Life Course Socioeconomic Position, Intergenerational Social Mobility, and Hypertension Incidence in ELSA-Brasil

The Dynamic Nature of the Socioeconomic Determinants of Cardiovascular Health: A Narrative Review

Despite decades of social epidemiologic research, health inequities remain pervasive and ubiquitous in Canada and elsewhere. One reason may be our use of socioeconomic measurement, which has often relied on single point-in-time exposures. To explore the extent to which researchers have incorporated dynamic socioeconomic measurement into cardiovascular health outcome evaluations, we performed a narrative review. We estimated the prevalence of socioeconomic longitudinal cardiovascular research studies that identified socioeconomic exposures at 2 or more points in time between the years of 2019 and 2023. We defined cardiovascular outcome studies as those that examined coronary artery disease, myocardial infarction, acute coronary syndrome, stroke, heart failure, cardiac arrhythmias, cardiac death, cardiometabolic factors, transient ischemic attacks, peripheral artery disease, or hypertension. Socioeconomic exposures included individual income, neighbourhood income, intergenerational social mobility, education, occupation, insurance status, and economic security. Seven percent of socioeconomic cardiovascular outcome studies have measured socioeconomic status at 2 or more points in time throughout the follow-up period, hypothesized mechanisms by which dynamic socioeconomic measures affected outcome focused on social mobility, accumulation, and critical period theories. Insights, implications, and future directions are discussed, in which we highlight ways in which postal code data can be better used methodologically as a dynamic socioeconomic measure. Future research must incorporate dynamic socioeconomic measurement to better inform root causes, interventions, and health-system designs if health equity is to be improved.

A prospective longitudinal approach to examine the association between social position in childhood, adolescence, and adulthood with the control of hypertension during adulthood

Introduction

Hypertension is one of the main concerns in public health, since it is related with increased morbidity, and potential years of life lost in addition to loss of quality of life. This study aimed to assess: (1) the distribution of indicators of life course SEP in a cohort of Colombian patients with hypertension and (2) to assess the association of life course SEP and control of hypertension among this cohort of patients.

Methods

Data were obtained using the baseline survey of 258 patients from the Social Determinants and Inequities in the Control of Blood Hypertension Program (ProDSICHA). Mother occupation and housing conditions were measured with the Event History Calendar. Mother educational level was measured with the questionnaire developed by the Project on Ethnicity and Race in Latin America (PERLA). Socioeconomic position during adulthood was measured using education, occupation, and income level based in the MacArthur Network.

Results

The group with a higher lifelong social position and the group of lower lifelong social position showed better control of hypertension (OR = 1.21; p <0.05; OR = 1.33; p < .05, respectively) compared to those whose social position throughout life varied the most. No statistical differences were found in the relations between single lifetime social position variables, and hypertension control in the three time points analyzed.

Discussion

These findings warrant further research to deeper our understanding on the role of a multidimensional and cumulative approach of social position in hypertension control.

Gender, race/skin colour and incidence of hypertension in ELSA-Brasil: an intersectional approach

OBJECTIVE

Race and gender inequities in the incidence of hypertension (HTN) are well documented; however, few empirical investigations looked into these associations, considering the synergies and heterogeneous experiences of intersectional gender and race/skin colour groups. This study investigated the association of intersectional identities defined by gender and race/skin colour with HTN incidence, and verified whether they are affected by educational level in adulthood.

DESIGN

We used the Longitudinal Study of Adult Health (ELSA-Brasil) data to estimate the incidence of HTN between visits 1 (2008-2010) and 2 (2012-2014), in 8528 participants without hypertension at visit 1. HTN was defined as systolic blood pressure ≥140 mmHg, or diastolic blood pressure ≥90 mmHg, or use of antihypertensive drugs. Generalized linear models with Poisson distribution and log link function were used to assess the associations.

