Individual, household and neighborhood socioeconomic status and mortality: a study of absolute and relative deprivation

Cumulative Risk Evaluation of Phthalates Under TSCA

The U.S. Environmental Protection Agency (EPA) is currently conducting separate Toxic Substances Control Act (TSCA) risk evaluations for seven phthalates: dibutyl phthalate (DBP), butyl benzyl phthalate (BBP), di(2-ethylhexyl) phthalate (DEHP), diisobutyl phthalate (DIBP), dicyclohexyl phthalate (DCHP), di-isodecyl phthalate (DIDP), and diisononyl phthalate (DINP). Phthalates are highly abundant plastic additives used primarily to soften materials and make them flexible, and biomonitoring shows widespread human exposure to a mixture of phthalates. Evidence supports biological additivity of phthalate mixture exposures, including the enhancement of toxicity affecting common biological targets. Risk estimates based on individual phthalate exposure may not be protective of public health. Thus, a cumulative risk approach is warranted. While EPA initially did not signal that it would incorporate cumulative risk assessment (CRA) as part of its current risk evaluation for the seven phthalates, the agency recently announced that it is reconsidering if CRA for phthalates would be appropriate. Based on our review of existing chemical mixtures risk assessment guidance, current TSCA scoping documents for the seven phthalates, and pertinent peer-reviewed literature, we delineate a CRA approach that EPA can easily implement for phthalates. The strategy for using CRA to inform TSCA risk evaluation for existing chemicals is based upon integrative physiology and a common adverse health outcome algorithm for identifying and grouping relevant nonchemical and chemical stressors. We recommend adjustments for how hazard indices (HIs) or margins of exposure (MOEs) based on CRA are interpreted for determining "unreasonable risk" under TSCA.

Construction and validation of CAPSES scale as a composite indicator of SES for health research: an application to modeling social determinants of cardiovascular diseases

BACKGROUND

The main objective of this study was to construct and validate a composite socioeconomic status indicator containing material capital, human capital, and social capital (CAPSES scale) and also appropriate it for CVDs in a large population-based study.

METHODS

This cross-sectional study, the Urban HEART-2 project, was conducted in Tehran, Iran, in 2011. A total of 34,116 households covering 118,542 individuals were assessed in this study. A 14-parts questionnaire was completed for all selected households. All the gathered data were based on the participants' self-reports. Literacy, wealth index, expenditure, skill level, and Townsend index were used as SES indexes. CVDs, including Hypertension, Myocardial infarction, and stroke, were considered the main outcomes. A structural equation model (SEM) was used to construct a CAPSES scale and a composition index of SES. Criterion validity and Construct validity were used to assess this scale.

RESULTS

A total of 91,830 subjects consisting of 33,884 (49%) men were included in this analysis. The mean age of the participants was 41.5 ± 11.37 years. Among the assessed participants, 5904(6.4%) reported hypertension, 1507(1.6%) myocardial infarction, and 407(0.4%) strokes. The overall weighted prevalence of self-reported cardiovascular events (hypertension, stroke, and MI) was 8.03% (95%CI: 7.8-8.2). Inverse associations were seen between the CAPSES scale and its domains with CVDs, adjusted for sex, age, BMI, smoking, and diabetes by a multiple logistic regression model.

CONCLUSION

The CAPSES scale was significantly associated with stroke and hypertension. Our findings showed that the CAPSES index could be useful for public health research.

Association of neighbourhood disadvantage and individual socioeconomic position with all-cause mortality: a longitudinal multicohort analysis

BACKGROUND

Few studies have examined the interactions between individual socioeconomic position and neighbourhood deprivation and the findings so far are heterogeneous. Using a large sample of diverse cohorts, we investigated the interaction effect of neighbourhood socioeconomic deprivation and individual socioeconomic position, assessed using education, on mortality.

METHODS

We did a longitudinal multicohort analysis that included six cohort studies participating in the European LIFEPATH consortium: the CoLaus (Lausanne, Switzerland), E3N (France), EPIC-Turin (Turin, Italy), EPIPorto (Porto, Portugal), Melbourne Collaborative Cohort Study (Melbourne, VIC, Australia), and Whitehall II (London, UK) cohorts. All participants with data on mortality, educational attainment, and neighbourhood deprivation were included in the present study. The data sources were the databases of each cohort study. Poisson regression was used to estimate the mortality rates and associations (relative risk, 95% CIs) with neighbourhood deprivation (Q1 being least deprived to Q5 being the most deprived). Baseline educational attainment was used as an indicator of individual socioeconomic position. Estimates were combined using pooled analysis and the relative excess risk due to the interaction was computed to identify additive interactions.

FINDINGS

The cohorts comprised a total population of 168 801 individuals. The recruitment dates were 2003-06 for CoLaus, 1989-91 for E3N, 1992-98 for EPIC-Turin, 1999-2003 for EPIPorto, 1990-94 for MCCS, and 1991-94 for Whitehall II. We use baseline data only and mortality data obtained using record linkage. Age-adjusted mortality rates were higher among participants residing in more deprived neighbourhoods than those in the least deprived neighbourhoods (Q1 least deprived neighbourhoods, 369·7 per 100 000 person-years [95% CI 356·4-383·2] vs Q5-most deprived neighbourhoods 445·7 per 100 000 person-years [430·2-461·7]), but the magnitude of the association varied according to educational attainment (relative excess risk due to interaction=0·18, 95% CI 0·08-0·28). The relative risk for Q5 versus Q1 was 1·31 (1·23-1·40) among individuals with primary education or less, but less pronounced among those with secondary education (1·12; 1·04-1·21) and tertiary education (1·16; 1·07-1·27). Associations remained after adjustment for individual-level factors, such as smoking, physical activity, and alcohol intake, among others.

INTERPRETATION

Our study suggests that the detrimental health effect of living in disadvantaged neighbourhoods is more pronounced among individuals with low education attainment, amplifying social inequalities in health. This finding is relevant to policies aimed at reducing health inequalities, suggesting that these issues should be addressed at both the individual level and the community level.

FUNDING

The European Commission, European Regional Development Fund, the Portugese Foundation for Science and Technology.

