Multiple measures of socio-economic position and psychosocial health: proximal and distal measures

Social Determinants and Consequences of Pain: Toward Multilevel, Intersectional, and Life Course Perspectives

Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain remain rarely addressed in the context of pain prevention and management. In this review, we aim to 1) examine the broad scope of social determinants and consequences of pain and their interactions across multiple levels of organization, and 2) provide a framework synthesizing existing concepts and potential areas for future work on social aspects of pain, drawing upon socioecological, intersectional, and life course approaches. Integrating interdisciplinary theory and evidence, we outline pathways through which multilevel social factors and pain may affect each other over time. We also provide a brief summary of intrapersonal aspects of pain, which are thought to operate at the interface between individuals and the social context. Progressing from micro- to macrolevel factors, we illustrate how social determinants of pain can directly or indirectly contribute to pain experiences, expression, risk, prognosis, and impact across populations. We consider 1) at the interpersonal level, the roles of social comparison, social relatedness, social support, social exclusion, empathy, and interpersonal conflict; 2) at the group or community level, the roles of intimacy groups, task groups, social categories, and loose associations; and 3) at the societal level, the roles of political, economic, and cultural systems, as well as their policies and practices. We present examples of multilevel consequences of pain across these levels and discuss opportunities to reduce the burden and inequities of pain by expanding multilevel social approaches in pain research and practice. PERSPECTIVE: Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain are often unclearly defined, hindering their use in pain prevention, management, and research. We summarize the scope of social aspects of pain and provide a framework synthesizing existing concepts and potential areas for future work.

Listening to Caregivers: Narratives of Health Seeking for Children Under Five with Pneumonia and Diarrhea: Insights from the NIGRAAN Trial in Pakistan

Background

Understanding health-seeking behaviors of caregivers is important to reduce child mortality. Several factors influence decision-making related to childhood illnesses.

Objective

The objective of this study was to gather caretaker narratives to develop a comprehensive understanding of the context and process of caregiving at household level during all stages of an episode of diarrhea and pneumonia in children <5.

Methods

Using a narrative interview approach, stories from caregivers of children <5 were collected from a rural district in Sindh Pakistan. Eleven households with children <5 were randomly selected and purposive sampling was done to interview 20 caregivers. All data collection was conducted privately in participants' homes and informed consent taken. Manual content analysis was carried out by three independent researchers and emerging themes drawn.

Results

The role of joint family system is integral in making decisions and the child's paternal grandmother, is an important and trusted source of information regarding child sickness in the household. They often promote home remedies with considerable authority prior to formal consultation with the health care system. Caregivers were generally dissatisfied with doctors in the public sector who were perceived to be providing free consultation with a poor quality of care and long waiting time as compared to private doctors. Financial considerations and child support were favorably addressed in households with a joint family system.

Conclusion

The joint family system provides a strong support system, but also tends to reduce parental autonomy in decision-making and delay first contact with formal health providers. Prevalent home remedies, and authority of elders in the family influence management practices. Interventions for reducing improving child mortality should be cognizant of the context of decision-making and social influences at the household level.

Role of inflammation in the socioeconomic inequalities of neurocognitive disorders

BACKGROUND

Socioeconomic position has been shown to be associated with inflammation. However, little is known about the role of inflammation in socioeconomic inequalities in relation to neurocognitive disorders in later life and the potential underlying inflammatory mechanisms. This study has used longitudinal data to investigate the mediation effects of inflammation in the relationship between socioeconomic position and neurocognitive disorders in older adults.

METHODS

Using data from the English Longitudinal Study of Ageing (ELSA, n = 4,815), we ascertained neurocognitive disorders using a recognised consensus criterion and included the following categories: (1) No Cognitive Impairment (NOCI) (2) Cognitive Impairment No Dementia (CIND) and (3) Dementia. We examined whether socioeconomic position (education, occupation, and wealth) measured in 2008/09 was associated with neurocognitive disorders measured in 2018/19. Mediation analyses were carried out to investigate the role of inflammatory markers [C-Reactive Protein (CRP), plasma fibrinogen and white blood cells (WBC)] in the association between socioeconomic inequalities and subsequent neurocognitive disorders. Sensitivity analyses were conducted to assess the mediating role of lifestyle behaviours and body mass index (BMI).

RESULTS

Higher education, occupation and wealth were longitudinally associated with a lower likelihood of cognitive impairment and dementia. WBC mediated the association between latent socioeconomic position and CIND [β = -0.037 (CI: -0.06 to -0.01)], but not the association with dementia. Indirect effects were attenuated but remained significant when other mediators, such as lifestyle behaviours and BMI were considered. In a separate analysis accounting for main confounders, CRP and fibrinogen mediated the association between education and CIND, all three inflammatory biomarkers mediated the association of occupation and CIND, while WBC mediated the association between wealth and CIND.

CONCLUSION

These findings emphasise that socioeconomic inequalities in mid and later life could contribute to the prevalence of neurocognitive disorders in later life. Our results provide some evidence for the biological embedding of WBC in the association between socioeconomic inequalities and cognitive impairment via elevated inflammation. Future studies should explore other plausible biological mechanisms.

Social inequalities, stressful work and non-fatal cardiovascular disease: follow-up findings from the CONSTANCES Study

BACKGROUND

Studies show that a disadvantaged socioeconomic position (SEP) and psychosocial stress at work are both independently associated with an increased risk of cardiovascular disease (CVD). But it is not clear if the effect of stress at work on CVD varies by SEP.

METHODS

We used baseline and follow-up data from the French population-based cohort study CONSTANCES, including 48 383 employed women and men aged 30-70 years. Three SEP indicators (education, income, occupation), stressful psychosocial work as measured by effort-reward imbalance, pre-existing CVD and confounders were assessed at baseline, and incident non-fatal CVD events reported during annual follow-up (up to five follow-ups) were used as outcomes. The effect modification hypothesis was both investigated on an additive and multiplicative scale.

