile. Increasing income does not always improve SRH. People in the very high income bracket tend to report slightly worse health, which may be explained by their lower education.

Income as mediator of the effect of occupation on the risk of myocardial infarction: does the income measurement matter?

AIM

To investigate whether the effect of occupational grade on the risk of myocardial infarction (MI) is mediated by income with different aspects of income taken into account.

METHODS

Data were used from three prospective population studies conducted in Copenhagen. A total of 16 665 employees, 43% women, aged 20-75 years, with an initial examination between 1974 and 1992 were followed up until 1999 for incident (hospital admission or fatal) MI. Register based information on job categories and income was used.

RESULTS

During follow up, 855 subjects were diagnosed with a MI: 708 men and 147 women (in total 47% fatal). The hazards by household and individual income showed a graded effect with a hazard ratio (HR) of 1.43 (95% CI 1.12 to 1.83) for the lowest household income group compared with the highest, whereas equivalent income showed an inverse "J shape" effect with a HR of 1.55 (95% CI 1.25 to 1.82) for the third income group compared with the highest. HR for unskilled workers as compared with executive managers was reduced from 1.55 (95% CI 1.24 to 1.93) to 1.42 (95% CI 1.12 to 1.81) after adjustment for household income.

CONCLUSIONS

Occupation and income are not mutually exclusive, but at least partly explained by or mediated through the other on the risk of MI. The mediating effect of income is independent of the choice of an income indicator. Income is not a big contributor to inequality in MI; probably because of the rather even income distribution in Denmark.

Multiple measures of socioeconomic circumstances and common mental disorders

While serious mental disorders typically show socioeconomic differences similar to physical illness-that is, that lower positions imply poorer health-differences for common mental disorders have been inconsistent. We aim to clarify the associations and pathways between measures of socioeconomic circumstances and common mental disorders by simultaneously analysing several past and present socioeconomic measures. The data were derived from middle-aged women and men employed by the City of Helsinki. Cross-sectional surveys were conducted in 2000-2002 among employees who, during each year, reached 40, 45, 50, 55 or 60 years of age. The pooled data include 8970 respondents (80% women; response rate 67%). Common mental disorders were measured by GHQ-12 and the SF-36 mental component summary. Seven socioeconomic measures were included: parental education, childhood economic difficulties, own education, occupational class, household income, home ownership, and current economic difficulties. Logistic regression analysis was used to examine associations between the socioeconomic circumstances and common mental disorders. Past and present economic difficulties were strongly associated with common mental disorders, whereas conventional past and present socioeconomic status measures showed weak or slightly reverse associations. Adjusting for age and gradually for each socioeconomic measure did not affect the main findings, which were very similar for women and men, as well as for both measures of common mental disorders. While the associations of conventional socioeconomic status measures with common mental disorders were weak and inconsistent, our results highlight the importance of past and present economic difficulties to these disorders.

Non-attendance and effective equity of access at four public specialist outpatient centers in Hong Kong

This study tests whether socio-economic status (SES), at either the individual or ecologic levels, exerts a direct impact on non-attendance or an indirect impact on attendance through longer waiting time for appointments and/or doctor-shopping behavior at four public specialist outpatient centers in Hong Kong. We collected information through three main sources, namely patients' referral letters, telephone interviews with both open- and closed-ended questions (e.g. doctor-shopping data) and hospital administrative databases from a total of 6495 attenders and non-attenders enrolled from July 2000 through October 2001. Individual-level SES was measured by education, occupation and monthly household income. Tertiary planning unit (TPU)-level SES data consisted of proportion unemployed, proportion with tertiary education, median income and Gini coefficient. Direct effects of SES on non-attendance were examined by logistic regression. Indirect contributions mediated through waiting time and doctor-shopping were analyzed by structural equation modeling. We found that SES, at the individual or ecologic level, did not exert a direct effect on non-attendance. Instead, TPU-level SES contributed positively to waiting time (beta=0.06+/-0.03, p=0.048), i.e. worse-off neighborhoods (and those with greater income inequality) had a shorter waiting time. Individual-level SES was also directly associated with the likelihood of doctor-shopping (beta=0.16+/-0.02, p<0.001), i.e. the poor were less likely to doctor-shop. Both waiting time (beta=0.12+/-0.02, p<0.001) and doctor-shopping (beta=0.37+/-0.02, p<0.001) were significantly related to non-attendance. Our findings suggest a highly equitable specialist ambulatory care public system in Hong Kong. Health care resources are appropriately targeted at the socially indigent, and the poor are not discriminated against and pushed to seek alternative sources of care by the system. These results should be confirmed using a prospective design.