Differentiating kinds of systemic stressors with relation to psychotic-like experiences in late childhood and early adolescence: the stimulation, discrepancy, and deprivation model of psychosis

INTRODUCTION

Conceptualizations that distinguish systems-level stress exposures are lacking; the Stimulation (lack of safety and high attentional demands), Discrepancy (social exclusion and lack of belonging), and Deprivation (lack of environmental enrichment) (SDD) theory of psychosis and stressors occurring at the systems-level has not been directly tested.

METHODS

Exploratory factor analysis was conducted on 3,207 youth, and associations with psychotic-like experiences (PLEs) were explored.

RESULTS

Though model fit was suboptimal, five factors were defined, and four were consistent with the SDD theory, and related to PLEs. Objective and subjective/self-report exposures for deprivation showed significantly stronger PLE associations compared to discrepancy and objective stimulation factors. Objective and subjective/self-report measures converged overall, though self-report stimulation exhibited a significantly stronger association with PLEs compared to objective stimulation.

DISCUSSION

Considering distinct system-level exposures could help clarify putative mechanisms and psychosis vulnerability. The preliminary approach potentially informs health policy efforts aimed at psychopathology prevention and intervention.

College Graduation and Wealth Accumulation: Blacks' Diminished Returns

Background

Based on the Minorities' Diminished Returns (MDRs) framework, indicators of high socioeconomic status (SES), such as high maternal educational attainment, show weaker protective effects on various developmental, behavioral, and health outcomes for Black than White families. As a result of these MDRs, families and individuals with high educational attainment still report high levels of depression, smoking, obesity, and chronic disease. Limited knowledge exists on MDRs of maternal education on indicators of wealth such as home ownership and home value.

Aims

Built on the MDRs framework, we tested the hypothesis of whether the effects of maternal educational attainment at birth on home ownership and home value, as proxies of wealth, vary between Black and White families. We hypothesized that: 1) high maternal education would be associated with more wealth 15 years later, and 2) compared to Whites, Blacks would be less likely to accumulate wealth (own a house) across all educational levels, given a weaker boosting effect of maternal educational attainment on wealth for Black than White families.

Methods

The Fragile Families and Child Well-being Study, is a 15-year follow up study of a random sample of births in cities larger than 200,000 population in the US. A total number of 2004 White or Black youth were included and were followed from birth to the age of 15. The predictor of interest was maternal educational attainment at birth, treated as a categorical variable (college graduation). The outcomes were home ownership and home value (worth - owed) 15 years later, as proxies of wealth. Logistic and linear regression were used for data analysis.

Results

High maternal education at birth was associated with home ownership and higher value of owned home at age 15. We also found that maternal educational attainment at birth and race interact with each other, suggesting that the effects of high maternal educational attainment at birth on home ownership/value at age 15 were weaker for Black than White families.

Conclusions

Diminished returns of maternal educational attainment at birth on wealth accumulation in Black families may be a mechanism that contributes to racial health disparities in high socioeconomic status and also poor outcomes of high SES Black families. That is, a smaller effect of maternal educational attainment on changing the real lives of Black than White youth may be one of the mechanisms by which health remains worse than expected in high SES Black families. Not all of the health, behavioral, and developmental disparities are due to the racial gap in SES but also diminishing returns of socioeconomic status indicators such as maternal educational attainment for racial minorities. Research should study how social stratification, discriminatory mortgage and banking, residential segregation, family formation, employment, and occupational prestige reduce Black families' ability to mobilize their human capital and secure tangible economic and non-economic outcomes.

Neighborhood deprivation, prefrontal morphology and neurocognition in late childhood to early adolescence

Background:

Neighborhood deprivation adversely effects neurodevelopment and cognitive function; however, mechanisms remain unexplored. Neighborhood deprivation could be particularly impactful in late childhood/early adolescence, in neural regions with protracted developmental trajectories, e.g., prefrontal cortex (PFC).

Methods:

The Adolescent Brain Cognitive Development (ABCD) study recruited 10,205 youth. Geocoded residential history was used to extract individual neighborhood characteristics. A general cognitive ability index and MRI scans were completed. Associations with neurocognition were examined. The relation of PFC surface area and cortical thickness to neighborhood deprivation was tested. PFC subregions and asymmetry, with putative differential environmental susceptibility during key developmental periods, were explored. Analyses tested PFC area as a possible mediating mechanism.

Results:

Neighborhood deprivation predicted neurocognitive performance (β = −0.11), even after accounting for parental education and household income (β = −0.07). Higher neighborhood deprivation related to greater overall PFC surface area (η²_p = 0.003), and differences in leftward asymmetry were observed for area (η²_p = 0.001), and thickness (η²_p = 0.003). Subregion analyses highlighted differences among critical areas that are actively developing in late childhood/early adolescence and are essential to modulating high order cognitive function. These included orbitofrontal, superior frontal, rostral middle frontal, and frontal pole regions (Cohen’s d = 0.03–0.09). PFC surface area partially mediated the relation between neighborhood deprivation and neurocognition.

Discussion:

Neighborhood deprivation related to cognitive function (a foundational skill tied to a range of lifetime outcomes) and PFC morphology, with evidence found for partial mediation of PFC on neurocognitive function. Results inform public health conceptualizations of development and environmental vulnerability.

Family Income and Gang Presence in the Neighborhood: Diminished Returns of Black Families

BACKGROUND

Based on the Minorities' Diminished Returns (MDRs) framework, indicators of high socioeconomic status, such as higher family income, show weaker protective effects on various developmental, behavioral, and health outcomes for Black than White families. As a result of these MDRs, Black families who access education and income still report high levels of depression, smoking, obesity, and chronic disease. Limited knowledge exists on MDRs of income on neighborhood quality.

AIMS

Built on the MDRs framework, this study tested the hypothesis of whether the effect of family income and maternal education at birth on neighborhood gang presence varies between Black and White families. The hypotheses were that: (1) higher income families would report lower gang presence in their neighborhood, and (2) compared to Whites, Blacks would show weaker protective effects of family income on gang presence in their neighborhood.

METHODS

The Fragile Families and Child Wellbeing Study is a 15-year follow up study of a random sample of births in cities with larger than 200,000 population. Two thousand nine hundred and nineteen White or Black families were included and were followed from birth of their child for 15 years. The predictors were family income and maternal education at birth, treated as categorical variables. The outcome was gang presence in the neighborhood at age 15. Logistic regression was used for data analysis.

