How do age and major risk factors for mortality interact over the life-course? Implications for health disparities research and public health policy

Disability Mortality Disparity: Risk Of Mortality For Disabled Adults Nearly Twice That For Nondisabled Adults, 2008-19

After years of advocacy by the disability community and allied organizations, on September 26, 2023, the National Institute on Minority Health and Health Disparities (NIMHD) designated disabled people as a health disparities population in the US. During its deliberations, the NIMHD emphasized that there was not sufficient empirical evidence on health disparities between disabled and nondisabled adults. My study addressed this gap by examining 2008-19 data from the National Health Interview Survey Linked Mortality Files on people ages eighteen and older to identify, categorize, and quantify disparities in mortality risk among disabled and nondisabled adults. The risk of mortality during the study period was 1.9 times higher overall for disabled compared with nondisabled adults. The risk increased with the number of reported disabilities and varied by disability category. These findings underscore the need to improve access to high-quality, evidence-based health care among disabled people. To gain a full understanding of the scope of disparity and the interventions needed to mitigate it, it is critical to develop more equitable and inclusive measures of disability and ableism for use in population health surveys.

Ageism and lookism as stereotypes of health disparity in intensive care units in Iran: a critical ethnography

BACKGROUND

The intensive care unit presents structural complexities, and the prevailing power imbalance between patients and staff can lead to health disparities. Hence, unveiling the underlying factors that give rise to and reinforce these disparities can contribute to their prevention. This study aims to shed light on the stereotypes linked to ageism and lookism, which perpetuate health disparities within the intensive care unit setting in Iran.

METHODS

This critical ethnographic study employed Carsepkan's approach and was carried out in intensive care units in the west of Iran from 2022 to 2023. The data collection and analysis were conducted through three interconnected stages. In the initial stage, more than 300 h of observations were made at the research site. In the subsequent stage, a horizon analysis was performed. Conversations with 14 informants were conducted in the final stage to enrich the dataset further. Then the analysis process was carried out as in the previous step to uncover an implicit culture of health disparity. To verify the validity and reliability of the study, credibility, conformability, dependability, and transferability were all taken into account.

FINDINGS

The ageism and lookism stereotypes emerged from seven main themes; youth-centric; negative ageism; age-friendliness; age-related priority; centered care for pediatric patients and families; appearance-centeredness; and a contradiction between belief and behavior.

CONCLUSION

This critical study showed that ageism and lookism stereotypes permeated the intensive care unit's culture. These stereotypes have the potential to influence equality dynamics, as well as to foster and support health disparity in the intensive care unit.

Age at diagnosis modifies associations of type 2 diabetes with cancer incidence and mortality: a retrospective matched-cohort study

AIMS/HYPOTHESIS

The age-specific associations between type 2 diabetes and cancer risk are not fully understood. The aim of this study was to assess how age at diagnosis modifies the associations between type 2 diabetes and cancer risk.

METHODS

We used data from the Yinzhou Health Information System, and included 42,279 individuals who were newly diagnosed with type 2 diabetes between 2010 and 2014, as well as 166,010 age- and sex-matched control individuals without diabetes who were selected randomly from the electronic health records of the entire population. Patients were divided into four age groups according to age at diagnosis: <50, 50-59, 60-69 and ≥70 years. Stratified Cox proportional hazards regression models, with age as the time scale, were used to estimate the HRs and 95% CIs for the associations of type 2 diabetes with the risks of overall and site-specific cancers. Population-attributable fractions were also calculated for outcomes associated with type 2 diabetes.

RESULTS

During median follow-up periods of 9.20 and 9.32 years, we identified 15,729 incident cancer cases and 5383 cancer deaths, respectively. Patients diagnosed with type 2 diabetes before 50 years of age had the highest relative risks of cancer incidence and mortality, with HRs (95% CI) of 1.35 (1.20, 1.52) for overall cancer incidence, 1.39 (1.11, 1.73) for gastrointestinal cancer incidence, 2.02 (1.50, 2.71) for overall cancer mortality, and 2.82 (1.91, 4.18) for gastrointestinal cancer mortality. Risk estimates decreased gradually with each decade increase in diagnostic age. The population-attributable fractions for overall cancer and gastrointestinal cancer mortality also decreased with increasing age.

CONCLUSIONS/INTERPRETATION

The associations of type 2 diabetes with cancer incidence and mortality varied by age at diagnosis, with a higher relative risk among patients who were diagnosed at a younger age.

Provider discussion of health goals and psychosocial needs: Comparing older to younger veteran experience

OBJECTIVE

To examine by age, the veterans' report on whether components of age-friendly health systems were discussed during primary care visits.