RESULTS

SEP was inversely associated with CVD risk (eg, for low vs high income, OR 1.28 (95% CI 1.12 to 1.46)), and for all three components of stressful work CVD risks were significantly increased (eg, for effort-reward ratio OR 1.26 (95% CI 1.17 to 1.36)). Employees with a disadvantaged SEP showed moderately increased effect sizes of stressful work on CVD. However, no clear evidence of an effect modification was found.

CONCLUSIONS

Disadvantaged SEP and stressful work contribute to higher CVD risk in this cohort. Despite moderately increased effect sizes for disadvantaged SEP groups, no evidence was found to support an effect modification hypothesis.

Fertility Decision-Making in the UK: Insights from a Qualitative Study among British Men and Women

Scholars are interested in better understanding the low fertility observed in higher income countries. While some people are choosing to have smaller families, countries also report a ‘fertility gap’, which is the proportion of people who end up with fewer children than originally desired. This paper investigates some causes of the fertility gap in the UK. We amassed qualitative data from seven focus groups conducted among men and women of reproductive age with different educational backgrounds. These focus groups suggest that social support is an influential factor for Britons thinking about having children, although discussions differed in terms of whether this was support from partners or parents. Discussions with university-educated women featured themes of career opportunity costs, and non-university men contributed insights on the financial burden of parenthood. This exploratory study provides up-to-date material on unwanted childlessness and the low fertility in the UK, and highlights the merit of using qualitative methods in understanding the fertility gap.

Sick of social status: A Bourdieusian perspective on morbidity and health inequalities

Self-reported health (SRH) is one of the most frequently used measures for examining socioeconomic inequalities in health. Studies find that when faced with 'identical objective health', individuals in lower socioeconomic groups consistently report worse SRH than those in higher socioeconomic groups. Such findings are often dismissed as being the result of reporting bias, and existing literature dominated by the biomedical conception of SRH has not investigated the underlying social mechanisms at work. To address this limitation, drawing on the work of Bourdieu we employ a relational thinking between health and social position. By way of multiple correspondence analysis, we construct social space of health determinants for three European countries from different welfare states and map the trajectories of educational groups experiencing similar levels of morbidity and their relation to SRH. Differences in SRH observed among social groups for the same level of morbidity are understood in relation to the position and the relative power of individuals in different educational groups to maintain or improve their social conditions, especially with increasing levels of health loss. Our analysis indicates that reporting differences in SRH among educational groups emerges from objectively healthy individuals and follows differences in accumulation of social advantages and disadvantages.

Influence of Social and Psychosocial Factors on Summer Vacationers’ Sun Protection Behaviors, the PRISME Study, France

Objectives: Summer intermittent sun exposure is a major risk factor for melanoma. Socioeconomic position, cognitive and psychosocial factors play a role in sun protection behaviors but the underlying mechanisms are unknown. This study aimed to measure the influence of educational level on sun protection behaviors in French summer vacationers on the Mediterranean coastline, and to identify the mediating psychosocial factors in this pathway.

Methods: In summer 2019, French vacationers aged 12–55 staying in coastline campsites were asked about their holiday sun protection behaviors, their knowledge, attitudes, perceived control, and social norm relative to sun protection. A structural equation model measured the direct and indirect effects of educational level on protection behaviors via cognitive and psychosocial factors.

Results: Sun protection during vacation increased with educational level. Theoretical knowledge partially mediated this association, from 22% to 86%, particularly for intermediate educational levels.

Conclusion: Our results highlight the importance of implementing suitable sun prevention interventions for vacationers, especially those with a lower socioeconomic position. Improving theoretical knowledge around sun protection may be an important part of broader efforts to encouraging improved preventive behaviors.

Estimating population norms for the health-related quality of life of adults in southern Jiangsu Province, China

Although national health-related quality of life population norms had been published based on the EuroQol 5-Dimensions 5-levels scale, China is a vast country with diverse cultural and social development in various regions. Therefore, regional population norms may better reflect the health status of residents in a given area. The purpose of the study was to derive the HRQoL population norm for adult general population in southern Jiangsu Province using the EQ-5D-5L scale and explore potential influencing factors. The data were based on a cross-sectional survey conducted in Liyang City from March 2019 to July 2020. EQ-5D-5L utility scores based on Chinese value set and EQ-VAS scores were used to assess HRQoL. The Tobit regression model and generalized linear model were performed to identify the association among potential covariates and HRQoL. The means (95% confidence interval) of the EQ-5D-5L utility scores and EQ-VAS scores were 0.981(0.980-0.983) and 83.6(83.2-83.9), respectively. Younger people (≤ 40 years old) were more likely to experience problems with anxiety or depression. Additionally, women had lower HRQoL scores although multivariate analysis found no statistical difference between the sexes. Lower HRQoL was associated with advanced age, lower socioeconomic status, no spouse, lack of regular physical activities, smoking cessation, and chronic non-communicable diseases. Subjects who declared that they were afflicted by diseases presented significantly lower utility scores, ranging from 0.823 (0.766-0.880) for memory-related diseases to 0.978 (0.967-0.989) for hepatic diseases. Regional population norms of HRQoL are needed in the health economic study owing to the great socioeconomic differences across regions in China. The present study provides HRQoL population norms for adults in southern Jiangsu. These norm values could help policy makers better allocate limited health resources and prioritize service plans.

Association between Bone Lead Concentration and Aggression in Youth from a Sub-Cohort of the Birth to Twenty Cohort

BACKGROUND

An association between blood-lead levels and aggression has been demonstrated in children and adolescent youth in South Africa. However, there are limited studies that have assessed aggression as an outcome for cumulative lead exposure using bone lead concentration. This study aims to assess the association between bone lead concentration and aggressive behaviour among a sample of youth in South Africa.