A comparative appraisal of the relationship of education, income and housing tenure with less than good health among the elderly in Europe

The objective of this study was to determine the strength of various socio-economic indicators for predicting less than good health among elderly people aged 60-79 years. Data were obtained from national health surveys from 10 European countries. Education, income and housing tenure were examined in relation to less than good health using standardised prevalence rates and (multiple) logistic regression analyses. The results illustrated that there are substantial health differences among the elderly according to education and income in each country. Both education and income (with men) showed a strong independent relationship with health status. Health differences according to housing tenure were generally somewhat smaller. However, in Great Britain and the Netherlands housing tenure demonstrated large health differences, even after adjustment for education and income. It is recommended that more refined socio-economic measures are developed and that in the meantime both education and income are used when studying socio-economic health differences among the elderly. In some countries, like Great Britain and the Netherlands, however, housing tenure has an additional value.

Comparaison du score individuel de précarité des Centres d'examens de santé, EPICES, à la définition socio-administrative de la précarité

In French Health Examination Centres, populations in deprived situation were usually defined by administrative criteria The aim of the study was to investigate whether EPICES, a new individual index of deprivation, was more strongly related to health status than an administrative classification. The EPICES score was calculated on the basis of 11 weighted questions related to material and social deprivation. Participants were 197, 389 men and women, aged over 18, encountered in 2002 in French Health Examination Centres. Relationships between health status, health-related behaviours, access to health care, EPICES and the administrative classification of deprivation were analyzed by logistic regression. The associations between EPICES and the study variables were stronger than those observed for the administrative definition. The comparison also showed socially disadvantaged people with poor health identified by the EPICES score who were not by the administrative classification. These results showed that the EPICES score can be a useful tool to improve the identification of deprived people having health problems associated to deprivation.

Association among individual deprivation, glycemic control, and diabetes complications: the EPICES score

OBJECTIVE

Previous studies have related poor glycemic control and/or some diabetes complications to low socioeconomic status. Some aspects of socioeconomic status have not been assessed in these studies. In the present study, we used an individual index of deprivation, the Evaluation de la Précarité et des Inégalités de santé dans les Centres d'Examens de Santé (Evaluation of Precarity and Inequalities in Health Examination Centers [EPICES]) score, to determine the relationship among glycemic control, diabetes complications, and individual conditions of deprivation.

RESEARCH DESIGN AND METHODS

We conducted a cross-sectional prevalence study in 135 consecutive diabetic patients (age 59.41 +/- 13.2 years [mean +/- SD]) admitted in the hospitalization unit of a French endocrine department. Individual deprivation was assessed by the EPICES score, calculated from 11 socioeconomic questions. Glycemic control, lipid levels, blood pressure, retinopathy, neuropathy, and nephropathy were assessed.

RESULTS

HbA(1c) level was significantly correlated with the EPICES score (r = 0.366, P < 0.001). The more deprived patients were more likely than the less deprived patients to have poor glycemic control (beta = 1.984 [SE 0.477], P < 0.001), neuropathy (odds ratio 2.39 [95% CI 1.05-5.43], P = 0.037), retinopathy (3.66 [1.39-9.64], P = 0.009), and being less often admitted for 1-day hospitalization (0.32 [0.14-0.74], P = 0.008). No significant relationship was observed with either nephropathy or cardiovascular risk factors.

CONCLUSIONS

Deprivation status is associated with poor metabolic control and more frequent microvascular complications, i.e., retinopathy and neuropathy. The medical and economic burden of deprived patients is high.

Occupational class inequalities across key domains of health: Results from the Helsinki Health Study

BACKGROUND

Studies comparing socioeconomic inequalities in health using several health indicators are scarce. Therefore, this study aims to compare the shape and magnitude of occupational class inequalities across key domains of health, i.e. the subjective, functional and medical domains. Additionally, we examine whether physical or mental workload will affect these inequalities, and whether these effects are specific to particular health indicators.

METHODS

Cross-sectional survey data from the Helsinki Health Study in 2000 and 2001 were used. Each year employees of the City of Helsinki, reaching 40, 45, 50, 55 and 60 years received a mailed questionnaire. 6243 employees responded (80% women, response rate 68%). The socioeconomic indicator was occupational social class. Nine health indicators were included: self-rated health, pain or ache, GHQ-12 mental well-being, limiting long-standing illness, SF-36 physical and mental health functioning, Rose angina symptoms, circulatory diseases and mental problems. Prevalence percentages, odds ratios and inequality indices from logistic regression analysis were calculated.

