Social class and cause of death

Territorial gaps on quality of causes of death statistics over the last forty years in Spain

BACKGROUND

The quality of the statistics on causes of death (CoD) does not present consolidated indicators in literature further than the coding group of ill-defined conditions of the International Classification of Diseases. Our objective was to assess the territorial quality of CoD by reliability of the official mortality statistics in Spain over the years 1980-2019.

METHODS

A descriptive epidemiological design of four decades (1980-, 1990-, 2000-, and 2010-2019) by region (18) and sex was implemented. The CoD cases, age-adjusted rates and ratios (to all-cause) were assigned by reliability to unspecific and ill-defined quality categories. The regional mortality rates were contrasted to the Spanish median by decade and sex by the Comparative Mortality Ratio (CMR) in a Bayesian perspective. Statistical significance was considered when the CMR did not contain the value 1 in the 95% credible intervals.

RESULTS

Unspecific, ill-defined, and all-cause rates by region and sex decreased over 1980-2019, although they scored higher in men than in women. The ratio of ill-defined CoD decreased in both sexes over these decades, but was still prominent in 4 regions. CMR of ill-defined CoD in both sexes exceeded the Spanish median in 3 regions in all decades. In the last decade, women's CMR significantly exceeded in 5 regions for ill-defined and in 6 regions for unspecific CoD, while men's CMR exceeded in 4 and 2 of the 18 regions, respectively on quality categories.

CONCLUSIONS

The quality of mortality statistics of causes of death has increased over the 40 years in Spain in both sexes. Quality gaps still remain mostly in Southern regions. Authorities involved might consider to take action and upgrading regional and national death statistics, and developing a systematic medical post-grade training on death certification.

The impact of the COVID-19 pandemic on mortality in Sweden-Did it differ across socioeconomic groups?

The characterization of the socioeconomic profile of COVID-19 mortality is limited. Likewise, the mapping of potential indirect adverse outcomes of the pandemic, such as suicide and alcohol abuse, along socioeconomic lines is still meagre. The main aim of this paper is to (i) depict SES-differences in COVID-19 mortality, and (ii) to assess the impact of the COVID-19 pandemic on suicide and alcohol mortality across socioeconomic groups. We used Swedish monthly data spanning the period January 2016-December 2021. We chose education as indicator of socioeconomic status (SES). The following causes of deaths were included in the analysis: COVID-19, all-cause mortality excluding COVID-19, suicide and a composite index of alcohol-specific deaths. SARIMA-modelling was used to assess the impact of the pandemic on suicide and alcohol-specific mortality. Two alternative measures of the pandemic were used: (1) a dummy that was coded 1 during the pandemic (March 2020 and onwards), and 0 otherwise, and (2) the Oxford COVID-19 Government Response Tracker's Stringency Index. There was a marked SES-gradient in COVID-19 mortality in the working-age population (25-64) which was larger than for other causes of death. A SES-gradient was also found in the old-age population, but this gradient did not differ from the gradient for other causes of death. The outcome from the SARIMA time-series analyses suggested that the pandemic did not have any impact on suicide or alcohol-specific mortality in any of the educational and gender groups.

Social disparities in sleep health of African populations: A systematic review and meta-analysis of observational studies

OBJECTIVES

To document the relationship between socioeconomic status (SES) and sleep health in African populations.

METHODS

Observational cross-sectional or cohort studies examining the association between SES indicators and sleep outcomes in participants from African countries were included. The search was performed in the MEDLINE, Embase, and Web of Science Core Collection electronic databases in June 2021. Selection, confounding, attrition/exclusion, detection, and selective reporting bias were assessed using the OHAT Risk of Bias Tool. Random effects meta-analysis was used for summarizing the effect estimates.

RESULTS

Forty-three reports were selected, having sampled 153,372 Africans from 26 countries. Education was the most frequent SES indicator and composite measures of sleep quality or disturbances was the most common sleep outcome. Low educational attainment was significantly associated with lower odds of short sleep (odds ratio [OR]=0.65, 95% confidence intervals [0.50, 0.84], p = .001) and higher odds of insomnia (OR=1.53, [1.18, 1.99], p = .001) or poor sleep quality (OR=1.60, [1.17, 2.18], p = .003). Low levels of income/assets were related to higher odds of insomnia (OR=1.38, [1.02, 1.86], p = .04) and low occupational/employment status was linked to lower odds of short sleep duration (OR=0.49, [0.30, 0.79], p = .004).