METHODS

Bone lead in 100 participants (53 males and 47 females) recruited and followed in the Birth to Twenty (BT20) Cohort were measured using 109 Cd-based, K-shell X-ray fluorescence (KXRF). The Buss-Perry Aggression questionnaire was used to measure aggressive behaviour. Linear regression models were fitted to determine the association between aggression score for physical, verbal, anger and hostility and bone lead, adjusting for known confounders.

RESULTS

A one-microgram-per-gram increase in bone lead was found to increase the score for all four scales of aggression, but significantly only for anger (β = 0.2 [95% CI 0.04-0.370]). Psychosocial factors such as a history of family violence and exposure to neighbourhood crime were significant predictors for aggression.

CONCLUSIONS

The study provides a preliminary overview of the relationship between cumulative lead exposure and behavioural problems such as aggression. A larger sample, across exposed communities, may prove more definitive in further investigating the association between these two important public health factors and to maximize generalizability.

Socio-economic differences in the uptake of HIV testing and associated factors in South Africa

BACKGROUND

Improved understanding of barriers to HIV testing is important for reaching the first of the UNAIDS 90-90-90 targets, which states that 90% of HIV positive individuals ought to know their HIV status. This study examined socio-economic status (SES) differences in HIV testing uptake and associated factors among youth and adults 15 years and older in South Africa.

METHODS

This study used data from a national cross-sectional, population-based household survey conducted in 2017 using a multi-stage sampling design. A composite SES score was created using multiple correspondence analyses of household assets; households were classified into wealth quintiles and dichotomised into low SES/poorest (lowest 3 quintiles) and high SES/less-poor (highest 2 quintiles). Bivariate and multivariate logistic regression models were used to examine factors associated with the uptake of HIV testing in low and high SES households.

RESULTS

HIV testing uptake was 73.8 and 76.7% among low and high SES households, respectively, both of which were below the first 90 targets. Among both low and high SES households, increased HIV testing uptake was significantly associated with females than males. The decreased likelihood was significantly associated with residing in rural formal areas than urban areas, those with no education or low levels of educational attainment and alcohol drinkers among low SES households. Whites and Indians/Asians had a decreased likelihood than Black Africans in high SES households.

CONCLUSIONS

HIV testing interventions should target males, residents in rural formal areas, those with no or low education and those that consume alcohol in low SES households, including Whites and Indians/Asians from high SES households in order to bridge socio-economic disparities in the uptake of HIV testing. This should entail expanding HIV testing beyond traditional centres for voluntary counselling and testing through outreach efforts, including mobile testing and home-based testing.

Which Risk Factors for Child Maltreatment Predict Mothers' Enrollment in a Parenting Support Program?

Parenting support programs are an effective means of preventing child maltreatment. However, these programs are often criticized for their limited ability to enroll and engage the parents who need them most. The present study aimed to determine which risk factors associated with child maltreatment predicted mothers' enrollment in the Triple P-Positive Parenting Program in Quebec. To this end, 240 mothers of children aged 6 months to 8 years enrolled in Triple P were compared with 834 mothers randomly selected from the general population. The results suggest that mothers who perceived their child to be more difficult, used fewer positive parenting practices, and reported a lower parenting sense of competence were more likely to enroll in the program. Being unemployed, having a lower income, and being a single parent or part of a stepfamily also increased the mothers' likelihood of participating in Triple P. These results suggest that Triple P was implemented in such a way as to attract families presenting various risk factors, which is promising in a child maltreatment prevention context.

Social mobility, accumulation of disadvantages and health. An analysis with retrospective data from the GSOEP (2002-14)

BACKGROUND

Socioeconomic position (SEP) in different life stages is related to health-related quality of life (HRQoL). Yet, research on the relevance of life course processes is scarce. This study aims to analyse the association between accumulation of disadvantages, social mobility and HRQoL.

METHODS

Analyses were conducted using population-averaged panel-data models and are based on data from the German Socio-Economic Panel 2002-14, including retrospective biographical information, comprising 25 473 observations from 8666 persons. Intergenerational and intragenerational mobility included the occupational positions in childhood (parental position), first job and middle age. Accumulation of disadvantages was measured using an accumulation index. HRQoL was assessed using the Mental and Physical Component Summary Scores of the SF12v2.

RESULTS

Accumulation of disadvantages was the main predictor for the Physical Component Summary in mid-age. Men and women in a stable low SEP or with a steep downward mobility showed the least favourable physical HRQoL. This holds for intergenerational and intragenerational mobility. Mental HRQoL did not seem to be associated with accumulation or social mobility.

CONCLUSION

The results show that physical HRQoL is related to social mobility and accumulation of (dis-)advantages. Further research is needed thoroughly analysing this association.

Towards a Central-Eastern European EQ-5D-3L population norm: comparing data from Hungarian, Polish and Slovenian population studies

BACKGROUND

EQ-5D-3L population data are available only from Hungary, Poland and Slovenia in Central and Eastern Europe (CEE). We aimed to compare the accessible studies and estimate a regional EQ-5D-3L population norm for CEE.

METHODS

A combined dataset using patient-level data of 8850 respondents was created. Based on the European Census of 2011, regional population norm estimates were calibrated by gender, age and education for the joint citizenry of 11 CEE countries.

RESULTS

EQ-5D-3L health states were available for 6926 and EQ VAS scores for 6569 respondents. Demographic characteristics of the samples reflected the recruitment methods (Hungary: online; Slovenia: postal survey, Poland: personal interviews). Occurrence of problems differed significantly by educational level in all the five dimensions (p < 0.001). The inter-country differences persisted after controlling for demographic variables. The estimated EQ-5D-3L index CEE norms with UK tariffs for age groups 18-24, 25-34, 35-44, 45-54, 55-64, 65-74 and 75 + were 0.911, 0.912, 0.871, 0.817, 0.762, 0.743 and 0.636 for males and 0.908, 0.888, 0.867, 0.788, 0.752, 0.68 and 0.584 for females, respectively. Estimates were provided also using Polish, European and Slovenian value sets.