RESULTS

Occupational class inequalities were found for self-rated health, pain or ache, limiting long-standing illness, physical health functioning, angina symptoms, and circulatory diseases. Physical or mental workload did not account for these inequalities. Inequalities were non-existent or slightly reversed for GHQ-12 mental well-being, SF-36 mental health functioning and mental problems.

CONCLUSION

Expected occupational class inequalities in health among both women and men were found for global and physical health but not for mental health. The observed inequalities could not be attributed to physical or mental workload.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Influence of material and behavioural factors on occupational class differences in health

OBJECTIVE

To examine material and behavioural factors as explanations for occupational class differences in health, while taking into account the interrelations between these two groups of factors.

METHODS

Data from cross sectional surveys among middle aged women and men employed by the City of Helsinki (n = 6062, response rate 68%) were used. The contribution of four material and seven behavioural factors to occupational class differences in self rated health was examined by logistic regression techniques. After examining the contribution of each material and behavioural factor individually these were combined into two groups, whose independent and shared effects on occupational class differences in health were examined.

RESULTS

In women, each material factor reduced the association between occupational class and health, while only financial difficulties and financial satisfaction were statistically significant in men. Smoking, dietary habits, and relative body weight were the strongest behavioural factors explaining the association in both women and men. When grouped, both material and behavioural factors explained a large part of occupational class differences in health. The direct effect of material factors was larger than their effect through behavioural factors, and the effect of behavioural factors depending on material factors was about half of their independent effect.

CONCLUSIONS

Material and behavioural factors explained more than a half of occupational class differences in self rated health among women and one third among men. The effects of material and behavioural factors were mostly independent of each other, although some part of their contribution was shared, especially in women.

Self-reported economic difficulties and coronary events in men: evidence from the Whitehall II study

BACKGROUND

Numerous studies have demonstrated social inequalities in coronary heart disease using a variety of measures of social position. In this study we examine associations between persistent economic difficulties and serious coronary events. Our aim is to assess whether these associations are (i) explained by other measures of socioeconomic status, and (ii) mediated by psychosocial, behavioural and biological factors.

METHODS

The data come from 5021 middle-aged, white-collar men in the Whitehall II study. Self-reported household financial problems, measured at baseline (1985-88) and Phase 3 (1991-93), were used to construct a five-category score of persistent economic difficulties. Associations between economic difficulties and incident coronary events were determined over an average follow-up of 7 years. Other socioeconomic, psychosocial, behavioural and biological explanatory variables were obtained from the Phase 3 questionnaire and clinical examination.

RESULTS

Age-adjusted Cox regression analyses demonstrated steep gradients in the incidence of coronary events with economic difficulties. The relative hazard between the bottom and the top of the difficulties hierarchy was 2.5 (95% confidence intervals (CI) 1.2-5.2) for fatal and non-fatal myocardial infarction (MI), 2.1 (1.3-3.6) for MI plus definite angina and 2.8 (1.9-4.2) for total coronary events. Adjustment for other markers of socioeconomic position, early life factors, psychosocial work environment characteristics and health-related behaviours had little effect, while adjustment for the biological factors reduced the association between difficulties and coronary events by 16-24%.

CONCLUSION

We have demonstrated an economic difficulties gradient in coronary events in men that is independent of other markers of socioeconomic position and appears to be only partially mediated by well-known risk factors in mid-life.

Socio-economic differences in the prevalence of acute, chronic and disabling chronic pain among ageing employees

Pain is a strong predictor of reduced work ability and well-being, but there is little information on the prevalence of and socio-economic differences in acute, chronic and disabling chronic pain among employees. A questionnaire survey conducted in 2000-2002 among employees aged 40, 45, 50, 55 and 60 of the City of Helsinki (N=8970, response rate 67%) included socio-demographic and socio-economic factors and measures of current pain, pain duration and pain-related disability. Pain was acute when lasting a maximum of 3 months and chronic when persisting for more than 3 months. Disabling chronic pain was determined using the disability subscale of Von Korff's Chronic Pain Grade questionnaire. Acute pain was reported by 15% of women, chronic pain by 29% and disabling chronic pain by 7%. The corresponding figures for men were 12, 24 and 5%. Chronic and disabling chronic pain were more common in older age groups among both genders. Among women, those with secondary or basic education were more likely to report chronic or disabling chronic pain than those with higher education, and semi-professionals, routine non-manual employees and manual workers were more likely to report disabling chronic pain than managers. Among men, separated/divorced or widowed men were more likely to report acute pain than married men, and manual workers were more likely to report chronic pain than managers. Chronic pain was relatively common in this population, and those with older age, lower education and occupational class appear to be at excess risk for chronic pain, especially for disabling chronic pain.