DATA SOURCES AND STUDY SETTING

Veterans Affairs (VA) Survey of Healthcare Experience of Patients from October 2015 to September 2019.

STUDY DESIGN

Cross-sectional survey of VA users by age group (18-44 years, 45-64 years, 65+ years; N = 1,042,318). We used weighted logistic regression models to evaluate disparities in whether veterans discussed with anyone in their provider's office: health goals, depression symptoms, stress, personal problems, and medications. Models were adjusted for socio-demographic characteristics (sex, socioeconomic status, education, rurality) and comorbidity.

DATA COLLECTION/EXTRACTION METHOD

Surveys were administered by mail and online. Additional veteran characteristics were extracted from VA administrative data.

PRINCIPAL FINDINGS

In unadjusted analyses, VA users age 18-44 had a higher (-8.2%; CI: -9.0, -7.3) and users aged 45 to 64 had lower (4.0%; CI: 3.7, 4.3) predicted, probably discussing health goals compared to age 65+. Fewer VA users age 65+ reported discussing depression symptoms, personal problems, and stress than other age groups, whereas more VA users age 65+ discussed medications. Results were unchanged after adjusting for socio-demographics and comorbidity.

CONCLUSIONS

Delivery of goal-concordant care relies on understanding the needs of individual patients. Lower rates of discussing what matters and mood represent potential missed opportunities to deliver age-friendly care for older veterans.

Diminished Advantage or Persistent Protection? A New Approach to Assess Immigrants' Mortality Advantages Over Time

Much research has debated whether immigrants' health advantages over natives decline with their duration at destination. Most such research has relied on (pooled) cross-sectional data and used years since immigration as a proxy for the duration of residence, leading to the challenge of distilling the duration effect from the confounding cohort-of-arrival and age-of-arrival effects. Because longitudinal studies tend to use self-rated health as the outcome, the changes they observed may reflect shifts in immigrants' awareness of health problems. We illuminate the debate by examining how immigrants' mortality risk-a relatively unambiguous measure tied to poor health-changes over time compared to natives' mortality risk. Our analysis uses the National Health Interview Survey (1992-2009) with linked mortality data through 2011 (n = 875,306). We find a survival advantage for U.S. immigrants over the native-born that persisted or amplified during the 20-year period. Moreover, this advantage persisted for all immigrants, regardless of their race/ethnicity and gender or when they began their U.S. residence. This study provides unequivocal evidence that immigrant status' health protection as reflected in mortality is stable and long-lasting.

How does it all end? Trends and disparities in health at the end of life

OBJECTIVES

To consider trends and disparities in end-of-life health in the US.

METHODS

I use data from the National Health Interview Survey, linked to death records through 2015, for respondents who died at ages 65+ to compare the prevalence of three health outcomes in the last six years of life across time, sex, age, race, and educational attainment. Self-rated health (SRH) is available for respondents interviewed in years 1987-2014, while information on activities of daily living (ADL) and instrumental activities of daily living (IADL) is available for the period 1997-2014.

RESULTS

By the end of the study period, individuals reported two fewer months of fair/poor health at the end of life than those dying in earlier years. In contrast, time lived with at least one activity limitation at the end of life generally remained comparable. Compared to men, women on average reported an additional year of living with an IADL limitation before death, and an additional eight months with an ADL limitation. Despite sex differences in disability, both sexes reported similar periods of fair/poor SRH before death. Similarly, while individuals who lived to older ages experienced a longer disabled period before death than individuals who died at younger ages, all age groups were equally likely to report fair/poor SRH. Black adults and adults with less formal schooling also spent more time with an end-of-life disability. For men, these racial and socioeconomic disparities lessened as death approached. For women, inequalities persisted until death.

DISCUSSION

These findings suggest that despite increasing life expectancy, the period of poor health and disability prior to death has not recently been extended. Black women and women with less than a high school degree, require extended support at the end of life.

The Impact of COVID-19 on Economic Growth of Countries: What Role Has Income Inequality in It?

This paper argues that income inequality explains the variation in the economic performance of different countries over the first year of the COVID-19 pandemic. Unlike the conclusions reported by some studies, this study shows that health casualties caused by COVID-19 has had a higher adverse economic impact on countries with lower income inequality. Notwithstanding, the decline in the economic growth as well as the number of casualties caused by COVID-19 were, overall, proportionate to the level of income inequality of the country. Furthermore, the results showed that countries with more dependence on the service sector and countries that implemented more restrictive measures (lockdowns) experienced a higher decline in GDP growth over the first year of the pandemic period. The paper concludes with some important policy implications that support the role of strong institutions in making economies resilient over a period of pandemic.