CONCLUSIONS

Socioeconomic disadvantage was a significant predictor of insomnia and poor sleep quality, while it was associated with longer sleep duration. Significant heterogeneity in terms of exposure and outcomes, scarcity of longitudinal designs, lack of objective outcome measurement, and low representation of rural samples and participants from low-income countries limit the quality of evidence.

Health inequalities in cause-specific mortality in Costa Rica: a population-based cohort study

OBJECTIVE

To analyze health inequalities in cause-specific mortality in Costa Rica from 2010 to 2018, observing the main causes for inequality in the country.

METHODS

The National Electoral Rolls were used to follow-up all Costa Rican adults aged 20 years or older from 2010 to 2018 (n = 2,739,733) in an ecological study. A parametric survival model based on the Gompertz distribution was performed and the event death was classified according to the ICD-10.

RESULTS

After adjustment for urbanicity, the poorest districts had a higher mortality than the wealthier districts for most causes of death except neoplasms, mental and behavioral disorders, and diseases of the nervous system. Urban districts showed significantly higher mortality than mixed and rural districts after adjustment for wealth for most causes except mental and behavioral disorders, diseases of the nervous system, and diseases of the respiratory system. Differences according to wealth were more frequent in women than men, whereas differences according to urbanicity were more frequent in men than in women.

CONCLUSIONS

The study's findings were consistent, but not fully similar, to the international literature.

Construction of an individual socioeconomic status index for analysing inequalities in colorectal cancer screening

OBJECTIVE

To construct an individual socioeconomic status index (ISESI) with information available in the Population Information System of the Region of Valencia, Spain, and use it to analyse inequalities in a colorectal cancer screening programme (CRCSP).

METHODS

Cross-sectional study of men and women aged between 50 and 75 at the time of the study (2020) that were selected from the target population of the Region of Valencia CRCSP. (study sample 1,150,684). First, a multiple correspondence analysis was performed to aggregate information from the Population Information System of the Region of Valencia into an ISESI. Second, data from the 2016 Region of Valencia Health Survey were used for validation, and finally the relationship between CRCSP participation and the ISESI was analysed by logistic regression models.

RESULTS

The variables included in the index were nationality, employment status, disability, healthcare coverage, risk of vulnerability and family size. The most important categories for determining the highest socioeconomic status were being employed and not being at risk of social vulnerability, and being unemployed and at risk of social vulnerability for determining the lowest socioeconomic status. Index validation demonstrated internal and external coherence for measuring socioeconomic status. The relationship between CRCSP participation and the ISESI categorised by quartile (Q) showed that Q4 (the lowest socioeconomic status) was less likely to participate OR = 0.769 (0.757-0.782) than Q1 (the highest socioeconomic status), and the opposite was found for Q2 OR = 1.368 (1.347-1.390) and Q3 OR = 1.156 (1.137-1.175).

CONCLUSIONS

An ISESI was constructed and validated using Population Information System data and made it possible to evaluate inequalities in colorectal cancer screening.

Inequality in mortality in pre-industrial southern Europe during an epidemic episode: socio-economic determinants (eighteenth - nineteenth centuries Spain)

The objective of this study is to gain more comprehensive knowledge about social inequality in mortality in pre-industrial periods. With this aim, we have reconstructed the life courses of the inhabitants of the town of Vera in south-east Spain for the period 1797-1812 in order to estimate the influence of socio-economic status on ordinary and extraordinary mortality, given that, during this period, the town suffered from several epidemic outbreaks of yellow fever. As a result of these outbreaks, around a quarter of the town's population died. The results obtained indicate social inequality in mortality at least from the end of the eighteenth century. Although the differences are higher in mortality caused by non-infectious diseases or ill-defined causes, the coefficients also show a certain social gradient in mortality derived from infectious diseases. However, with respect to this latter type of mortality, the place of residence - seems to have a greater influence on the chances of survival than socio-economic status.

Theory driven analysis of social class and health outcomes using UK nationally representative longitudinal data

BACKGROUND

Social class is frequently used as a means of ranking the population to expose inequalities in health, but less often as a means of understanding the social processes of causation. We explored how effectively different social class mechanisms could be measured by longitudinal cohort data and whether those measures were able to explain health outcomes.