CONCLUSIONS

Besides gender and age, education should be considered during the design and interpretation of quality-of-life studies in CEE. The estimated regional EQ-5D-3L population norm may be used as a benchmark by CEE countries with lack of local dataset. However, the substantial inter-country differences in health status and scarcity of data over age 65 call for harmonized country-specific EQ-5D-3L population norm studies in the CEE region.

Earlier Onset of Maternal Excess Adiposity Associated with Shorter Exclusive Breastfeeding Duration

BACKGROUND

Exclusive breastfeeding for 6 months is recommended; however, women with obesity have lower exclusive breastfeeding rates than their normal weight peers. The impact of the timing of maternal excess adiposity onset is unknown.

RESEARCH AIM

We examined whether the timing of onset of excess weight was related to exclusive breastfeeding duration.

METHODS

Snowball sampling was used for the cross-sectional Breastfeeding Opinions, Outcomes, Behaviors, and Services online survey. The sample was 1,570 mothers who reported their breastfeeding and weight history. Exclusive breastfeeding duration (for first biological child only) was calculated in months and dichotomously (0=< 6 months exclusive breastfeeding; 1=⩾ 6 months exclusive breastfeeding). Participants self-reported their excess weight onset (0=before/during puberty or 1=after puberty).

RESULTS

Analysis of covariance results indicated that earlier onset of excess weight was associated with shorter exclusive breastfeeding ( F (1, 1518) = 11.29, p<.001, η²=.01). Those with excess adiposity onset before or during puberty were 1.6 times more likely to experience exclusive breastfeeding failure (< 6 months exclusive breastfeeding) than those with onset after puberty ( OR = 1.57, β = .46, Wald = 11.81, p = .001).

CONCLUSION

Earlier onset of excess adiposity had an adverse influence on exclusive breastfeeding duration. Women with a history of excess adiposity before or during puberty who want to breastfeed may require additional intervention to promote their breastfeeding success.

Associations of socio-demographic, perceived environmental, social and psychological factors with active travel in Hong Kong adolescents: the iHealt(H) cross-sectional study

Adolescent active travel (AT) can contribute to health-enhancing physical activity, sense of community, social interactions, spatial and navigational skills and is a sustainable form of transport. Data analysed were from surveys with validated scales, translated and adapted for Chinese speaking Hong Kong adolescents and their parents, and administered to 1,299 adolescent/parent dyads. Using hierarchical modelling, this study examined independent associations of socio-demographic, perceived environmental, social and psychological factors (in that order) with adolescent AT to/from school (ATS) and AT to other destinations in Hong Kong. Moderation by gender and age on perceived environmental and social factors and number of household vehicles on proximity to destinations with AT were also estimated. The adolescents participating in ATS (58%), averaged 7.93 trips and 139.79 min per week. Adolescents averaged 7.68 trips/week to destinations other than school. Perceived proximity of school to home and social support for PA from peers were independently associated with higher odds of engaging in ATS. Social support for PA from household adults was associated with lower odds of engaging in ATS, especially in older adolescents. Trip frequency in those who engaged in ATS was positively associated with perceived proximity of school, access to services and parental transport-related PA. Perceived proximity of school was negatively associated with weekly minutes of ATS. Gender modified the association between social support for PA from peers and ATS frequency, and that of perceived proximity to public transport from home with weekly minutes of ATS. Perceived environmental, social and psychological factors were independently associated with AT to destinations other than school. In conclusion, Hong Kong adolescents appear to have high frequencies of ATS and AT to other destinations than reported elsewhere. Social support from peers, parental AT and having schools and other destinations within walking distance from home may independently contribute to adolescents' AT.

Disability and Access to Sexual and Reproductive Health Services in Cameroon: A Mediation Analysis of the Role of Socioeconomic Factors

There is growing evidence showing that people with disabilities face more frequently socioeconomic inequities than their non-disabled peers. This study aims to examine to what extent socioeconomic consequences of disability contribute to poorer access to sexual and reproductive health (SRH) services for Cameroonian with disabilities and how these outcomes vary with disabilities characteristics and gender. It uses data from a population-based survey conducted in 2015 in Yaounde, Cameroon. Mediation analysis was performed to determine how much of the total association between disability and the use, satisfaction and difficulties to access SRH services was mediated by education level, material wellbeing lifetime work participation and availability of social support. Overall, disability was associated with deprivation for all socioeconomic factors assessed though significant variation with the nature and severity of the functional limitations was observed. Lower education level and restricted lifetime work mediated a large part of the association between disability and lower use of HIV testing and of family planning. By contrast, while people with disabilities reported more difficulties to use a SRH service, no mediating was identified. In conclusion, Cameroonians with disabilities since childhood have restricted access to SRH services resulting from socioeconomic factors occurring early during the life-course.

Race, Depression, and Financial Distress in a Nationally Representative Sample of American Adults

Background: Although depression and financial distress are correlated, this association may differ for demographic groups, particularly based on race. Aim: Using a national sample of American adults, this study tested whether the association between Major Depressive Episode (MDE) and financial distress differs between African Americans and Whites. Methods: The National Survey of American Life (NSAL), 2003, enrolled 3570 African American and 891 Non-Hispanic White American adults. Demographic data (age and gender), socioeconomic position (SEP; i.e., education, employment, marital status, and income), financial distress, and 12-month MDE were measured. Logistic regression was used for data analysis. Results: In the pooled sample, 12-month MDE was associated with higher odds of financial distress, above and beyond objective SEP measures. We found MDE by race interaction on financial distress, suggesting stronger association between MDE and financial distress among African Americans, compared to Whites. Conclusions: The link between MDE and financial distress depends on race. The financial needs of African Americans with depression should be addressed. Depression screening is also needed for African Americans with financial distress.

Pain and health-related quality of life (HRQoL): a national observational study in community-dwelling older adults

PURPOSE

Regarding the epidemiology of pain in older adults, data are lacking about the association between pain severity and its impact on health-related quality of life (HRQoL). This study was aimed to investigate pain prevalence and sites, self-reported interferences with daily life activities, and the effect of pain severity on HRQoL in a Swiss community-dwelling population aged ≥ 65 years.