RESULTS

Higher maternal education at birth was inversely associated with gang presence in the neighborhoods, while family income at birth did not show an effect on reducing gang presence in the neighborhood at age 15. Family income at birth and race interact, suggesting that the association between family income at birth and gang presence in the neighborhood at age 15 was weaker for Black than White families. Our race-stratified models also showed an inverse effect of family income at birth on gang presence in the neighborhood at age 15 in White but not Black families.

CONCLUSIONS

Diminished returns of family income at birth on neighborhood safety and social disorder may be a mechanism that contributes to racial health disparities in higher socioeconomic status and also poor outcomes for Black families across socioeconomic status (SES) levels. That is, a smaller protective effect of family income on changing the real lives of Black compared to White families may be one of the mechanisms by which health is worse than expected in Black families, across the entire SES spectrum. The health, behavioral, and developmental disparities are not only due to the racial gap in SES but also diminishing returns of socioeconomic status indicators such as family income for racial minorities. Research should study contextual and structural factors that reduce Black families' ability to mobilize their human capital and secure health outcomes in urban settings.

Sex differences in the association between marital status and the risk of cardiovascular, cancer, and all-cause mortality: a systematic review and meta-analysis of 7,881,040 individuals

Purpose

To ascertain whether sex differences exist in the relationship between marital status and cardiovascular diseases (CVD), coronary heart disease (CHD), cancer and all-cause mortality in the general population and to explore the potential effect of age, location, the duration of follow-up and publication years on these outcomes.

Methods

A systematic search was performed in PubMed and EMBASE from inception through to April 2018 and review of references to obtain sex-specific relative risks and their 95% confidence intervals. These were used to derive the women-to-men ratio of RRs (RRR) and 95% CI for each study. RRs and RRRs for each outcome were then pooled using random effects inverse-variance weighted meta-analysis.

Results

Twenty-one studies with 7,891,623 individuals and 1,888,752 deaths were included in the meta-analysis. Compared with married individuals, being unmarried was significantly associated with all-cause, cancer, CVD and coronary heart disease mortalities for both sexes. However, the association with CVD and all-cause mortality was stronger in men. Being divorced/separated was associated with a higher risk of all-cause mortality in men and a stronger risk of cancer and CVD mortality. The pooled ratio for women versus men showed 31 and 9% greater risk of stroke mortality and all-cause mortality associated with never married in men than in women.

Conclusions

Being unmarried conferred higher risk of stroke and all-cause mortality for men than women. Moreover, divorced/separated men had higher risk of cancer mortality and CVD mortality. Further studies are warranted to clarify the biological, behavioral, and/or social mechanisms involved in sex differences by these associations.

Relative wealth, subjective social status, and their associations with depression: Cross-sectional, population-based study in rural Uganda

Depression is a leading cause of disability worldwide, and has been found to be a consistent correlate of socioeconomic status (SES). The relative deprivation hypothesis proposes that one mechanism linking SES to health involves social comparisons, suggesting that relative SES rather than absolute SES is of primary importance in determining health status. Using data from a whole-population sample of 1,620 participants residing in rural southwestern Uganda, we estimated the independent associations between objective and subjective relative wealth and probable depression, as measured by the depression subscale of the Hopkins Symptom Checklist (HSCLD). Objective relative wealth was measured by an asset index based on information about housing characteristics and household possessions, which was used to rank study participants into quintiles (within each village) of relative household asset wealth. Subjective relative wealth was measured by a single question asking participants to rate their wealth, on a 5-point Likert scale, relative to others in their village. Within the population, 460 study participants (28.4%) screened positive for probable depression. Using Poisson regression with cluster-robust error variance, we found that subjective relative wealth was associated with probable depression, adjusting for objective relative wealth and other covariates (adjusted relative risk [aRR] comparing lowest vs. highest level of subjective relative wealth = 1.90, 95% confidence interval [CI]: 1.18, 3.06). Objective relative wealth was not associated with probable depression (aRR comparing lowest vs. highest quintile of objective relative wealth = 1.09, 95% CI: 0.77, 1.55). These results suggest that, in this context, subjective relative wealth is a stronger correlate of mental health status compared with objective relative wealth. Our findings are potentially consistent with the relative deprivation hypothesis, but more research is needed to explain how relative differences in wealth are (accurately or inaccurately) perceived and to elucidate the implications of these perceptions for health outcomes.

Gout Severity, Socioeconomic Status, and Work Absence: A Cross-Sectional Study in Primary Care

OBJECTIVE

To examine the association between gout severity and socioeconomic status (SES) and gout severity and work absence.

METHODS

Postal questionnaires were sent to adult patients who were registered with 20 general practices and who had consultations regarding gout or had been prescribed allopurinol or colchicine in the preceding 2 years. Gout severity was defined using the following proxy measures: number of attacks, history of oligoarticular/polyarticular attacks, disease duration, and allopurinol use. SES was defined using the English index of multiple deprivation (area level) and using self-reported educational attainment (individual level). Work absence was defined as taking time off from work in the past 6 months because of gout. Adjusted odds ratios (OR_adj ; 95% confidence intervals [95% CIs]) were calculated using logistic regression models (adjusted for age, sex, body mass index, gout severity, and comorbidities).

RESULTS

A total of 1,184 completed questionnaires were returned. The mean age of patients was 65.6 years, and 84% were male. Not having attended further education ("further education" is defined as attendance after the statutory minimum school-leaving age of 16 years) was associated with having had ≥2 gout attacks in the last year (OR_adj 0.54 [95% CI 0.36-0.81]) and oligoarticular/polyarticular attacks (OR_adj 0.72 [95% CI 0.50-1.05]). Lower area-level deprivation was associated with fewer attacks (≥2) (OR_adj 0.71 [95% CI 0.51-0.98]). Work absence was associated with having had ≥2 gout attacks in the last year (OR_adj 2.91 [95% CI 1.22- 6.92]), oligoarticular/polyarticular attacks (OR_adj 3.10 [95% CI 1.46-6.61]), and shorter disease duration (>18 years) (OR_adj 0.13 [95% CI 0.03-0.50]).