METHODS

Using a theoretically informed approach, we sought to map variables within the National Child Development Study (NCDS) to five different social class mechanisms: social background and early life circumstances; habitus and distinction; exploitation and domination; location within market relations; and power relations. Associations between the SF-36 physical, emotional and general health outcomes at age 50 years and the social class measures within NCDS were then assessed through separate multiple linear regression models. R2 values were used to quantify the proportion of variance in outcomes explained by the independent variables.

RESULTS

We were able to map the NCDS variables to the each of the social class mechanisms except 'Power relations'. However, the success of the mapping varied across mechanisms. Furthermore, although relevant associations between exposures and outcomes were observed, the mapped NCDS variables explained little of the variation in health outcomes: for example, for physical functioning, the R2 values ranged from 0.04 to 0.10 across the four mechanisms we could map.

CONCLUSIONS

This study has demonstrated both the potential and the limitations of available cohort studies in measuring aspects of social class theory. The relatively small amount of variation explained in the outcome variables in this study suggests that these are imperfect measures of the different social class mechanisms. However, the study lays an important foundation for further research to understand the complex interactions, at various life stages, between different aspects of social class and subsequent health outcomes.

SES inequalities in cause-specific adult mortality: a study of the long-term trends using longitudinal individual data for Sweden (1813-2014)

Higher socioeconomic status (SES) is associated with lower mortality, and this correlation has been confirmed using different indicators across several geographical settings. Nevertheless, the timing of the emergence of the SES gradient remains unclear. We used individual-level longitudinal data for a regional population in southern Sweden covering the period between 1813 and 2014, and we applied a cause-specific proportional hazard model. We estimated SES differences in all-cause, nonpreventable, preventable, and cause-specific adult mortality in four subperiods (1813–1921, 1922–1967, 1968–1989, 1990–2014) by gender adjusting for birth year, place of residence, marital status, and migration status. The SES gradient in mortality present today for both genders emerged only around 1970, and with few exceptions, it emerged at approximately the same time for all causes of death. It emerged earlier for women than for men, particularly in infectious diseases. In the nineteenth and early twentieth centuries, we found a positive association between SES and mortality from circulatory diseases for men. SES has not always been a fundamental cause of mortality; it only emerged as such in the second half of the twentieth century. We argue that habits and behaviors embedded in the different social strata played a major role in the emergence of the SES gradient.

Understanding the mobility chances of children from working-class backgrounds in Britain: How important are cognitive ability and locus of control?

Research in social stratification has shown that children from working-class backgrounds tend to obtain substantially lower levels of educational attainment and lower labor market positions than children from higher social class backgrounds. However, we still know relatively little about the micro-level processes that account for this empirical regularity. Our study examines the roles of two individual-level characteristics-cognitive ability and locus of control-in mediating the effect of individuals' parental class background on their educational attainment and social class position in Britain. We find that cognitive ability mediates only about 35% of the total parental class effect on educational attainment and only about 20% of the total parental class effect on respondents' social class position, net of their educational attainment. These findings contradict existing claims that differences in the life chances of children from different social class backgrounds are largely due to differences in cognitive ability. Moreover, we find that although individuals' locus of control plays some role in mediating the parental class effect, its role is substantially smaller than the mediating role of cognitive ability. We measure individuals' social class positions at different points in their careers-at labor market entry and at occupational maturity-and find that the mediating roles of cognitive ability and locus of control are remarkably stable across individuals' working lives.

Leisure time and occupational physical activity, resting heart rate and mortality in the Arctic region of Norway: The Finnmark Study

Aims

This study examined the association of leisure time physical activity, occupational physical activity, and resting heart rate with all-cause and cardiovascular disease mortality in Sami and non-Sami populations.

Study design

This was a longitudinal, observational population-based study.

Methods

The Finnmark 3 study cohort was examined in 1987–1988 and followed for all-cause and cardiovascular disease mortality for 26 years. The cohort included 17,697 men and women with a mean age of 47.2 years at baseline. Leisure time physical activity and occupational physical activity were assessed with a validated questionnaire at baseline, whereas cause of death was obtained from the Norwegian Cause of Death Registry.

