Variations between world regions in individual health: a multilevel analysis of the role of socio-economic factors

Aging and self-reported health in 114 Latin American cities: gender and socio-economic inequalities

BACKGROUND

Understanding how urban environments influence people's health, especially as individuals age, can help identify ways to improve health in the rapidly urbanizing and rapidly aging populations.

OBJECTIVES

To investigate the association between age and self-reported health (SRH) in adults living in Latin-American cities and whether gender and city-level socioeconomic characteristics modify this association.

METHODS

Cross-sectional analyses of 71,541 adults aged 25-97 years, from 114 cities in 6 countries (Argentina, Brazil, Colombia, Chile, El Salvador, and Guatemala), as part of the Salud Urbana en America Latina (SALURBAL) Project. We used individual-level age, gender, education, and self-reported health (SRH) data from harmonized health surveys. As proxies for socioeconomic environment we used a city-level socioeconomic index (SEI) calculated from census data, and gross domestic product (GDP) per-capita. Multilevel Poisson models with a robust variance were used to estimate relative risks (RR), with individuals nested in cities and binary SRH (poor SHR vs. good SRH) as the outcome. We examined effect modification by gender and city-level socioeconomic indicators.

RESULTS

Overall, 31.4% of the sample reported poor SRH. After adjusting for individual-level education, men had a lower risk of poor SRH (RR = 0.76; CI 0.73-0.78) compared to women, and gender modified the association between age and poor SRH (p-value of interaction < 0.001). In gender stratified models, the association between older age and poor SRH was more pronounced in men than in women, and in those aged 25-65 than among those 65+ (RR/10 years = 1.38 vs. 1.10 for men, and RR/10 years = 1.29 vs. 1.02 for women). Living in cities with higher SEI or higher GDP per-capita was associated with a lower risk of poor SRH. GDP per-capita modified the association between age (25-65) and SRH in men and women, with SEI the interaction was less clear.

CONCLUSIONS

Across cities in Latin America, aging impact on health is significant among middle-aged adults, and among men. In both genders, cities with lower SEI or lower GDP per-capita were associated with poor SRH. More research is needed to better understand gender inequalities and how city socioeconomic environments, represented by different indicators, modify exposures and vulnerabilities associated with aging.

Improving job strain might reduce inequalities in cardiovascular disease mortality in european men

Unfavorable psychosocial working conditions can lead to cardiovascular disease (CVD) mortality. Lower-occupational groups typically experience unfavorable psychosocial working conditions as compared to higher-occupational groups. We investigate the extent to which CVD mortality inequalities might be reduced if psychosocial working conditions for manual workers are raised to the level experienced by non-manual workers (upward-leveling scenario). We also investigate what would occur if psychosocial working conditions among manual and non-manual workers are raised to better levels as observed in the 'ideal' region (best practice scenario). Individual-level CVD mortality data from 12 European countries were obtained from the EURO-GBD-SE project (1998-2007). Psychosocial working conditions data (i.e. job strain) were extracted from the European Working Conditions Survey (2005) and rate ratios from literature reviews. Population attributable fractions (PAF) and two counterfactual scenarios (namely, upward-leveling scenario and best-practice scenario) were developed to examine employed male non-manual and manual workers. Results appeared to show that CVD mortality might be reduced in men when unfavorable psychosocial working conditions are improved for manual workers (PAF = 7.7%, 95% CI: 6.5-10.0). The upward-leveling scenario seems to reduce CVD mortality inequalities for manual workers, by 13-74%. Best-practice scenario shows the largest reduction in CVD mortality in the Baltic region (87 deaths per 100,000 person years). Findings suggest that rendering job strain in manual workers to the level experienced by non-manual workers might substantially reduce CVD mortality inequalities in European men.