CONCLUSION

Gout severity was associated with individual-level deprivation, countering the historic and negative perception of gout as a "rich man's disease." The association of gout severity with work absence reinforces the argument for earlier urate-lowering therapy to prevent attacks from becoming frequent and debilitating.

What can ecological studies tell us about death?

Using an ecological study design, Gordon et al. (Isr J Health Policy Res 6:39, 2017) demonstrate variations in mortality patterns across districts and sub-districts of Israel during 2008-2013. Unlike other epidemiological study designs, the units of analysis in ecological studies are groups of people, often defined geographically, and the exposures and outcomes are aggregated, and often known only at the population-level. The ecologic study has several appealing characteristics (such as reliance on public-domain anonymous data) alongside a number of important potential limitations including the often mentioned 'ecological fallacy'. Advantages and disadvantages of the ecological design are described briefly below.

Associations of cause-specific mortality with area level deprivation and travel time to health care in France from 1990 to 2007, a multilevel analysis

Background

It is now widely accepted that social and physical environment participate in shaping health. While mortality is used to guide public health policies and is considered as a synthetic measure of population health, few studies deals with the contextual features potentially associated with mortality in a representative sample of an entire country. This paper investigates the possible role of area deprivation (FDep99) and travel time to health care on French cause-specific mortality in a proper multilevel setting.

Methods

The study population was a 1% sample representative of the French population aged from 30 to 79 years in 1990 and followed up until 2007. A frailty Cox model was used to measure individual, contextual effects and spatial variances for several causes of death. The chosen contextual scale was the Zone d’Emploi of 1994 (348 units) which delimits the daily commute of people. The geographical accessibility to health care score was constructed with principal component analysis, using 40 variables of hospital specialties and health practitioners’ travel time.

Results

The outcomes highlight a positive and significant association between area deprivation and mortality for all causes (HR = 1.24), cancers, cerebrovascular diseases, ischemic heart diseases, and preventable and amenable diseases (HR from 1.14 to 1.29). These contextual associations exhibit no substantial differences by sex except for premature ischemic heart diseases mortality which was much greater in women. Unexpectedly, mortality decreased as the time to reach health care resources increased. Only geographical disparities in cerebrovascular and ischemic heart diseases mortality were explained by compositional and contextual effects.

Discussion

The findings suggest the presence of confounding factors in the association between mortality and travel time to health care, possibly owing to population density and health-selected migration. Although the spatial scale considered to define the context of residence was relatively large, the associations with area deprivation were strong in comparison to the existing literature and significant for almost all the causes of deaths investigated.

Conclusion

The broad spectrum of diseases associated with area deprivation and individual education support the idea of a need for a global health policy targeting both individual and territories to reduce social and socio-spatial inequalities.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4562-7) contains supplementary material, which is available to authorized users.

Neighborhood Environment and Cognition in Older Adults: A Systematic Review

CONTEXT

Some evidence suggests that treating vascular risk factors and performing mentally stimulating activities may delay cognitive impairment onset in older adults. Exposure to a complex neighborhood environment may be one mechanism to help delay cognitive decline.

EVIDENCE ACQUISITION

PubMed, Web of Science, and ProQuest Dissertation and Theses Global database were systematically reviewed, identifying 25 studies published from February 1, 1989 to March 5, 2016 (data synthesized, May 3, 2015 to October 7, 2016). The review was restricted to quantitative studies focused on: (1) neighborhood social and built environment and cognition; and (2) community-dwelling adults aged ≥45 years.

EVIDENCE SYNTHESIS

The majority of studies were cross-sectional, U.S.-based, and found at least one significant association. The diversity of measures and neighborhood definitions limited the synthesis of findings in many instances. Evidence was moderately strong for an association between neighborhood SES and cognition, and modest for associations between neighborhood demographics, design, and destination accessibility and cognition. Most studies examining effect modification found significant associations, with some evidence for effect modification of the neighborhood SES-cognition association by individual-level SES. No studies had low risk of bias and many tested multiple associations that increased the chance of a statistically significant finding. Considering the studies to date, the evidence for an association between neighborhood characteristics and cognition is modest.

CONCLUSIONS

Future studies should include longitudinal measures of neighborhood characteristics and cognition; examine potential effect modifiers, such as sex and disability; and study mediators that may help elucidate the biological mechanisms linking neighborhood environment and cognition.

Neighborhood Sociodemographics and Change in Built Infrastructure

While increasing evidence suggests an association between physical infrastructure in neighbourhoods and health outcomes, relatively little research examines how neighbourhoods change physically over time and how these physical improvements are spatially distributed across populations. This paper describes the change over 25 years (1985-2010) in bicycle lanes, off-road trails, bus transit service, and parks, and spatial clusters of changes in these domains relative to neighbourhood sociodemographics in four U.S. cities that are diverse in terms of geography, size and population. Across all four cities, we identified increases in bicycle lanes, off-road trails, and bus transit service, with spatial clustering in these changes that related to neighbourhood sociodemographics. Overall, we found evidence of positive changes in physical infrastructure commonly identified as supportive of physical activity. However, the patterning of infrastructure change by sociodemographic change encourages attention to the equity in infrastructure improvements across neighbourhoods.

The mediating roles of perceived stress and health behaviors in the relation between objective, subjective, and neighborhood socioeconomic status and perceived health

BACKGROUND

Objective, subjective, and neighborhood socioeconomic status (SES) are associated with perceived health, morbidity, and mortality.

PURPOSE

We investigated whether perceived stress and health behaviors mediated the relation between the three types of SES and perceived health.

METHODS

Participants (N = 508) attending a public clinic completed a computerized survey assessing objective SES (income, education, employment); health behaviors; perceived stress; and perceived health. They also indicated their social standing relative to others (subjective SES) and provided their current address to determine neighborhood SES.

RESULTS

In a structural equation model including all three SES types, lower objective and subjective SES were related to poorer perceived health. When mediators were included in the model, there were significant indirect effects of (a) SES on health through stress and (b) SES on health through stress and health-compromising behaviors.

CONCLUSIONS

Interventions to reduce the impact of stressors could improve the health of socioeconomically disadvantaged individuals.