Multiple dimensions of socioeconomic position and obesity among employees: The Helsinki Health Study

OBJECTIVE

To examine socioeconomic differences in obesity using several different socioeconomic indicators, ranging from childhood socioeconomic environment and adult socioeconomic status to material resources and economic satisfaction.

RESEARCH METHODS AND PROCEDURES

The data derived from the Helsinki Health Study baseline surveys in 2000 and 2001. Respondents to postal surveys were middle-aged employees of the City of Helsinki (4,975 women and 1,252 men, response rate 68%). Associations between eight socioeconomic indicators and obesity (BMI > or = 30 kg/m(2)), calculated from self-reported data, were examined by fitting a series of logistic regression models.

RESULTS

In women, all socioeconomic indicators except household income and economic satisfaction were associated with obesity. Parental education and childhood economic difficulties, i.e., socioeconomic conditions in childhood, remained associated with obesity after adjusting for all indicators of current socioeconomic position. Indicators of adult socioeconomic status, own education and occupational class, were no longer associated with obesity when childhood socioeconomic conditions were adjusted for. Home ownership and economic difficulties were associated with obesity after full adjustments. In men, the findings paralleled those among women, but few associations reached statistical significance.

DISCUSSION

Obesity was associated with several dimensions of socioeconomic position. Childhood socioeconomic disadvantage was associated with obesity independently of the various indicators of current socioeconomic position. Associations between obesity and both educational level and occupational class disappeared after adjustment for other indicators of socioeconomic position. This suggests that the variation observed in the prevalence of obesity by these key socioeconomic indicators may reflect differences in the related material resources.

Gender differences in the association of age with physical workload and functioning

AIMS

To test whether (1) physically demanding work is less frequent for older than younger employees, and whether (2) the association of physically demanding work with decline of physical functioning is stronger for older employees than their younger counterparts. The gender differences in these associations were examined.

METHODS

Subjects of the study were 40-60 year old employees of the City of Helsinki. Data (n = 5802) were collected with mail questionnaires in 2000 and 2001. Functioning was measured with the Role Limitations due to Physical Health Problems scale of the SF36 health questionnaire. Logistic regression models were used to analyse the data.

RESULTS

There was a linear trend of less physically demanding work in older than in younger age groups. This trend was more marked for men than women. Age and physically demanding work were associated with poor functioning. In women the association of physically demanding work with poor functioning tended to be stronger for older than for younger age groups, while the opposite was observed in men.

CONCLUSIONS

Results suggest that physically demanding work causes more ailments in women of high age than men. It is possible that less men than women are still employed in physically demanding occupations at high age, even though direct evidence of exit from physically demanding work cannot be obtained from cross-sectional data. In these data the physically demanding occupations for men and women were largely different. High physical workload among women working in social and health care is likely to contribute to the gender differences.

Neighbourhoods and self rated health: a comparison of public sector employees in London and Helsinki

STUDY OBJECTIVE

Mortality and morbidity vary across neighbourhoods and larger residential areas. Effects of area deprivation on health may vary across countries, because of greater spatial separation of people occupying high and low socioeconomic positions and differences in the provision of local services and facilities. Neighbourhood variations in health and the contribution of residents' characteristics and neighbourhood indicators were compared in London and Helsinki, two settings where inequality and welfare policies differ.

DESIGN

Data from two cohorts were used to investigate associations between self rated health and neighbourhood indicators using a multilevel approach.

SETTING

London and Helsinki.

PARTICIPANTS

From the Whitehall II study (London, aged 39-63) and the Helsinki health study (aged 40-60).

MAIN RESULTS

Socioeconomic segregation was higher in London than in Helsinki. Age and sex adjusted differences in self rated health between neighbourhoods were also greater in London. Independent of individual socioeconomic position, neighbourhood unemployment, proportion of residents in manual occupations, and proportion of single households were associated with health. In pooled data, residence in a neighbourhood with highest unemployment was associated with an odds ratio of less than good self rated health of 1.51 (95% CI 1.30 to 1.75). High rates of single parenthood were associated with health in London but not in Helsinki.

CONCLUSIONS

Neighbourhood socioeconomic context was associated with health in both countries, with some evidence of greater neighbourhood effects in London. Greater socioeconomic segregation in London may have emergent effects at the neighbourhood level. Local and national social policies may reduce, or restrict, inequality and segregation between areas.