Results

A total of 1983 women and 3147 men died during follow-up. Leisure time physical activity was linearly and inversely associated with all-cause mortality, but not coronary heart disease mortality. Compared to inactive subjects, all-cause mortality was significantly reduced by 16% in the active leisure time physical activity group (hazard ratio 0.84; 95% confidence interval 0.76–0.92). Both for all-cause and cardiovascular disease mortality, we observed a U-shaped relationship with occupational physical activity, as participants in the walking and lifting group had significantly lower mortality than both the mostly sedentary and the heavy manual labour group ( p < 0.05). An increase in resting heart rate by one beat per minute was associated with a 1.1% increase in all-cause mortality (hazard ratio 1.011; 95% confidence interval 1.009–1.013). The associations were similar in Sami and non-Sami subjects.

Conclusion

In this population-based study, leisure time physical activity was inversely associated with all-cause mortality, whereas resting heart rate was positively associated with all-cause and cardiovascular disease mortality. There was a U-shaped association between occupational physical activity and cardiovascular disease and all-cause mortality.

Divergence and Convergence: How Do Income Inequalities in Mortality Change over the Life Course?

BACKGROUND

Do inequalities in health by income increase or decrease with age? The empirical evidence is not conclusive and competing theories arrive at different conclusions.

OBJECTIVE

This study examined inequality in mortality by income over the adult life course with longitudinal data on people aged 30-99 between the years 1990 and 2009. Each person was followed for 19 years.

METHODS

We used Swedish total population data with 5,011,414 individual observations. We calculated the probability of having died for ages between 31 and 99. This approach to calculating death risk incorporates selective mortality during the follow-up period into the measure. Age and year standardized income positions were calculated for all individuals. Inequality was assessed by comparing the top 10% income group and the bottom 10% income group. Relative inequality was measured by risk ratios (RR) and absolute inequality by percentage point differences.

RESULTS

The results showed that the highest relative income inequality in mortality was at age 56 for men (RR: 4.7) and at age 40 for women (RR: 4.1) with differing patterns across the younger age categories between the sexes. The highest absolute income inequality in mortality was found at age 78 for men (19% difference) and at age 89 for women (14% difference) with similar patterns for both sexes. Both measures of inequality decreased after the peak, with small or no inequalities above age 95. Income inequality in mortality remained in advanced age, with larger absolute inequalities in older ages and larger relative inequalities in younger ages.

CONCLUSION

The results for absolute and relative measures of inequality differed substantially; this highlights the importance of discussing and making an active choice of inequality measure. To explain and understand the patterns of inequality in mortality over the adult life course, we conclude that the "age-as-leveler" and "cumulative disadvantage" theories are best applied to an absolute measure of inequality.

Social class and infirmity. The role of social class over the life-course

In an aging society, it is important to promote the compression of poor health. To do so, we need to know more about how life-course trajectories influence late-life health and health inequalities. In this study, we used a life-course perspective to examine how health and health inequalities in late-midlife and in late-life are influenced by socioeconomic position at different stages of the life course. We used a representative sample of the Swedish population born between 1925 and 1934 derived from the Swedish Level of Living Survey (LNU) and the Swedish Panel Study of Living Conditions of the Oldest Old (SWEOLD) to investigate the impact of socioeconomic position during childhood (social class of origin) and of socioeconomic position in young adulthood (social class of entry) and late-midlife (social class of destination) on infirmity in late-midlife (age 60) and late-life (age 80). The results of structural equation modelling showed that poor social class of origin had no direct effect on late-midlife and late-life infirmity, but the overall indirect effect through chains of risks was significant. Thus, late-midlife and late-life health inequalities are the result of complex pathways through different social and material conditions that are unevenly distributed over the life course. Our findings suggest that policies that break the chain of disadvantage may help reduce health inequalities in late-midlife and in late-life.