METHODS

This is a cross-sectional survey conducted with a national sample of individuals randomly selected from population records, stratified by age and gender. Respondents answered a face-face interview addressing pain location, intensity and interferences, and quality-of-life variables. Logit regression models were applied for binary outcomes, linear regression for continuous outcomes, and Poisson regression for count outcomes. For each analysis, Wald Chi square and 95% confidence intervals were used.

RESULTS

Among the 2995 individuals considered, 36.4% reported pain. The results indicate that pain prevalence and intensity increased from age 80 onwards. Pain intensity was strongly associated with functional health, i.e., all scales involving physical activities were affected in individuals reporting severe pain; it was also associated with the individuals' perception of their overall HRQoL.

CONCLUSION

Our results point to the importance of devoting attention to pain intensity rather than to the number of pain sites. Because of the demographic transition, the management of pain problems should emphasize early referral and timely treatment to prevent the burden of disease and functional loss associated with pain intensity.

Social inequalities in health and mental health in France. The results of a 2010 population-based survey in Paris Metropolitan Area

The present study aimed to assess socioeconomic inequalities in general and mental health, depression and substance use disorders (daily tobacco use, hazardous alcohol use). Data from the 2010 SIRS (French acronym for Health, Inequalities, and Social Ruptures) study, which is deemed to be representative of the French-speaking adult population living in the Paris Metropolitan Area, were analysed. Different socioeconomic position indicators were selected: education, income and perceived financial status. Absolute measures (the slope index of inequality (SII)) and relative measures (the odds ratio (OR) and relative index of inequality (RII)) of health inequalities were used. The OR, RII and SII were adjusted for age, household type and migration characteristics and all analyses were performed separately for men and women. The study included 3,006 adults. The results showed significant relative and absolute socioeconomic inequalities in general, mental health and depression for all socioeconomic position indicators considered (education, income, and perceived financial status). The absolute inequalities were greater for women than for men. Strongest inequalities were observed by perceived financial status for men and women. Education seemed to play a stronger role in inequalities for women, whereas, for men, income seemed to play a stronger role. Only few socioeconomic inequalities were found in daily tobacco use, while a reversed gradient was observed for hazardous alcohol use. We hope that these results will be regularly re-evaluated and compared across time in order to monitor socioeconomic inequalities in health.

The role of health literacy in explaining the association between educational attainment and the use of out-of-hours primary care services in chronically ill people: a survey study

Background

Low socioeconomic status (SES) is persistently associated with poor health and suboptimal use of healthcare services, and more unplanned healthcare use. Suboptimal use of emergency and acute healthcare services may increase health inequalities, due to late diagnosis or lack of continuity of care. Given that health literacy has been associated with healthcare utilisation and with education attainment, we sought to explore whether health literacy is related to the use of out-of-hours (OOH) Primary Care Services (PCSs). Additionally, we aimed to study whether and to what extent health literacy accounts for some of the association between education and OOH PSC use.

Methods

A survey including measures of education attainment, health literacy (assessed by means of the Dutch version of the nine-dimension Health Literacy Questionnaire) and use of PCS was conducted among a sample of adults diagnosed with (any) somatic chronic condition in the Netherlands (response 76.3%, n = 1811). We conducted linear and logistic regression analyses to examine associations between education level and PCS use in the past year. We performed mediation analyses to assess whether the association between education and PCS use was (partly) explained by different aspects of health literacy. We adjusted the models for patient characteristics such as age and morbidity.

Results

Higher education attainment was associated with higher scores on the health literacy aspects Appraisal of health information, and Navigating the healthcare system. Additionally, appraisal and navigating the healthcare system partially accounted for educational differences in PCS use. Finally, higher appraisal of health information scores were associated with higher PCS utilisation.

Conclusion

Several aspects of health literacy were demonstrated to relate to PCS use, and partly accounted for educational differences herein. Accordingly, developing health literacy within individuals or communities may help to reduce inappropriate PCS use among people with low education.

Socioeconomic status, education, and aortic stiffness progression over 5 years: the Whitehall II prospective cohort study

Objective:

The inverse association between socioeconomic status (SES) and cardiovascular disease (CVD) risk is well documented. Aortic stiffness assessed by aortic pulse wave velocity (PWV) is a strong predictor of CVD events. However, no previous study has examined the effect of SES on arterial stiffening over time. The present study examines this association, using several measures of SES, and attained education level in a large ageing cohort of British men and women.

Methods:

Participants were drawn from the Whitehall II study. The sample was composed of 3836 men and 1406 women who attended the 2008–2009 clinical examination (mean age = 65.5 years). Aortic PWV was measured in 2008–2009 and in 2012–2013 by applanation tonometry. A total of 3484 participants provided PWV measurements on both occasions. The mean difference in 5-year PWV change was examined according to household income, education, employment grade, and father's social class, using linear mixed models.

Results:

PWV increase [mean: confidence interval (m/s)] over 5 years was higher among participants with lower employment grade (0.38: 0.11–0.65), household income (0.58, 95%: 0.32–0.85), and education (0.30: 0.01, 0.58), after adjusting for sociodemographic variables, BMI, alcohol consumption, smoking, and other cardiovascular risk factors, namely SBP, mean arterial pressure, heart rate, cholesterol, diabetes, and antihypertensive use.

Conclusion:

The present study supports the presence of robust socioeconomic disparities in aortic stiffness progression. Our findings suggest that arterial aging could be an important pathophysiological pathway explaining the impact of lower SES on CVD risk.

Socioeconomic position and self-harm among adolescents: a population-based cohort study in Stockholm, Sweden

BACKGROUND

Understanding the association between parental socioeconomic position and self-harm in adolescence is crucial due to its substantial magnitude and associated inequality. Most previous studies have been either of cross-sectional nature or based solely on self-reports or hospital treated self-harm. The aim of this study is to determine the association between parental socioeconomic position and self-harm among adolescents with a specific focus on gender and severity of self-harm.