The association of gout with socioeconomic status in primary care: a cross-sectional observational study

Objective. Little is known about the association between gout and socioeconomic status (SES). Inequalities in rheumatology provision associated with SES may need to be addressed by health care planners. The aim of this study is to investigate the association of gout and SES in the community at both the individual and area levels.

Methods. Questionnaires were sent to all patients older than age 50 years who were registered with eight general practices in North Staffordshire. Data on individual SES were collected by questionnaire while area SES was measured using the Index of Multiple Deprivation derived from respondents’ postcodes. Responders reported their occupation, education and the adequacy of their income; their medical records were searched for consultations for gout.

Results. Of the 348 consultations for gout in this period, at the individual level there was a significant association between gout and income. An association of gout with education was seen only in the unadjusted analyses. No association was found between gout and area level deprivation.

Conclusion. Gout is associated with some aspects of individual level but not area level deprivation. More extensive musculoskeletal services may need to be provided in low income areas, although further research is needed.

The role of different predictors in 20-year mortality among Krakow older citizens

BACKGROUND

The aim of this study was to assess the change in the predictive ability of gender-related 20-year all-cause mortality in community-dwelling older people.

METHODS

The baseline investigation was conducted in 1986-1987 and survival of 2472 subjects aged 65 years and older was followed up for 20 years. The associations of socioeconomic conditions and health measures with mortality were assessed using Cox hazard model with time-dependent covariates.

RESULTS

Our study confirmed that higher education and being employed during the baseline were protective factors in males, but not among females. Healthy lifestyle was a predictive factor for all-cause mortality for both men and women and its predictive value was strong over the whole observation period. The study showed that poor self-rated health (SRH) was a valid predictor of mortality in elderly women, but not in men, and the effect of the length of follow-up on mortality was not observed. Overall, different sets of all-cause mortality predictors were found for men and women. For men the role of socioeconomic status factors was confirmed as well as healthy lifestyle and presence of chronic conditions, especially coronary heart disease (CHD) and asthma. For women the most important predictors were lifestyle factors and the feeling of life-weariness as well as SRH and diabetes mellitus present during the baseline study.

CONCLUSIONS

The impact of most of the examined factors on mortality was found to be stable over the twenty years of observation with the exception of the self-reported CHD, whose predictive value decreased over time.

Son preference in Indian families: absolute versus relative wealth effects

The desire for male children is prevalent in India, where son preference has been shown to affect fertility behavior and intrahousehold allocation of resources. Economic theory predicts less gender discrimination in wealthier households, but demographers and sociologists have argued that wealth can exacerbate bias in the Indian context. I argue that these apparently conflicting theories can be reconciled and simultaneously tested if one considers that they are based on two different notions of wealth: one related to resource constraints (absolute wealth), and the other to notions of local status (relative wealth). Using cross-sectional data from the 1998-1999 and 2005-2006 National Family and Health Surveys, I construct measures of absolute and relative wealth by using principal components analysis. A series of statistical models of son preference is estimated by using multilevel methods. Results consistently show that higher absolute wealth is strongly associated with lower son preference, and the effect is 20%-40% stronger when the household's community-specific wealth score is included in the regression. Coefficients on relative wealth are positive and significant although lower in magnitude. Results are robust to using different samples, alternative groupings of households in local areas, different estimation methods, and alternative dependent variables.

Do neighborhoods affect individual mortality? A systematic review and meta-analysis of multilevel studies

There has been increasing interest in investigating whether inhabitants in socially or physically deprived neighborhoods have higher mortality when individual socioeconomic status is adjusted for. Results so far appear ambiguous and the objective of this study was to conduct a systematic literature review of previous studies and to quantify the association between area-level socioeconomic status (ALSES) and all-cause mortality in a meta-analysis. Current guidelines for systematic reviews and meta-analyses were followed. Articles were retrieved from Medline, Embase, Social Sciences Citation Index and PsycInfo and individually evaluated by two researchers. Only peer-reviewed multilevel studies from high-income countries, which analyzed the influence of at least one area-level indicator and which controlled for individual SES, were included. The ALSES estimates in each study were first combined into a single estimate using weighted linear regression. In the meta-analysis we calculated combined estimates with random effects to account for heterogeneity between studies. Out of the 40 studies found eligible for the systematic review 18 studies were included in the meta-analysis. The systematic review suggests that there is an association between social cohesion and mortality but found no evidence for a clear association for area-level income inequality or for social capital. Studies including more than one area level suggest that characteristics on different area levels contribute to individual mortality. In the meta-analysis we found significantly higher mortality among inhabitants living in areas with low ALSES. Associations were stronger for men and younger age groups and in studies analyzing geographical units with fewer inhabitants.

Clinical care and health disparities

Health disparities, also known as health inequities, are systematic and potentially remediable differences in one or more aspects of health across population groups defined socially, economically, demographically, or geographically. This topic has been the subject of research stretching back at least decades. Reports and studies have delved into how inequities develop in different societies and, with particular regard to health services, in access to and financing of health systems. In this review, we consider empirical studies from the United States and elsewhere, and we focus on how one aspect of health systems, clinical care, contributes to maintaining systematic differences in health across population groups characterized by social disadvantage. We consider inequities in clinical care and the policies that influence them. We develop a framework for considering the structural and behavioral components of clinical care and review the existing literature for evidence that is likely to be generalizable across health systems over time. Starting with the assumption that health services, as one aspect of social services, ought to enhance equity in health care, we conclude with a discussion of threats to that role and what might be done about them.

Socioeconomic deprivation impact on meat intake and mortality: NIH-AARP Diet and Health Study

OBJECTIVE

Previous studies have not examined potential interactions between meat intake and characteristics of the local environment on the risk of mortality. This study examined the impact of area socioeconomic deprivation on the association between meat intake and all-cause and cause-specific mortality after accounting for individual-level risk factors.

METHODS

In the prospective NIH-AARP Diet and Health Study, we analyzed data from adults, ages 50-71 years at baseline (1995-1996). Individual-level dietary intake and health risk information were linked to the demographic and socioeconomic context of participants' local environment based on census tract data. Deaths (n = 33,831) were identified through December 2005. Multilevel Cox models were used to estimate hazard ratios and 95% confidence intervals for quintiles of area deprivation scores.