Socioeconomic differences in the association between maternal age and maternal obesity: a register-based study of 707,728 women in Finland

AIMS

To examine the association between maternal age and maternal obesity across socioeconomic groups and to determine whether socioeconomic status modifies the association between maternal age and maternal obesity with a view to informing public health policies.

METHODS

Data for this register-based study were sourced from the Finnish Medical Birth Register and Statistics Finland, using the information of 707,728 women who gave birth in Finland from 2004 to 2015. We used multivariable regression models to assess the association between maternal age and maternal obesity across socioeconomic groups. We further assessed interactions on both multiplicative and additive scales.

RESULTS

Across all socioeconomic groups, the adjusted odds ratio for the association between maternal age and maternal obesity increased, peaking for women 35 years or older. Using women below 20 years of age in the category of upper-level employees as a single reference group, in the category of upper-level employees, the adjusted odds ratio and 95% confidence intervals among women 35 years or older was 1.92 (1.39-2.64) for maternal obesity. Equally, the adjusted odds ratio and 95% confidence intervals in the category of long-term unemployed was 4.35 (3.16-5.98). Synergistic interactions on both multiplicative and additive scales were found across age and socioeconomic groups.

CONCLUSIONS

The association between maternal age and maternal obesity was strongest among women 35 years or older with lower socioeconomic status. Population-level interventions that address maternal risk factors from teenage years are needed alongside individual-level interventions that target high-risk mothers in areas of low socioeconomic status and maternal obesity.

The Association Between Educational Attainment and Mortality: Examining Absolute and Relative Effects by Race/Ethnicity

OBJECTIVES

To determine whether the association between educational attainment and mortality varies by race/ethnicity on the absolute and relative scales, including among understudied races/ethnicities.

METHODS

Data were obtained from the US National Longitudinal Mortality Study (1983-1984). Hazard models for adults aged ≥25 years (n=725,756) with race/ethnicity by educational interaction terms were used to test relative interaction; linear binomial models were used to test for absolute interaction.

RESULTS

For the most part, educational gradients in mortality did not differ across race/ethnicity on the multiplicative scale. Conversely, additive interactions appear to be significant. Blacks gained more in terms of reduced mortality rates for each additional year of schooling. The educational gradient in Whites is also notable as the lowest educated Whites have similar absolute numbers of expected deaths as Blacks similarly educated. At higher levels of education, Whites gain substantially in terms of longer longevity. The educational gradient in Asians, Hispanics, and Native Americans is narrower compared to both Whites and Blacks.

CONCLUSIONS

The association between educational attainment and mortality does not function uniformly across race/ethnicity.

Vascular risk factors and stroke risk across the life span: A population-representative study of half a million people

Background:

The incidence of stroke in developed countries is increasing selectively in young individuals, but whether this is secondary to traditional vascular risk factors is unknown.

Methods:

We used the Canadian Community Health Survey from 2000 to 2016 to create a large population-representative cohort of individuals over the age of 30 and free from prior stroke. All analyses were stratified by age decile. We linked with administrative databases to determine emergency department visits or hospitalizations for acute stroke until December 2017. We calculated time trends in risk factor prevalence (hypertension, diabetes, obesity, and smoking) using meta-regression. We used Cox proportional hazard models to evaluate the association between vascular risk factors and stroke risk, adjusted for demographic, co-morbid, and social variables. We used competing risk regression to account for deaths and calculated population-attributable fractions. In a sensitivity analysis, we excluded those with prior heart disease or cancer.

Results:

We included 492,400 people in the analysis with 8865 stroke events over a median follow-up time of 8.3 years. Prevalence of hypertension, diabetes, and obesity increased over time while smoking decreased. Associations of diabetes, hypertension, and obesity with stroke risk were progressively stronger at younger age (adjusted hazard ratio for diabetes was 4.47, 95% confidence interval (CI) = 1.95–10.28 at age 30–39, vs 1.21, 95% CI = 0.93–1.57 at age 80+), although the obesity association was attenuated with adjustment. Smoking was associated with higher risk of stroke without a gradient across age deciles, although had the greatest population-attributable fraction at younger age. The hazard ratio for stroke with multiple concurrent risk factors was much higher at younger age (adjusted hazard ratio for 3–4 risk factors was 8.60, 95% CI = 2.97–24.9 at age 30–39 vs 1.61, 95% CI = 0.88–2.97 at age 80+) and results were consistent when accounting for the competing risk of death and excluding those with prior heart disease or cancer.