METHODS

A total of 165,932 adolescents born 1988-1994 who lived in Stockholm at the age of 13 were followed in registers until they turned 18. Self-harm was defined as first time self-harm and severity of self-harm was defined as hospitalized or not. Socioeconomic position was defined by parental education and household income. Cox proportional hazards regression were used to estimate hazard ratios (HR) with 95% confidence intervals (CI).

RESULTS

Analyses showed an association between parental socioeconomic position and self-harm. Among adolescents with parents with primary and secondary education compared to tertiary parental education the HR were 1.10 (95% CI 0.97-1.24) and 1.16 (95% CI 1.08-1.25) respectively. Compared to the highest income category, adolescents from the lower income categories were 1.08 (95% CI 0.97-1.22) to 1.19 (95% CI 1.07-1.33) times more likely to self-harm. In gender-stratified analyses, an association was found only among girls. Further, restriction to severe cases eliminated the association.

CONCLUSIONS

This study suggested that low parental socioeconomic position is associated with self-harm in adolescence, predominantly among girls. The desertion of an association among severe cases may be explained by differences in suicidal intent and underlying psychiatric diagnosis. Efforts to prevent self-harm should consider children with low parental socioeconomic position as a potential target group.

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

Background

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

Methods

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

Results

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

Discussion

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

Conclusion

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

Electronic supplementary material

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

Indicators of subjective social status: Differential associations across race and sex

Background

Subjective social status (SSS), or perception of rank on the social hierarchy, is an important indicator of various health outcomes. However, the psychosocial influences on this construct are unclear, and how these influences vary across different sociodemographic groups is poorly understood.

Methods

Participants were 2077 African-American and Whites (M age=47.85; 57% female; 58% African American, and 58% above poverty) from the Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study. Multiple regression analyses examined (1) hypothesized psychosocial indicators of SSS and (2) the moderating effect of race and sex on the variables associated with SSS.

Results

In addition to the traditional measures of SES (i.e. income, employment, and education), psychosocial variables (i.e. depressive symptomatology, neighborhood satisfaction, and self-rated health) were significantly associated with SSS. However, some of these indicators varied with respect to race and sex. Three significant interactions were found: sex by employment, race by employment, and race by education, wherein objective measures of SES were more associated with SSS for Whites and men compared to African Americans and women.

Conclusion

Psychosocial measures may influence individuals’ perceptions of themselves on the social hierarchy. Additionally, SSS may vary by demographic group. When considering the impact of SSS on health, it is important to consider the unique interpretations that various demographic groups have when perceiving themselves on the social hierarchy.

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Subjective Social Status (SSS) is an important health indicator, but its psychosocial correlates are unknown.

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Additionally, it is unclear if indicators of SSS vary by demographic group (i.e. race and sex).

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Findings suggest that in addition to traditional measures of socioeconomic status (e.g. education), numerous psychosocial variables (e.g. depressive symptoms) were related to SSS.

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Indicators of SSS varied across race and sex, wherein objective measures of SES were more associated with SSS for Whites and men, than African Americans and women.

Globalization, Work, and Cardiovascular Disease

Cardiovascular disease (CVD), a global epidemic, is responsible for about 30% of all deaths worldwide. While mortality rates from CVD have been mostly declining in the advanced industrialized nations, CVD risk factors, including hypertension, obesity, and diabetes, have been on the increase everywhere. Researchers investigating the social causes of CVD have produced a robust body of evidence documenting the relationships between the work environment and CVD, including through the mechanisms of psychosocial work stressors. We review the empirical evidence linking work, psychosocial stressors, and CVD. These work stressors can produce chronic biologic arousal and promote unhealthy behaviors and thus, increased CVD risk. We offer a theoretical model that illustrates how economic globalization influences the labor market and work organization in high-income countries, which, in turn, exacerbates job characteristics, such as demands, low job control, effort-reward imbalance, job insecurity, and long work hours. There is also a growing interest in “upstream” factors among work stress researchers, including precarious employment, downsizing/restructuring, privatization, and lean production. We conclude with suggestions for future epidemiologic research on the role of work in the development of CVD, as well as policy recommendations for prevention of work-related CVD.

Sickness Absence and Precarious Employment: A Comparative Cross-National Study of Denmark, Finland, Sweden, and Norway

BACKGROUND

Precarious employment is a major social determinant of health and health inequalities with effects beyond the health of workers.

OBJECTIVE

To investigate the association between precarious employment and sickness absence in 4 Nordic countries, Denmark, Finland, Norway, and Sweden.

METHODS

Logistic regression analyses were conducted separately for each country on data from 4186 respondents aged 15-65 years in Denmark, Finland, Norway, and Sweden derived from the 2010 European Working Conditions Survey. Sickness absence was based on self-reports and defined as absence of seven or more day per year. Precarious employment was operationalized as a multidimensional construct of indicators. Analyses were also conducted separately for men and women.

RESULTS

The prevalence of sickness absence was lowest in Sweden (18%), and highest in Finland (28%). 3 precarious employment indicators were positively associated with sickness absence; the pattern being largely similar in the total sample. In the sex-disaggregated sample, 5 precarious employment indicators increased the likelihood of sickness absence; the pattern was heterogeneous, with women generally having significantly higher odds of sickness absence than men. "Low household income" and "sickness presenteeism" were strong predictors of sickness absence among both sexes in most of the 4 studied countries. Sickness absence varied between the Nordic countries in the sex-disaggregated analyses.

CONCLUSION

Precarious employment indicators predicted sickness absence in the Nordic countries. Findings emphasize the need to prioritize informed and monitored collective bargaining for all workers, increase working time flexibility, and improving work conditions.