International Perspective on Health Literacy and Health Equity: Factors That Influence the Former Soviet Union Immigrants

Among the world's 272 million international migrants, more than 25 million are from the former Soviet Union (FSU), yet there is a paucity of literature available about FSU immigrants' health literacy. Besides linguistic and cultural differences, FSU immigrants often come from a distinct healthcare system affecting their ability to find, evaluate, process, and use health information in the host countries. In this scoping review and commentary, we describe the health literacy issues of FSU immigrants and provide an overview of FSU immigrants' health literacy based on the integrated health literacy model. We purposefully consider the three most common locations where FSU immigrants have settled: the USA, Germany, and Israel. For context, we describe the healthcare systems of the three host countries and the two post-Soviet countries to illustrate the contribution of system-level factors on FSU immigrants' health literacy. We identify research gaps and set a future research agenda to help understand FSU immigrants' health literacy across countries. Amidst the ongoing global population changes related to international migration, this article contributes to a broad-scope understanding of health literacy among FSU immigrants related to the system-level factors that may also apply to other immigrants, migrants, and refugees.

Associations between effort-reward imbalance and health indicators among school teachers in Chuquisaca, Bolivia: a cross-sectional study

OBJECTIVE

To assess the association between effort-reward imbalance (ERI) and health indicators among Bolivian school teachers.

DESIGN

School-based cross-sectional study.

SETTING

Sixty randomly selected schools from rural (33) and urban (27) schools in Chuquisaca, Bolivia.

PARTICIPANTS

A total of 1062 school teachers were invited to participate, of which 597 answered the questionnaire (response 56.2%).

EXPOSURE MEASURE

Psychosocial factors at work were explored through the short version of the Effort-Reward Questionnaire.

PRIMARY AND SECONDARY OUTCOME MEASURES

Health outcomes included self-rated overall health, mental distress (12-item General Health Questionnaire ≥5) and the 7-day prevalence of low back pain (LBP) as well as neck or shoulder pain (Nordic Questionnaire). Crude and adjusted ORs and their 95% CIs for each health outcome were calculated using logistic regression models.

RESULTS

The median value for the effort-reward ratio was 0.91 (range: 0.3-2.3) with higher values for teachers from rural versus urban schools. Overall, about 43% of the teachers reported their overall health as fair or poor; 45% suffered mental distress, 17% reported LBP and 29% neck or shoulder pain. Prevalences were higher for teachers employed at rural schools compared with those at urban schools. After adjusting for potential confounders and school location, ERI was statistically significantly associated with fair/poor self-rated health (adjusted OR 1.7, 95% CI 1.0 to 2.9); mental distress (1.9; 95% CI 1.2 to 3.1) and LBP (2.3; 95% CI 1.3 to 4.1).

CONCLUSION

Our results indicate the urgent need to improve psychosocial working conditions among Bolivian school teachers, in order to promote their health and well-being.

Direct and indirect health economic impact of hypoglycaemia in a global population of patients with insulin-treated diabetes

AIMS

The Hypoglycaemia Assessment Tool (HAT) study investigated the health economic impact of hypoglycaemic events in 24 countries, including countries without previously published data on hypoglycaemia.

METHODS

Self-assessment questionnaires and patient diaries (4-week prospective period) were completed by adults with type 1 (T1D) or type 2 diabetes (T2D) treated with insulin for more than 12 months (N = 27,585).

RESULTS

Direct economic impacts of hypoglycaemia during the 4-week prospective period, included increased blood glucose monitoring (reported by 69.7% [T1D] and 60.9% [T2D] of patients), hospitalisation (T1D 2.1%; T2D 3.4% of patients) and medical contact (clinic or telephone; T1D 3.8%; T2D 6.8% of patients). Regional variation in medical contact and hospitalisation was found, with the highest usage in Russia (T1D 17.1%; T2D 17.3%), and Latin America (T1D 5.2%; T2D 6.8%) respectively. Indirect economic impacts following hypoglycaemia included loss of productivity due to absence from work or study; 3.9% (T1D) and 6.2% (T2D) of patients. Regional differences in work productivity were noted among patients with T2D, with a low prevalence in Northern Europe and Canada (0.9%) and high in Southeast Asia (14.6%).

CONCLUSIONS

This study shows that hypoglycaemia has a significant but variable impact on the economics of diabetes healthcare globally.