Conclusions:

Diabetes and hypertension were associated with progressively elevated relative risk of stroke in younger individuals and prevalence was increasing over time. The association of obesity with stroke was not significant after adjustment for other factors. Smoking had the greatest prevalence and population-attributable fraction for stroke at younger age. Our findings assist in understanding the relationship between vascular risk factors and stroke across the life span and planning public health measures to lower stroke incidence in the young.

Does time heal all wounds? Life course associations between child welfare involvement and mortality in prospective cohorts from Sweden and Britain

Child welfare involvement reflects childhood adversity and is associated with increased adult mortality, but it remains unclear how this association changes over the life course. Drawing on the Stockholm Birth Cohort Multigenerational Study (Sweden) and the National Childhood Development Study (Great Britain) this study examines whether inequalities within these cohorts diverge or converge. Involvement with child welfare services (ICWS) is divided into two levels ('child welfare contact' and 'out-of-home care'). For each cohort, we quantify absolute health inequalities as differences in cumulative probabilities of death (18-58 years) and temporary life expectancy; and relative inequalities as hazard ratios in ten-year intervals and ratios of lifetime lost. Persistently, ICWS was associated with premature mortality. The strength of the association varied by age, sex and level of ICWS. Consistently across both countries, the most robust relationship was between out-of-home care and mortality, with statistically significant age-specific hazard ratios ranging between 1.8 and 3.4 for males and 1.8-2.1 for females. Child welfare contact that did not result in out-of-home placement showed less consistent results. Among females the mortality gap developed later compared to males. Estimates attenuate after controlling for family socioeconomic and other background variables but patterns remain intact. Our results show that absolute inequalities widen with increasing age, while relative inequalities might peak in early adulthood and then stabilize in midlife. The relative disadvantage among looked-after children in early adulthood is heightened by overall low rates of mortality at this age. Absolute inequality increases with age, highlighting the weight of the accumulation of disadvantage in mortality over time. The bulk of excess deaths that could be attributed to ICWS occurs from midlife onwards. Mechanisms that uphold the disadvantage after childhood experiences require further exploration. This study highlights that the association between out-of-home care and premature mortality seems to transcend welfare systems.

Associations between maternal age and socioeconomic status with smoking during the second and third trimesters of pregnancy: a register-based study of 932 671 women in Finland from 2000 to 2015

OBJECTIVES

This study aimed to explore the association between maternal age and smoking during the second and third trimesters of pregnancy across socioeconomic groups and to evaluate the interacting effect of maternal age and socioeconomic status on smoking with a view to informing public health interventions.

DESIGN

This is a register-based study.

SETTINGS

Data from the Finnish Medical Birth Register were cross-linked with background data from Statistics Finland.

PARTICIPANTS

The information of 932 671 pregnant women who gave birth in Finland from 2000 to 2015.

MAIN OUTCOME MEASURES

Maternal smoking during the second and third trimesters of pregnancy by occupation and maternal age.

RESULTS

The proportion of women who smoked during the second and third trimesters of pregnancy was 10.5%. Using women 30-34 years as the reference group, adjusted ORs (aOR) and 95% CIs for smoking were 6.02 (5.81 to 6.24) in women below 20 years and 2.77 (2.71 to 2.84) in women 20 to 24 years. The prevalence of smoking across socioeconomic groups compared with upper-level employees increased, peaking for women in manual occupations (aOR 3.39, 95% CI 3.25 to 3.52) and unemployed women (aOR 4.49, 95% CI 4.30 to 4.68). Significant interactions on the additive scale with the relative excess risk due to interaction >2 were found for unemployed women aged 25-29 years and for teenage mothers and mothers aged 20-24 years across all socioeconomic groups, but not for self-employed women.

CONCLUSIONS

Smoking during the second and third trimesters of pregnancy was most common among teenage mothers across all socioeconomic groups. The association between maternal age and smoking differed by socioeconomic status for young mothers. Interventions should address a wider range of maternal risk factors among young mothers with low socioeconomic status and simultaneously target a broader number of women who smoke during the pregnancy.

Socio-Demographic Determinants of Mortality from Chronic Noncommunicable Diseases in Women of Reproductive Age in the Republic of Georgia: Evidence from the National Reproductive Age Mortality Study (2014)

Purpose

Worldwide, noncommunicable diseases (NCDs) are the leading cause of premature death of women, taking the highest toll in developing countries. This study aimed to identify key socio-demographic determinants of NCD mortality in reproductive-aged women (15-49 years) in Georgia.