RESULTS

The incidence of HTN was 43.4/1000 person-years, ranging from 30.5/1000 in White women to 59.4/1000 in Black men. After adjusting by age and family history of HTN, the incidence rate ratio (IRR) was higher in Black men (2.25; 95%CI: 1.65-3.08), Brown (Pardo) men (1.89; 95%CI: 1.59-2.25), Black women (1.85; 95%CI: 1.50-2.30), Brown (Parda) women (1.47; 95%CI: 1.31-1.67) and White men (1.76; 95%CI: 1.49-2.08), compared to White women. These associations were maintained even after considering socioeconomic, behavioural and health mediators in the model. No interaction was found between education level and intersectional identities in the IRRs observed.

CONCLUSION

By using an intersectional approach, we showed the complex relations between race/skin colour and gender inequities in the incidence of HTN, pointing not only that Black men have the highest risk of developing HTN, but also that the risk of HTN is greater in Black women than in White men, when compared to White women.

Effect of health coaching on blood pressure control and behavioral modification among patients with hypertension: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Health coaching has emerged as a potential supporting tool for improving hypertension health behavior. However, health coaching efficacy on hypertension has not been reviewed systematically.

OBJECTIVE

To evaluate the effects of health coaching on blood pressure and behavioral changes among patients with hypertension in randomized controlled trials.

DESIGN

A systematic review and meta-analysis.

METHODS

We searched Medline (via PubMed), Web of Science, Embase, Cochrane Central Register of Controlled Trials, Proquest, and Scopus from inception to November 30, 2021. All randomized controlled trials that estimated the effects of health coaching on blood pressure and behavioral changes in adults with hypertension were included. The Cochrane risk-of-bias tool was used to evaluate the quality of the included studies. Standardized mean differences (SMD) and 95 % confidence intervals (CIs) were calculated using random-effects or fixed-effects meta-analysis. Sensitivity analysis and subgroup analysis were also conducted.

RESULTS

A total of 1655 studies were screened and 12 randomized controlled trials were selected for inclusion, with 2497 participants were included. Most of the studies were at low risk of bias and the quality of evidence was high. The meta-analysis demonstrated that health coaching could significantly reduce systolic blood pressure (SMD: -0.26, 95 % CI: -0.39, -0.13, p < 0.001) and diastolic blood pressure in hypertension (SMD: -0.13, 95 % CI: -0.22, -0.03, p = 0.009). In addition, health coaching showed statistically significant positive effects on dietary behaviors (SMD: 0.76, 95 % CI: 0.08, 1.44, p = 0.02) and self-efficacy (SMD: 0.39, 95 % CI: 0.05, 0.73, p = 0.02). Subgroup analysis indicated that the most common and effective type of health coaching was the phone-based interventions (systolic blood pressure: SMD: -0.27, 95 % CI: -0.44, -0.10, p = 0.002; diastolic blood pressure: SMD: -0.14, 95 % CI: -0.25, -0.03, p = 0.02). The effects of nurse-delivered interventions were larger than other health care professionals (systolic blood pressure: SMD: -0.42, 95 % CI: -0.68, -0.16, p = 0.002; diastolic blood pressure: SMD: -0.19, 95 % CI: -0.35, -0.04, p = 0.02).

CONCLUSION

Current evidence suggested that health coaching could reduce blood pressure, improve dietary behaviors, and increase self-efficacy among patients with hypertension and thus could be an effective and alternative method in the management of hypertension. The most common and effective types of health coaching were phone-based and nurse-delivered interventions. Thus, more strategies and policies may be needed to implement these types of interventions to more patients with hypertension.

Determinants and health outcomes of trajectories of social mobility in Australia

Objectives

To investigate trajectories in socio-economic position (SEP) and the onset of a range of physical and mental health outcomes and commencement of treatment.