RESULTS

Associations of red and processed meats with mortality were consistent across deprivation quintiles. Men residing in least-deprived neighborhoods had a stronger protective effect for white meat consumption. No differences by deprivation index were observed for women.

CONCLUSION

Red and processed meat intake increases mortality risk regardless of level of deprivation within a given neighborhood suggesting biological mechanisms rather than neighborhood contextual factors may underlie these meat-mortality associations. The effect of white meat intake on cancer mortality was modified by area deprivation among men.

Small area contextual effects on self-reported health: evidence from Riverside, Calgary

Background

We study geographic variation within one community in the City of Calgary using a more fine-grained geographic unit than the Census tract, the Census Dissemination Area (DA). While most Riverside residents consider their neighbourhood to be a fairly cohesive community, we explore the effect of socio-economic variation between these small geographic areas on individuals' self-reported health, net of individual level determinants.

Methods

We merge data from the 2001 Census for Riverside, Calgary with a 2004 random telephone survey of Riverside residents. Our data are unique in that we have information on individuals from every DA wholly contained in the Riverside community. These data enable us to conduct multinomial logistic regression analyses of self-reported health using both individual-level and DA-level variables as predictors.

Results

We find significant variation in measures of DA socio-economic status within the Riverside community. We find that individual self-reported health is affected by variation in an index of DA-level socio-economic disadvantage, controlling for individual variation in gender, age, and socio-economic status. We investigate each aspect of the DA index of disadvantage separately, and find that average education and the percent of households that are headed by a lone parent are most important.

Conclusions

These findings demonstrate that, even within a cohesive community, contextual effects on health can be located at a smaller geographic level than the Census tract. Research on the effects of local area socio-economic disadvantage on health that combines administrative and survey data enables researchers to develop more comprehensive measures of social and material deprivation. Our findings suggest that both social and material deprivation affect health at the local level.

Does the Relationship Between Neighborhood Socioeconomic Status and Health Outcomes Persist Into Very Old Age? A Population-Based Study

Objective: The purpose of this article is (a) to extend previous research on the relationship between neighborhood socioeconomic status (SES) and health by considering a wide range of health-related measures derived from administrative health care records and (b) to explore whether this relationship persists into old age. Method: The study involved a complete cohort of community-dwelling residents in Winnipeg, Canada, who were 65 years or older in 2004/2005 ( N = 77,930). Health measures were derived from administrative claims data. Census data were used to derive neighborhood-level SES. Results: Multilevel logistic regressions indicated that, relative to individuals living in the most affluent areas, those in the poorest areas had significantly higher odds of having arthritis, diabetes, hypertension, congestive heart failure, ischemic heart disease, chronic obstructive pulmonary disease, depression, and stroke. Significant neighborhood income effects tended to be evident among individuals age 65 to 75 as well as those age 75+. Discussion: A wide range of health conditions among older adults are disproportionately clustered into the poorest areas. Programs and services should be designed to meet the needs of older adults of any age in such neighborhoods.

Racial and socioeconomic disparities in nutrition behaviors: targeted interventions needed

OBJECTIVE

To compare dietary knowledge, behaviors and self-efficacy of black middle school students of low socioeconomic status with their white counterparts of higher socioeconomic status.

DESIGN

Cross-sectional, school-based survey.

SETTING

Large metropolitan area in the United States.

PARTICIPANTS

Middle school students (1,208 of low socioeconomic and 978 of higher socioeconomic status).

MAIN OUTCOME MEASURES

Dietary behaviors, dietary knowledge, and dietary self-efficacy were assessed by questionnaire.

ANALYSIS

Differences between black students of low socioeconomic status and white students of higher socioeconomic status in the above variables.

RESULTS

Black students of low socioeconomic status scored significantly lower than did white students of higher socioeconomic status on several of the variables. They were more likely to consume empty calorie food, meat, and fried food and less likely to eat fruit, vegetables, dairy products, and grains; they were less knowledgeable about dietary variables; and they had significantly lower self-efficacy regarding their ability to change dietary habits.

CONCLUSIONS AND IMPLICATIONS

The results of this study suggest that black students of low socioeconomic status should be targeted for early intervention related to dietary behaviors. This age group is amenable to change, and interventions designed specifically for them may result in lifetime reductions in risk of morbidity and mortality.

Material resources and population health: disadvantages in health care, housing, and food among adults over 50 years of age

OBJECTIVES

We examined associations between material resources and late-life declines in health.

METHODS

We used logistic regression to estimate the odds of declines in self-rated health and incident walking limitations associated with material disadvantages in a prospective panel representative of US adults aged 51 years and older (N = 15,441).

RESULTS

Disadvantages in health care (odds ratio [OR] = 1.39; 95% confidence interval [CI] = 1.23, 1.58), food (OR = 1.69; 95% CI = 1.29, 2.22), and housing (OR = 1.20; 95% CI = 1.07, 1.35) were independently associated with declines in self-rated health, whereas only health care (OR = 1.43; 95% CI = 1.29, 1.58) and food (OR = 1.64; 95% CI = 1.31, 2.05) disadvantage predicted incident walking limitations. Participants experiencing multiple material disadvantages were particularly susceptible to worsening health and functional decline. These effects were sustained after we controlled for numerous covariates, including baseline health status and comorbidities. The relations between health declines and non-Hispanic Black race/ethnicity, poverty, marital status, and education were attenuated or eliminated after we controlled for material disadvantage.

CONCLUSIONS

Material disadvantages, which are highly policy relevant, appear related to health in ways not captured by education and poverty. Policies to improve health should address a range of basic human needs, rather than health care alone.

Health inequalities in Israel: explanatory factors of socio-economic inequalities in self-rated health and limiting longstanding illness

We examined an integrated multi-level model of psychosocial, community and behavioral factors as explanatory pathways to socio-economic inequalities in health in Israel. Using a random national sample of 1328 individuals aged 30-70 and measurements of socio-economic position (education, number of cars), health outcomes-self-rated health, limiting longstanding illness (LLI), we evaluated the contribution of psychosocial factors (stressors and psychosocial resources), community factors (individual and aggregate-level social participation and social capital) and health behaviors, to the explanation of health inequalities. Community factors contributed more than psychosocial factors or health behaviors. The integrative model provided an explanation of social inequalities in both health outcomes and a full explanation for the education-LLI association.