Death Is Not the End: A Register-Based Study of the Effect of Parental Death on Adult Children's Childbearing Behavior in Sweden

Macro-level studies have shown that rapid increases in mortality can affect fertility rates. Parental death has also been linked to negative psychological and physical outcomes, reduced relationship quality, and making bereaved children attach more importance to their families. No prior study has examined whether parental death influences adult children's fertility at the microlevel. This study applies event history techniques to Swedish multigeneration registers listing 1.5 million individuals with micro data on mortality and fertility to investigate short-term (first birth risk) and long-term (childlessness at age 45) effects of parental death on adult children's fertility. The principal finding is that parental death during reproductive age affects children's fertility and this effect is mainly short term. The effects differ to some degree between men and women and depend on the stage of the life course in which the bereavement occurs. Younger individuals experiencing a parental death have a significantly higher first birth risk after the parental death compared with peers who did not experience a parental death. Individuals older than 23 who experience a parental death have no or lower first birth risk after the parental death compared with baseline. Men, compared with women, are more likely to end childless if they experience a parental death.

The shape of the association between income and mortality in old age: A longitudinal Swedish national register study

This study used data on the total population to examine the longitudinal association between midlife income and mortality and late-life income and mortality in an aging Swedish cohort. We specifically examined the shape of the associations between income and mortality with focus on where in the income distribution that higher incomes began to provide diminishing returns. The study is based on a total Swedish population cohort between the ages of 50 and 60 years in 1990 (n=801,017) followed in registers for up to 19 years. We measured equivalent disposable household income in 1990 and 2005 and mortality between 2006 and 2009. Cox proportional hazard models with penalized splines (P-spline) enabled us to examine for non-linearity in the relationship between income and mortality. The results showed a clear non-linear association. The shape of the association between midlife (ages 50-60) income and mortality was curvilinear; returns diminished as income increased. The shape of the association between late-life (ages 65-75) income and mortality was also curvilinear; returns diminished as income increased. The association between late-life income and mortality remained after controlling for midlife income. In summary, the results indicated that a non-linear association between income and mortality is maintained into old age, in which higher incomes give diminishing returns.

Association between trauma and socioeconomic deprivation: a registry-based, Scotland-wide retrospective cohort study of 9,238 patients

Background

Trauma remains a leading cause of morbidity and mortality in the UK and throughout the world. Socioeconomic deprivation has been linked with many types of ill-health and previous studies have shown an association with injury in other parts of the world. The aim of this study was to investigate the association between socioeconomic deprivation and trauma incidence and case-fatality in Scotland.

Methods

The study included nine thousand two hundred and thirty eight patients attending Emergency Departments following trauma across Scotland in 2011-12. A retrospective cohort study was conducted using secondary data extracted from the national trauma registry. Postcode of residence was used to generate deciles using the Scottish Index of Multiple Deprivation. The incidence rate ratio (IRR) was calculated to allow comparison of incidence of trauma across SIMD deciles. For mortality, observed: expected ratios were obtained using observed mortality in the cohort and expected deaths using probability of survival based on Trauma and Injury Severity Score (TRISS) method.

Results

Compared with the most deprived decile, the least deprived had an incidence rate ratio (IRR) for all trauma of 0.43 (95 % CI 0.32–0.58, p < 0.001). The association was stronger for penetrating trauma (IRR 0.07, 95 % CI .01–0.56, p = 0.011). There was a significant interaction between age, gender and SIMD. For case fatality, multivariate logistic regression showed that, severity of trauma (ISS > 15) OR 18.11 (95 % CI 13.91 to 23.58) and type of injury (Penetrating versus blunt injury) OR 2.07 (95 % CI 1.15 to 3.72) remain as independent predictors of case fatality in this dataset.

Discussion

Our data shows a higher incidence of trauma amongst a socioeconomically deprived population, in keeping with other areas of the world. In our dataset, outcome, as measured by in-hospital mortality, does not appear to be associated with socioeconomic deprivation.

Conclusion

In Scotland, populations living in socioeconomically deprived areas have a higher incidence of trauma, especially penetrating trauma, requiring hospital attendance. Case fatality is associated with more severe trauma and penetrating trauma, but not socioeconomic deprivation.

Electronic supplementary material

The online version of this article (doi:10.1186/s13049-016-0275-7) contains supplementary material, which is available to authorized users.