Methods

The Household Income and Labour Dynamics Australia (HILDA) study, a nationally representative prospective cohort study over the period 2001 to 2020 was used to define trajectories of SEP. Trajectories of low, low-middle, upper-middle and high SEP and decreasing (low-middle to upper-middle SEP) or increasing (upper-middle to lower-middle SEP) SEP were identified using k-longitudinal means. Cox-regression was used to assess SEP trajectories and physical (arthritis or osteoporosis, any cancer, asthma, chronic bronchitis or emphysema, Type 1 diabetes, Type 2 diabetes, hypertension or high blood pressure, and coronary heart disease), and mental health (depression or anxiety) outcomes, and treatment commencement. Predictors of SEP trajectories were also investigated using multinomial logistic regression and random forests.

Results

Decreasing SEP had a higher relative risk of new onset illness than increasing SEP for all health outcomes. Increasing SEP had relative risk estimates that were more consistent with upper-middle income groups and decreasing SEP had a relative risk consistent with lower-middle income groups. In contrast, there was no socio-economic gradient in treatment commencement for physical health outcomes, or depression or anxiety, with the exception of arthritis or osteoporosis.

Conclusion

Decreasing SEP was associated with poor health outcomes, and increasing SEP with better health outcomes. A range of socio-demographic and psychosocial determinants of SEP trajectories were identified to inform policy responses that could modify trajectories of health inequalities in the Australian context.

Racismo e iniquidade racial na autoavaliação de saúde ruim: o papel da mobilidade social intergeracional no Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil)

Resumo: Pretos e pardos apresentam grandes desvantagens de saúde, possuem menores chances de ascensão na hierarquia social no curso de vida e menores níveis socioeconômicos do que brancos como resultado do racismo estrutural. Entretanto, pouco se sabe sobre o papel mediador da mobilidade intergeracional na associação entre racismo e saúde. O objetivo do presente estudo foi investigar a associação entre racismo e a autoavaliação de saúde, e verificar em que medida a mobilidade social intergeracional media essa associação. Estudo transversal realizado com dados de 14.386 participantes da linha de base (2008-2010) do Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil). Escolaridade materna, escolaridade do participante, classe sócio-ocupacional do chefe de família e classe sócio-ocupacional do participante compuseram os indicadores de mobilidade social intergeracional (educacional e sócio-ocupacional). Modelos de regressão logística foram utilizados. A prevalência de autoavaliação de saúde ruim foi de 15%, 24% e 28% entre brancos, pardos e pretos, respectivamente. Após ajustes por idade, sexo e centro de investigação foram encontradas maiores chances de autoavaliação de saúde ruim entre pretos (OR = 2,15; IC95%: 1,92-2,41) e pardos (OR = 1,82; IC95%: 1,64-2,01) quando comparados aos brancos. A mobilidade educacional e sócio-ocupacional intergeracional mediaram, respectivamente, 66% e 53% da associação entre a raça/cor e autoavaliação de saúde ruim em pretos, e 61% e 51% em pardos, respectivamente. Resultados confirmam a iniquidade racial na autoavaliação de saúde e apontam que a mobilidade social intergeracional desfavorável é um importante mecanismo para explicar essa iniquidade.

Invited Commentary: Is the Long Shadow of Childhood Disadvantage on Lifelong Health Getting Worse Over Time?

Social inequalities in health and their early-life origins have been extensively documented. Although the complex direct and intermediate mechanisms linking early-life disadvantage to later health are not yet fully understood, new findings on biological markers distinctly related with early-life experiences suggest a causal relationship. In this issue, Fuller-Rowell et al. (Am J Epidemiol. 2021:190(11):2284-2293) step back to examine the role of childhood disadvantage in the United States in different periods, observing that the relationship with later health seems to have strengthened over time. The main explanation the authors bring up has to do with increased income segregation and changes in labor market composition that limit opportunities for persons with low educational attainment. In other words, while the rich get richer, the poor get poorer, the middle class shrinks, and there are fewer interactions across different socioeconomic groups and the social ladder is blocked. Other evidence suggests that investments in children, through early education and academic support programs, could help reduce the consequences of childhood disadvantage on long-term health.