Social comparisons and health: can having richer friends and neighbors make you sick?

Do richer friends and neighbors improve your health through positive material effects, or do they make you feel worse through the negative effect of social comparison and relative deprivation? Using the newly available National Social Life, Health, and Aging Project (NSHAP) data set that reports individuals' income positions within their self-defined social networks, this paper examines whether there is an association between relative position and health in the US. Because this study uses measures of individuals' positions within their self-defined social groups rather than researcher-imputed measures of relative position, I am able to more precisely examine linkages between individual relative position and health. I find a relationship between relative position and health status, and find indirect support for the biological mechanism underlying the relative deprivation model: lower relative position tends to be associated with those health conditions thought to be linked to physiological stress. I also find, however, that only extremes of relative position matter: very low relative position is associated with worse self-rated physical health and mobility, increased overall disease burden, and increased reporting of cardiovascular morbidity; very high relative position is associated with lower probabilities of reporting diabetes, ulcers, and hypertension. I observe few associations between health and either moderately high or moderately low positions. This analysis suggests that the mechanism underlying the relative deprivation model may only have significant effects for those at the very bottom or the very top.

Healthy Israel 2020: a visionary national health targeting initiative

This article describes the development of a national health targeting initiative entitled 'Healthy Israel 2020' which was created to enhance the health and wellbeing of Israelis through a variety of health promotion and disease prevention interventions. This initiative builds upon the experience of two major worldwide targeting efforts, "Health People 2010" of the US and the World Health Organization's Health21', as well as lessons learned from other countries. Important philosophical underpinnings are highlighted, particularly the evidence-based nature of the process. Real-world organizational and policy challenges and creative solutions are presented. It is hoped that this report will be of value to others in Israel and elsewhere who are interested in improving the health of their nations.

The effect of DHEA complementary treatment on heroin addicts participating in a rehabilitation program: a preliminary study

We evaluated the effect of DHEA complementary treatment in opiate addicts undergoing detoxification. DHEA (100 mg/day) or placebo was added to the routine medication protocol in a randomized, double blind controlled study. Follow-up for 12 months was conducted. Two separate DHEA-treated subgroups were identified by the Fuzzy clustering method: one showed statistically significant improvement in the severity of withdrawal symptoms, depression and anxiety scores (n=34; p<0.001 for all) and the other subgroup deteriorated in all measures (n=15). DHEA at the end of the detoxification program showed a tendency towards correlation with the duration of abstinence (r=0.6843; p>0.05; n=6), while a negative correlation was obtained with the cortisol level (r=-0.900; p=0.005, n=8). The completion-rate of the DHEA-improved subgroup was greater than in the DHEA-deteriorated subgroup (64.7% vs. 33.3%, respectively). The influence of supplementary DHEA treatment was mostly effective in heroin addicts who had not previously used either cocaine or benzodiazepines and who had experienced only few withdrawal programs.

Educational inequalities in mortality among Israeli Jews: Changes over time in a dynamic population

Changes in educational inequalities in mortality in a country that underwent a sudden population growth were examined using two census-based longitudinal studies from Israel (I, 1983-1992, n=152,150 and II, 1995-2004, n=209,125). Relative changes in educational inequalities in mortality were assessed using mortality rates and odds ratios and their corresponding 95% confidence intervals. Decreases in mortality rates and widening relative educational inequalities in mortality were seen over time. Among recent immigrants, educational inequalities in mortality existed but to a lesser degree than for residents. The widening gap (2.5-fold) in cardiovascular disease mortality risks observed for low versus high educated middle-aged women, was particularly alarming. The observed decreasing mortality rates, indicative of a healthier society, alongside widening educational inequalities in mortality indicates uneven changes within the population.

Toward the next generation of research into small area effects on health: a synthesis of multilevel investigations published since July 1998

To map out area effects on health research, this study had the following aims: (1) to inventory multilevel investigations of area effects on self rated health, cardiovascular diseases and risk factors, and mortality among adults; (2) to describe and critically discuss methodological approaches employed and results observed; and (3) to formulate selected recommendations for advancing the study of area effects on health. Overall, 86 studies were inventoried. Although several innovative methodological approaches and analytical designs were found, small areas are most often operationalised using administrative and statistical spatial units. Most studies used indicators of area socioeconomic status derived from censuses, and few provided information on the validity and reliability of measures of exposures. A consistent finding was that a significant portion of the variation in health is associated with area context independently of individual characteristics. Area effects on health, although significant in most studies, often depend on the health outcome studied, the measure of area exposure used, and the spatial scale at which associations are examined.

Do places affect the probability of death in Australia? A multilevel study of area-level disadvantage, individual-level socioeconomic position and all-cause mortality, 1998-2000

BACKGROUND

In Australia, studies finding an association between area-level socioeconomic disadvantage and mortality are often based on aggregate-ecological designs which confound area-level and individual-level sources of socioeconomic variation. Area-level socioeconomic differences in mortality therefore may be an artefact of varying population compositions and not the characteristics of areas as such.

OBJECTIVE

To examine the associations between area-level disadvantage and all-cause mortality before and after adjustment for within-area variation in individual-level socioeconomic position (SEP) using unlinked census and mortality-register data in a multilevel context. Setting, participants and

DESIGN

The study covers the total Australian continent for the period 1998-2000 and is based on decedents aged 25-64 years (n = 43,257). The socioeconomic characteristics of statistical local areas (SLA, n = 1317) were measured using an index of relative socioeconomic disadvantage, and individual-level SEP was measured by occupation.

RESULTS

Living in a disadvantaged SLA was associated with higher all-cause mortality after adjustment for within-SLA variation in occupation. Death rates were highest for blue-collar workers and lowest among white-collar employees. Cross-level interactions showed no convincing evidence that SLA disadvantage modified the extent of inequality in mortality between the occupation groups.

CONCLUSIONS

Multilevel analysis can be used to examine area variation in mortality using unlinked census and mortality data, therefore making it less necessary to use aggregate-ecological designs. In Australia, area-level and individual-level socioeconomic factors make an independent contribution to the probability of premature mortality. Policies and interventions to improve population health and reduce mortality inequalities should focus on places as well as people.