Socioeconomic status and cutaneous malignant melanoma in Northern Europe

Socioeconomic status (SES) is associated with cutaneous malignant melanoma (CMM) in Northern Europe, despite equal access to health care. SES per se is not responsible for this association, which must be ascribed to important risk factors for CMM such as intermittent ultraviolet radiation (UVR) exposure, and screening for CMM possibly owing to a greater knowledge and understanding of CMM. Our review of the literature showed that high SES is associated with increased risk of CMM, thinner tumours, increased survival and decreased mortality from CMM - the latter shown among women, and in recent studies also among men. There is evidence that high SES is associated with sun holidays, whereas low SES is associated with the use of sunbeds. Findings suggest that high SES is associated with the use of physicians and dermatologists for marks and moles, possibly owing to more knowledge and better understanding of CMM. We conclude that there has been a true increase in CMM incidence among high SES individuals in Northern Europe probably due to past intense intermittent UVR exposure, especially in connection with sun holidays. However, the increased risk of CMM and a better outcome of CMM in high SES individuals may also be conditioned by frequent recourse to physicians, which may be ascribed to more knowledge and better understanding of CMM, although more studies on this subject are warranted. Thicker CMM tumours and increased CMM mortality among low SES individuals in recent decades may reflect exposure to intermittent UVR, such as the use of sunbeds, as well as delayed diagnosis.

Mortality differentials by immigrant groups in Sweden: the contribution of socioeconomic position

OBJECTIVES

We studied mortality differentials between specific groups of foreign-born immigrants in Sweden and whether socioeconomic position (SEP) could account for such differences.

METHODS

We conducted a follow-up study of 1 997 666 men and 1 964 965 women ages 30 to 65 years based on data from national Swedish total population registers. We examined mortality risks in the 12 largest immigrant groups in Sweden between 1998 and 2006 using Cox regression. We also investigated deaths from all causes, circulatory disease, neoplasms, and external causes.

RESULTS

We found higher all-cause mortality among many immigrant categories, although some groups had lower mortality. When studying cause-specific mortality, we found the largest differentials in deaths from circulatory disease, whereas disparities in mortality from neoplasms were smaller. SEP, especially income and occupational class, accounted for most of the mortality differentials by country of birth.

CONCLUSIONS

Our findings stressed that different aspects of SEP were not interchangeable in relation to immigrant health. Although policies aimed at improving immigrants' socioeconomic conditions might be beneficial for health and longevity, our findings indicated that such policies might have varying effects depending on the specific country of origin and cause of death.

A longitudinal analysis of the relationship between changes in socio-economic status and changes in health

In this paper we contribute to discussion on the relationship between different aspects of socio-economic status (SES) and health. Separating different aspects of SES facilitates the specification of a structural relationship between SES indicators and morbidity. Longitudinal data and the utilization of growth curve modelling enable an empirical analysis of the direct relationship between changes over time in SES indicators and changes in morbidity. Our empirical analysis is based on panel data (N = 2976) derived from the annual Swedish Survey of Living Conditions. The panel, which consists of respondents that at the first panel wave were between 31 and 47 years old, is followed for 16 years, starting in 1979. Data are gathered at three points of time. A growth curve model is set up using structural equation modelling. The structural relationship and changes over time are simultaneously estimated. It is shown that in relation to health occupational position is crucial, canalising the effects of class of origin and education. More prestigious jobs are related to initially good health and to a less rapid deterioration in health. At the same time initial health affects occupational mobility, confirming a health selection into less prestigious jobs. It is also shown that change of occupation and income are related to change in health. The analysis confirms a strong relationship between SES and morbidity and shows that initial SES affects later changes in morbidity, i.e., a causal relationship exists between SES and morbidity. But, the analysis also demonstrates the existence of selection effects, meaning that initial morbidity causes less favourable changes in SES. It is finally revealed that changes in occupational prestige and income changes co-vary with changes in morbidity. Hence, the analysis provides basic information necessary to make any assumption about causality and selection in relation to SES and health.

Assessment of environmental and socio-economic stress

Since long, socio-economic status, often expressed as an index, is known to correlate with health outcomes like behavioural problems. We constructed a new index that encapsulated not only economic and social but also environmental stressors (ESES), using data of the German Health Interview and Examination Survey for Children and Adolescents, a nation-wide representative surveillance of 17,641 participants aged between 0-17 years. Different factors were selected to account for socio-economic stress (low parental education, low household income, low occupational status of the householder), domestic stress (living in large cities, exposure to tobacco smoke at home, crowded housing, mouldy walls), and prenatal stress (maternal smoking during pregnancy, drinking alcohol during pregnancy). Prior to the calculation of ESES, the different factors were multiplied by weights which were estimated by multivariate linear regression on a number of health outcomes. ESES was then used to predict emotional and social problems (SDQ scores). The resulting ORs were compared with those obtained for an established socio-economic index (SEI). ESES was superior to SEI as it could more clearly identify children and adolescents with emotional or social problems. Different types of stressors (i.e. socio-economic stress, domestic stress and prenatal stress) contributed independently to emotional and social problems.