Materials and Methods

The study employed the verbal autopsy data from the second National Reproductive Age Mortality Survey 2014. Univariate and multivariate logistic regression models were fitted to explore the association between each risk factor and NCD mortality, measured by crude and adjusted odds ratio (AOR) with respective 95% confidence intervals (95% CI).

Results

In the final sample of 843 women, 586 (69.5%) deaths were attributed to NCDs, the majority of which occurred outside a hospital (72.7%) and among women aged 45-49 years (46.8%), ethnic Georgians (85.2%), urban residents (60.1%), those being married (60.6%), unemployed (75.1%) or having secondary and higher education (69.5%), but with nearly equal distribution across the wealth quintiles. After multivariate adjustment, the odds of dying from NCDs were significantly higher in women aged 45-49 years (AOR=17.69, 95% CI= 9.35 to 33.50), those being least educated (AOR=1.55, 95% CI= 1.01 to 2.37) and unemployed (AOR=1.47, 95% CI= 1.01 to 2.14) compared, respectively, to their youngest (15-24 years), more educated and employed counterparts. Strikingly, the adjusted odds were significantly lower in "other" ethnic minorities (AOR=0.29, 95% CI= 0.14 to 0.61) relative to ethnic Georgians. Contrariwise, there were no significant associations between NCD mortality and women's marital or wealth status, place of residence (rural/urban) or place of death.

Conclusion

Age, ethnicity, education, and employment were found to be strong independent predictors of young women's NCD mortality in Georgia. Further research on root causes of inequalities in mortality across the socioeconomic spectrum is warranted to inform equity- and life course-based multisectoral, integrated policy responses that would be conducive to enhancing women's survival during and beyond reproduction.

Education and adult health: Is there a causal effect?

Many studies find a strong positive correlation between education and adult health. A subtler question is whether this correlation can be interpreted as a causal relationship. We combine multi-country data from two cross-sections of the European Union Statistics on Income and Living Conditions (EU-SILC) survey and use exogenous variation in compulsory years of schooling across countries and cohorts induced by compulsory schooling laws. We find no causal effect of education on any of our several health measures. This finding is extremely robust to different changes in our main specification and holds using other databases. We discuss different explanations for our results.

Obesity-mortality link over the life course: the contribution of population compositional changes

A key uncertainty in the obesity-mortality association continues to be how this association changes over the life course. Prior studies tend to rely on cross-sectional design with static weight status taken at the time of the survey. This study tracks a cohort of individuals and employs lifelong body mass index information from the Framingham Heart Study original cohort (1948-2010). We focus on respondents who were younger than age 45 at time of their first survey (n = 2,176) and evaluate how the mortality risk associated with obesity changes over three age groups (below 45, 45-59, and 60 and above) and how population compositions may contribute to this pattern. We find the hazard ratio associated with obesity compared to normal weight decreases over three age groups, but this pattern is influenced by different ages of onset of obesity, inconsistency in the reference group (normal weight) over ages, and mortality selection effects. These factors explain away the decreasing effect of obesity (with onset before age 45) on mortality up to age 60; after age 60, the detrimental effect still declines, but to a much less degree. Later onset of obesity, however, is not significantly associated with excess mortality risks after age 60.

Analysis of Sociodemographic and Information Factors on Family Behaviour in Early Detection of High-Risk Pregnancy

Introduction: Pregnancy and childbirth are physiological processes experienced by women, but they sometimes have risky conditions. There are still many pregnant women and their families who are unable to detect a high-risk of pregnancy early. This study aims to determine family behaviour in conducting early detection of a high-risk of pregnancy in terms of sociodemographic and information factors.Methods: This study uses an explanatory survey design with a cross sectional design. The sample size of this study was 146, with simple random sampling. The independent variables were sociodemographic factors (age, gender, ethnicity, education, income and religion) and information factors (experience, and media exposure) while the dependent variable is family behaviour. The instrument with the questionnaire used the Likert scale. The data was analysed using partial least square.Results: The results showed that Structural Equation Modelling-Partial least square (SEM-PLS) statistical analysis, through Confirmatory Factor Analysis (CFA), obtained sociodemographic factors on family behaviour of 1,999, and information factors on family behaviour of 13,78. The value of the influence of sociodemographic factors (0.102) and the value of the influence of information factors (0.754). R2 (0.63) and Q2 value of 0.65.Conclusion: Sociodemographic  factors and information factors significantly influenced family behaviour factors in early detection of high-risk of pregnancy. Information factors have a greater effect on family behaviour than sociodemographic factors. Midwives as health service providers at the health care centre need to optimize family empowerment through health information efforts in health promotion efforts. Further research requires the involvement of other factors to improve family behaviour, especially in the ability of families to detect early high-risk pregnancies.