A fixed-effects multilevel analysis of how community family structure affects individual mortality in Norway

By using register data for the entire Norwegian population aged 50–89 in the period 1980–1999, during which there were about 720,000 deaths, I estimate how the proportions of persons who were divorced or never married in the municipality affected all-cause mortality, net of individual marital status. The data include individual histories of changes in marital status and places of residence, providing a rare opportunity to enter municipality fixed effects into the model, thereby capturing the time-invariant unobserved factors at that level. The positive health externality of marriage that is suggested in the literature is supported by some of the estimates for women. Other estimates—especially those for men—point in the opposite direction. One possible interpretation of these findings is that social cohesion is perhaps not as beneficial for people’s health as often claimed, at least not for both sexes. Alternatively, the results may reflect that marriage perhaps undermines rather than strengthens social cohesion, or that other mechanisms are involved—for example, those that are related to people’s perceptions of their health relative to the health of others. Estimates from models without such municipality fixed effects are markedly different, but these also shed doubt on the notion that a high proportion of unmarried persons generally increases individual mortality.

Socioeconomic status and health behaviors in adolescence: a review of the literature

OBJECTIVE

The goal of this review was to determine the direction of associations between SES and health behaviors during the period of adolescence.

METHOD

We searched the PsychInfo and Pubmed databases for studies that measured the association between SES and cigarette smoking, alcohol consumption, marijuana use, diet, and physical activity in adolescents between 10- and 21-years old.

RESULTS

Associations between SES and health behaviors conformed to two patterns. First, low SES was associated with poorer diets, less physical activity, and greater cigarette smoking. Second, there was no clear pattern of associations between SES and alcohol consumption or marijuana use.

CONCLUSION

Results from this review indicate that, although some associations between SES and health behaviors exist during adolescence, the associations are not as robust as those in adulthood. Efforts to curb poor diet, inactivity, and smoking behaviors should target low SES adolescents, whereas efforts to curb teen drinking and marijuana use may be useful across the SES spectrum.

Area deprivation and oral health in Scottish adults: a multilevel study

OBJECTIVES

To explore the association between area deprivation and adult oral health.

METHODS

Multilevel regression analysis of data taken from the 1998 Adult Dental Health Survey in the UK comprising 632 participants living in 346 households located in 31 postcode sectors in Scotland. Three oral health outcomes were investigated: number of sound (including restored) teeth; has one or more unsound teeth; has periodontal pocketing 4 mm or more in one or more teeth.

RESULTS

In the most deprived areas, individuals had a mean of 4.6 fewer sound teeth than those in the least deprived areas. The difference in normalised number of sound teeth between least and most deprived areas was -0.707 (95% CI -1.164, -0.250), P = 0.024. After adjusting for age, sex, qualification status, head of household social class and household income, the estimated difference was -0.238 (-0.591 to 0.115) (P = 0.164). Area deprivation was not associated with having one or more unsound teeth or periodontal pocketing 4 mm or more in one or more teeth.

CONCLUSIONS

There is a univariate association of area deprivation with the number of sound teeth. This association is largely explained by household and individual level socioeconomic variables. A small area deprivation effect cannot be excluded in these data. The findings challenge current understanding of the relationship between area deprivation and oral health. Further multilevel research exploring the relationship between area deprivation and oral health is required using a larger sample and a prospective longitudinal design.

Marital status and mortality in the elderly: a systematic review and meta-analysis

Although a relationship between marital status and mortality has long been recognized, no summary estimates of the strength of the association are available. A meta-analysis of cohort studies was conducted to produce an overall estimate of the excess mortality associated with being unmarried in aged individuals as well as to evaluate whether and to what degree the effect of marriage differs with respect to gender, geographical/cultural context, type of non-married condition and study methodological quality. All included studies were published after the year 1994, used multivariate analyses and were written in English. Pooling 53 independent comparisons, consisting of more than 250,000 elderly subjects, the overall relative risk (RR) for married versus non-married individuals (including widowed, divorced/separated and never married) was 0.88 (95% Confidence Interval: 0.85-0.91). This estimate did not vary by gender, study quality, or between Europe and North America. Compared to married individuals, the widowed had a RR of death of 1.11 (1.08-1.14), divorced/separated 1.16 (1.09-1.23), never married 1.11 (1.07-1.15). Although some evidence of publication bias was found, the overall estimate of the effect of marriage was robust to several statistical approaches and sensitivity analyses. When the overall meta-analysis was repeated with an extremely conservative approach and including eight non-significant comparisons, which were initially excluded because of data unavailable, the marriage protective influence remained significant, although the effect size was reduced (RR=0.94; 0.92-0.95). Despite some methodological and conceptual limitations, these findings might be important to support health care providers in identifying individuals "at risk" and could be integrated into the current programs of mortality risk estimation for the elderly.

Disentangling contextual effects on cause-specific mortality in a longitudinal 23-year follow-up study: impact of population density or socioeconomic environment?

BACKGROUND

Various studies have investigated urban/rural differences in cause-specific mortality. A separate body of literature has analysed effects of socioeconomic environment on mortality. Almost no studies have attempted to disentangle effects of population density and socioeconomic environment on mortality, beyond the effects of individual characteristics.

METHODS

Considering all individuals living in the region of Scania, Sweden, from 1970-93, we performed 10 year mortality follow-ups on (i) individuals aged 55, (ii) individuals aged 65, and (iii) individuals aged 75 years at baseline. Cox multilevel models adjusted for individual factors allowed us to investigate the independent effects of population density and median income in the parish of residence on mortality from ischaemic heart disease (IHD), lung cancer, and chronic obstructive pulmonary disease (COPD) among individuals who had lived in the same parish for at least 10 years prior to mortality follow-up.

RESULTS

In females, as in males, after adjustment for individual and contextual socioeconomic status, we found a dose-response association between population density and mortality from lung cancer and COPD in all age groups investigated, and from IHD especially in the youngest age group. Overall, the population density effect was the strongest on lung cancer mortality. Median income had an additional impact only in 2 out of 16 subgroups of age x gender x cause of death.

CONCLUSIONS

In our region-wide study conducted at the parish level, contextual disparities in mortality were dominated by the population density effect. However, it may be unwise to conclude that truly contextual effects exist on mortality, before identification of plausible mediating processes through which urbanicity may influence mortality risk.