Translating research evidence into practice to reduce health disparities: a social determinants approach

Translating research evidence to reduce health disparities has emerged as a global priority. The 2008 World Health Organization Commission on Social Determinants of Health recently urged that gaps in health attributable to political, social, and economic factors should be closed in a generation. Achieving this goal requires a social determinants approach to create public health systems that translate efficacy documented by research into effectiveness in the community. We review the scope, definitions, and framing of health disparities and explore local, national, and global programs that address specific health disparities. Such efforts translate research evidence into real-world settings and harness collaborative social action for broad-scale, sustainable change.

In search of 'low health literacy': threshold vs. gradient effect of literacy on health status and mortality

Studies have demonstrated significant associations between limited literacy and health outcomes. Yet differences in literacy measurement and the cutoffs used for analysis have made it difficult to fully understand the relationship between literacy and health across the entire spectrum of literacy (i.e., whether the relationship is continuous and graded or whether a threshold exists below which literacy is independently associated with health). To analyze this question, we re-examined the relationship between literacy, baseline physical functioning and mental health, and all-cause mortality for a cohort of 3260 US community-dwelling elderly who were interviewed in 1997 to determine demographics, socioeconomic status, chronic conditions, self-reported physical and mental health (SF-36 subscales), health behaviors, and literacy based upon the Short Test of Functional Health Literacy in Adults (S-TOFHLA). All-cause mortality was determined using data from the US National Death Index through 2003. Seven categories of S-TOFHLA literacy scores were created and used in this analysis instead of the existing three categories identified with the measure. In multivariate analyses, a continuous, graded relationship between literacy and baseline physical functioning was identified. However, participants scoring below the third literacy category had significantly worse mental health compared to the highest literacy category, displaying a notable threshold. Finally, all six literacy categories were significantly associated with greater all-cause mortality risk compared to the highest literacy category, but again there was a marked threshold below the third category at which the adjusted mortality rate significantly increased compared to all other categories. We conclude that the nature of the relationship between literacy and health may vary depending upon the outcome under examination.

The association of early IQ and education with mortality: 65 year longitudinal study in Malmö, Sweden

OBJECTIVES

To establish whether differences in early IQ explain why people with longer education live longer, or whether differences in father's or own educational attainment explain why people with higher early IQ live longer.

DESIGN

Population based longitudinal study. Mortality risks were estimated with Cox proportional hazards regressions.

SETTING

Malmö, Sweden.

PARTICIPANTS

1530 children who took IQ tests at age 10 and were followed up until age 75.

RESULTS

Own educational attainment was negatively associated with all cause mortality in both sexes, even when early IQ and father's education were adjusted for (hazard ratio (HR) for each additional year in school 0.91 (95% CI 0.85 to 0.97) for men and HR 0.88 (95 % CI 0.78 to 0.98) for women). Higher early IQ was linked with a reduced mortality risk in men, even when own educational attainment and father's education were adjusted for (HR for one standard deviation increase in IQ 0.85 (95 % CI 0.75 to 0.96)). In contrast, there was no crude effect of early IQ for women, and women with above average IQ had an increased mortality risk when own educational attainment was adjusted for, but only after the age of 60 (HR 1.60 (95 % CI 1.06 to 2.42)). Adding measures of social career over and above educational attainment to the model (for example, occupational status at age 36 and number of children) only marginally affected the hazard ratio for women with above average IQ (<5%).

CONCLUSIONS

Mortality differences by own educational attainment were not explained by early IQ. Childhood IQ was independently linked, albeit differently, to male adult mortality and to female adult mortality even when father's education and own educational attainment was adjusted for, thus social background and own social career seem unlikely to be responsible for mortality differences by childhood IQ. The clear difference in the effect of IQ between men and women suggests that the link between IQ and mortality involves the social and physical environment rather than simply being a marker of a healthy body to begin with. Cognitive skills should, therefore, be addressed in our efforts to create childhood environments that promote health.