Regional inequalities in self-rated health and disability in younger and older generations in Turkey: the contribution of wealth and education

Background

In Turkey, large regional inequalities were found in maternal and child health. Yet, evidence on regional inequalities in adult health in Turkey remains fragmentary. This study aims to assess regional and rural/urban inequalities in the prevalence of poor self-rated health and in disability among adult populations in Turkey, and to measure the contribution of education and wealth of individual residents. The central hypothesis was that geographical inequalities in adult health exist even when the effect of education and wealth were taken into account.

Methods

We analyzed data of the 2002 World Health Survey for Turkey on 10791 adults aged 20 years and over. We measured respondents’ rating of their own general health and the prevalence of five types of physical disability. Logistic regression was used to estimate how much these two health outcomes varied according to urban/rural place of residence, region, education level and household wealth. We stratified the analyses by gender and age (‹50 and ≥50 years).

Results

Both health outcomes were strongly associated with educational level (especially for older age group) and with household wealth (especially for younger age group). Both health outcomes also varied according to region and rural/urban place of residence. Higher prevalence rates were observed in the East region (compared to West) with odd ratios varying between 1.40–2.76. After controlling for education and wealth, urban/rural differences in health disappeared, while regional differences were observed only among older women. The prevalence of poor self-rated health was higher for older women in the Middle (OR = 1.69), Black Sea (OR = 1.53) and East (OR = 2.06) regions.

Conclusion

In Turkey, substantial geographical inequalities in self-reported adult health do exist, but can mostly be explained by differences in socioeconomic characteristics of residents. The regional disadvantage of older women in the East, Middle and Black Sea may have resulted from life-long exposure to gender discrimination under a patriarchal ideology. Yet, not geographic inequalities, but the more fundamental socioeconomic inequalities, are of key public health concern, also in Turkey.

The color of health: skin color, ethnoracial classification, and discrimination in the health of Latin Americans

Latin America is one of the most ethnoracially heterogeneous regions of the world. Despite this, health disparities research in Latin America tends to focus on gender, class and regional health differences while downplaying ethnoracial differences. Few scholars have conducted studies of ethnoracial identification and health disparities in Latin America. Research that examines multiple measures of ethnoracial identification is rarer still. Official data on race/ethnicity in Latin America are based on self-identification which can differ from interviewer-ascribed or phenotypic classification based on skin color. We use data from Brazil, Colombia, Mexico, and Peru to examine associations of interviewer-ascribed skin color, interviewer-ascribed race/ethnicity, and self-reported race/ethnicity with self-rated health among Latin American adults (ages 18-65). We also examine associations of observer-ascribed skin color with three additional correlates of health - skin color discrimination, class discrimination, and socio-economic status. We find a significant gradient in self-rated health by skin color. Those with darker skin colors report poorer health. Darker skin color influences self-rated health primarily by increasing exposure to class discrimination and low socio-economic status.

Global educational disparities in the associations between body mass index and diabetes mellitus in 49 low-income and middle-income countries

BACKGROUND

Despite the well-established link between body mass index (BMI) and diabetes mellitus (DM), it remains unclear whether this association is more pronounced at certain levels of education. This study assessed the modifying effect of educational attainment on the associations between BMI and DM-as well as the joint associations of BMI and education with DM-in low-income countries (LICs) and middle-income countries (MICs).

METHODS

The authors used cross-sectional data from 160 381 participants among 49 LICs and MICs in the World Health Survey. Overweight and obesity levels were defined using WHO's classification. Educational attainment was classified in four categories: 'no formal education', 'some/completed primary school', 'secondary/high school completed' and 'college and beyond'. We used random-intercept multilevel logistic regressions to investigate the modifying influence of educational attainment on the associations of different BMI levels-as well as their joint associations-with DM.

RESULTS

We found positive associations between excessive BMI and DM at each education level in both LICs and MICs. We found that the joint associations of BMI and education with DM were larger than the product of their separate single associations among females in LICs. With joint increases in BMI and education, males and females in LICs had similar increased odds of DM, but males had higher such odds than females in MICs.

CONCLUSIONS

BMI and education are associated with the DM, but the associations seem to differ in complex ways between LICs and MICs and by gender.

The modifying influence of country development on the effect of individual educational attainment on self-rated health

OBJECTIVES

We investigated how much the Human Development Index (HDI), a global measure of development, modifies the effect of education on self-reported health.