The Predictive Value of Depressive Symptoms for All-Cause Mortality: Findings From the PRIME Belfast Study Examining the Role of Inflammation and Cardiovascular Risk Markers

OBJECTIVES

To improve understanding about the potential underlying biological mechanisms in the link between depression and all-cause mortality and to investigate the role that inflammatory and other cardiovascular risk factors may play in the relationship between depressive symptoms and mortality.

METHODS

Depression and blood-based biological markers were assessed in the Belfast PRIME prospective cohort study (N = 2389 men, aged 50-59 years) in which participants were followed up for 18 years. Depression was measured using the 10-item Welsh Pure Depression Inventory. Inflammation markers (C-reactive protein [CRP], neopterin, interleukin [IL]-1 receptor antagonist [IL-1Ra], and IL-18) and cardiovascular-specific risk factors (N-terminal pro-b-type natriuretic peptide, midregion pro-atrial natriuretic peptide, midregion pro-adrenomedullin, C-terminal pro-endothelin-1 [CT-proET]) were obtained at baseline. We used Cox proportional hazards modeling to examine the association between depression and biological measures in relation to all-cause mortality and explore the mediating effects.

RESULTS

During follow-up, 418 participants died. Higher levels of depressive symptoms were associated with higher levels of CRP, IL-1Ra, and CT-proET. After adjustment for socioeconomic and life-style risk factors, depressive symptoms were significantly associated with all-cause mortality (hazard ratio = 1.10 per scale unit, 95% confidence interval = 1.04-1.16). This association was partly explained by CRP (7.3%) suggesting a minimal mediation effect. IL-1Ra, N-terminal pro-b-type natriuretic peptide, midregion pro-atrial natriuretic peptide, midregion pro-adrenomedullin, and CT-proET contributed marginally to the association between depression and subsequent mortality.

CONCLUSIONS

Inflammatory and cardiovascular risk markers are associated with depression and with increased mortality. However, depression and biological measures show additive effects rather than a pattern of meditation of biological factors in the association between depression and mortality.

Educational Attainment and Women's Environmental Mastery in Midlife: Findings From a British Birth Cohort Study

Using data from 1,184 women in the MRC National Survey of Health and Development, we estimated associations between education and Ryff’s environmental mastery scale scores at age 52. Confirmatory factor analysis indicated two subscales, here termed mastery skills and mastery accomplishments. Low education was associated with higher mastery skills. This was partly explained by childhood socioeconomic position, as mastery was lower among those with fathers in the most and least advantaged occupational classes. Education was not associated with mastery accomplishments in unadjusted models. Lower ambitions for family/home were associated with higher mastery accomplishments and may have partly suppressed as an association between education and mastery accomplishments. This study highlights childhood as well as adult correlates of mastery and adds to mounting evidence that higher mastery is not universally found among those who are more educated.

[Inequalities in mental health in the working population]

OBJECTIVES

To analyze inequalities in mental health in the working population by gender and professional qualifications and to identify psychosocial risk factors and employment conditions related to the mental health of this population.

METHODS

We performed a cross-sectional study using data from the Barcelona Health Survey 2000. The working population aged 16-64 years (2322 men and 1836 women) was included. Mental health was measured with the General Health Questionnaire (GHQ-12). Adjusted odds ratios (aOR) and their 95% confidence intervals (CI) were calculated by means of multivariate logistic regression models separated by job qualifications and gender.

RESULTS

The prevalence of poor mental health ranged from 8% among men working in non-manual occupations to 19% in women working in manual jobs. Women were more likely to report poor mental health status than men, although sex differences were greater among manual workers (aOR = 2.26; 95%CI, 1.68-3.05 for women compared to men in the same group). Differences according to qualifications were found among women only (aOR = 1.58 [95%CI, 1.22-2.05] for women working in manual jobs compared to those working in non-manual jobs), while no differences were found among men according to qualifications. Psychosocial risk factors were associated with mental health: demand was associated in all groups, autonomy only in non-manual occupations, and social support only in the most highly qualified working women. Employment conditions such as working a split shift (working day with a long lunch break) or having a temporary contract were associated with mental health in manual occupations only.

CONCLUSIONS

Mental health among the working population is related to professional qualifications and gender. Women are at greater risk than men, especially those working in manual occupations. Psychosocial occupational factors are related to mental health status, showing different patterns depending on gender and professional qualifications.

Mother's Perception of General Family Functioning and Sugar Consumption of 3- and 4-Year-Old Children: The East London Family Study

Frequent consumption of sugary foods is a common risk factor for chronic diseases such as dental caries and obesity. Dietary patterns are acquired at home during early life and form a blueprint for dietary behaviours in later life. A favourable family environment can provide a supportive context that enhances the adoption of healthy dietary habits. The aim of this study was to identify the contribution of general family functioning towards the frequent consumption of sugary foods by 3- and 4-year-old children in Outer North East London. The research question was explored with data from the East London Family study, which collected data through home visits from a representative sample of adults and children living in Outer North East London in 2008-2010. This study analysed data from 3- and 4-year-old children (n = 698) and their mothers and included logistic regression, conceptual hierarchical modelling and mediation analysis. The results showed that 17% of the sample consumed sugary foods more than 4 times per day, and that effective general family functioning may help reducing frequent consumption of sugary foods. There was a 67% reduction in children's frequent consumption of sugary foods with every unit increase in the general family functioning score. Mother's higher education may also help reduce the frequent consumption of sugary foods by children. The negative impact of mother's lower education was buffered by the effect of effective general family functioning. The study findings underscore the prospect of identifying factors that contribute to the acquisition of good dietary behaviours.

A mediation approach to understanding socio-economic inequalities in maternal health-seeking behaviours in Egypt

BACKGROUND

The levels and origins of socio-economic inequalities in health-seeking behaviours in Egypt are poorly understood. This paper assesses the levels of health-seeking behaviours related to maternal care (antenatal care [ANC] and facility delivery) and their accumulation during pregnancy and childbirth. Secondly, it explores the mechanisms underlying the association between socio-economic position (SEP) and maternal health-seeking behaviours. Thirdly, it examines the effectiveness of targeting of free public ANC and delivery care.