METHODS

We analyzed cross-sectional World Health Survey data on 217,642 individuals from 49 countries, collected in 2002 to 2005, with random-intercept multilevel linear regression models.

RESULTS

We observed greater positive associations between educational levels and self-reported good health with increasing HDI. The magnitude of this effect modification of the education-health relation tended to increase with educational attainment. For example, before adjustment for effect modification, at comparable HDI, on average, finishing primary school was associated with better general health (b = 1.49; 95% confidence interval [CI] = 1.18, 1.80). With adjustment for effect modification by HDI, the impact became 4.63 (95% CI = 3.63, 5.62) for every 0.1 increase in HDI. Among those who completed high school, these associations were, respectively, 5.59 (95% CI = 5.20, 5.98) and 9.95 (95% CI = 8.89, 11.00).

CONCLUSIONS

The health benefits of educational attainment are greater in countries with greater human development. Health inequalities attributable to education are, therefore, larger in more developed countries.

Decomposing socioeconomic inequalities in self assessed health in Turkey

Introduction

This study aimed to measure socioeconomic inequalities in Self Assessed Health (SAH) and evaluate the determinants of such inequalities in terms of their contributions amongst the Turkish population.

Methods

We used data from the Turkish part of World Health Survey 2003 with 10,287 respondents over 18 years old. Concentration index (CI) of SAH was calculated as a measure of socioeconomic inequalities in health, and contributions of each determinant to inequality were evaluated using a decomposition method.

Results

In total 952 participants (9.3%) rated their health status as either bad or very bad. The CI for SAH was −0.15, suggesting that suboptimal SAH was reported more by those categorised as poor. The multiple logistic regression results indicated that having secondary, primary or less than primary school education, not being married and being in the lowest wealth quintile, significantly increased the risk of having poor SAH. The largest contributions to inequality were attributed to education level (70.7%), household economic status (9.7%) and geographical area lived in (8.4%).

Conclusion

The findings indicate that socioeconomic inequalities measured by SAH are apparent amongst the Turkish population. Education and household wealth were the greatest contributing factors to SAH inequality. These inequalities need to be explicitly addressed and vulnerable subgroups should be targeted to reduce the socioeconomic disparities.

Neighbourhood socioeconomic inequalities in incidence of acute myocardial infarction: a cohort study quantifying age- and gender-specific differences in relative and absolute terms

Background

Socioeconomic status has a profound effect on the risk of having a first acute myocardial infarction (AMI). Information on socioeconomic inequalities in AMI incidence across age- gender-groups is lacking. Our objective was to examine socioeconomic inequalities in the incidence of AMI considering both relative and absolute measures of risk differences, with a particular focus on age and gender.

Methods

We identified all patients with a first AMI from 1997 to 2007 through linked hospital discharge and death records covering the Dutch population. Relative risks (RR) of AMI incidence were estimated by mean equivalent household income at neighbourhood-level for strata of age and gender using Poisson regression models. Socioeconomic inequalities were also shown within the stratified age-gender groups by calculating the total number of events attributable to socioeconomic disadvantage.

Results

Between 1997 and 2007, 317,564 people had a first AMI. When comparing the most deprived socioeconomic quintile with the most affluent quintile, the overall RR for AMI was 1.34 (95 % confidence interval (CI): 1.32 – 1.36) in men and 1.44 (95 % CI: 1.42 – 1.47) in women. The socioeconomic gradient decreased with age. Relative socioeconomic inequalities were most apparent in men under 35 years and in women under 65 years. The largest number of events attributable to socioeconomic inequalities was found in men aged 45–74 years and in women aged 65–84 years. The total proportion of AMIs that was attributable to socioeconomic inequalities in the Dutch population of 1997 to 2007 was 14 % in men and 18 % in women.

Conclusions

Neighbourhood socioeconomic inequalities were observed in AMI incidence in the Netherlands, but the magnitude across age-gender groups depended on whether inequality was expressed in relative or absolute terms. Relative socioeconomic inequalities were high in young persons and women, where the absolute burden of AMI was low. Absolute socioeconomic inequalities in AMI were highest in the age-gender groups of middle-aged men and elderly women, where the number of cases was largest.