METHODS

Data from the 2008 Demographic and Health Survey were used to capture two latent constructs of SEP: individual socio-cultural capital and household-level economic capital. These variables were entered into an adjusted mediation model, predicting twelve dimensions of maternal health-seeking; including any ANC, private ANC, first ANC visit in first trimester, regular ANC (four or more visits during pregnancy), facility delivery, and private delivery. ANC and delivery care costs were examined separately by provider type (public or private).

RESULTS

While 74.2% of women with a birth in the 5-year recall period obtained any ANC and 72.4% delivered in a facility, only 48.8% obtained the complete maternal care package (timely and regular facility-based ANC as well as facility delivery) for their most recent live birth. Both socio-cultural capital and economic capital were independently positively associated with receiving any ANC and delivering in a facility. The strongest direct effect of socio-cultural capital was seen in models predicting private provider use of both ANC and delivery. Despite substantial proportions of women using public providers reporting receipt of free care (ANC: 38%, delivery: 24%), this free-of-charge public care was not effectively targeted to women with lowest economic resources.

CONCLUSIONS

Socio-cultural capital is the primary mechanism leading to inequalities in maternal health-seeking in Egypt. Future studies should therefore examine the objective and perceived quality of care from different types of providers. Improvements in the targeting of free public care could help reduce the existing SEP-based inequalities in maternal care coverage in the short term.

Health status and quality of life: results from a national survey in a community-dwelling sample of elderly people

PURPOSE

To investigate the relation between age and HRQoL indicators in a community-dwelling population aged 65 years and older.

METHODS

Data were collected within a sample stratified by age (65-69; 70-74; 75-79; 80-84; 85-89; 90 years and above) and sex and randomly selected in the population records in Switzerland. The EQ-5D was used to assess HRQoL. Analyses were conducted on the entire available sample (N = 3,073) and on the subsample with no missing data in the EQ-5D (N = 2,888), considering age, gender, education and region.

RESULTS

Results of multiple regression analyses showed different age-related patterns across the EQ-5D. The proportion of respondents reporting no problems ranged from 51 % in the 65- to 69-year age group to 20 % in the 90 years and above age group. Odds ratio (OR) for Mobility problems increased from 2.04 in the 75- to 79-year age group to 13.34 in the 90 years and above age group; OR for Usual Activities increased from 1.76 to 11.68 and from 1.55 to 2.32 for Pain/Discomfort; OR for Self-Care increased from 5.26 in the 80- to 84-year age group to 30.36 in the 90 years and above age group. Problems with Self-Care remained low, increasing from 6.22 % in the 80- to 84-year age group to 26.21 % in the oldest age group. The magnitude of the gender, region and education effects was much lower than that of age.

CONCLUSION

HRQoL is globally preserved in older adults in Switzerland, even if substantial impairment is reported in very old age affecting mainly functional health dimensions. Anxiety/Depression and Pain/Discomfort did not appear to be affected by age; high rates of difficulties were reported for Pain/Discomfort but not for Anxiety/Depression.

The relationship between postnatal depression, sociodemographic factors, levels of partner support, and levels of physical activity

Background: postnatal depression (PND) is defined as a psychological mood disorder that occurs in a mother within 6 weeks of her giving birth. It refers to an episode that causes mood disturbance and it could begin in, or extend into, the postpartum period. It is thought to have a high impact upon the mother's health as well as the family's functioning and the child's development. Socio-demographic, psych-social, and physical activity factors may all contribute to postpartum mood and ability to cope with responsibilities. The primary aim of this study was to determine which of these factors predicted PND in postpartum women. A secondary aim was to identify the socio-demographic and psycho-social predictors of physical activity in postpartum women.

Methods: The study used a cross-sectional correlational design. A sample of 150 postpartum women was sent a package of six standardized questionnaires.

Results: There was no association between physical activity and PND; however, older mothers, mothers of younger children, mothers who are less reluctant to ask for help, and mothers who are more satisfied with the help they get experience lower levels of PND. Mothers of older babies, mothers with more children, and less educated mothers are more likely to engage in caregiving activities, whereas mothers with fewer children and higher levels of partner support are more likely to engage in occupational activities. None of the socio-demographic factors or any of the parenting factors predicted levels of sporting activity.

Race-based job discrimination, disparities in job control, and their joint effects on health

OBJECTIVES

To examine disparities between job control scores in Black and White subjects and attempt to discern whether self-rated low job control in Blacks may arise from structural segregation into different jobs, or represents individual responses to race-based discrimination in hiring or promotion.

METHODS

Data from the National Survey of Midlife in the United States (MIDUS) were analyzed by mixed-effects linear regression and variance regression to determine the effects of grouping by occupation, and racial discrimination in hiring or promotion, on control scores from the Job Content Questionnaire in Black and White subjects. Path analyses were constructed to determine the mediating effect of discrimination on pathways from education and job control to self-rated health.

RESULTS

Black subjects exhibited lower mean job control scores compared to Whites (mean score difference 2.26, P < 0.001) adjusted for age, sex, education, and income. This difference narrowed to 1.86 when adjusted for clustering by occupation, and was greatly reduced by conditioning on race-based discrimination (score difference 1.03, P = 0.12). Path analyses showed greater reported discrimination in Blacks with increasing education, and a stronger effect of job control on health in Black subjects.

CONCLUSIONS

Individual racially-based discrimination appears a stronger determinant than structural segregation in reduced job control in Black workers, and may contribute to health disparities consequent on work.

Life-course occupational social class and health in later life: the importance of frequency and timing of measures

Research investigating associations between social class over the life-course and later health relies primarily on secondary analysis of existing data, limiting the number and timing of available measurements. This paper aims to examine the impact of these constraints on the measurement of life-course occupational social class and subsequent explanatory analyses predicting health in later life. Participants of the UK Boyd Orr Lifegrid Subsample (n = 294), aged an average of 68 years, provided retrospective information on their life-course occupational social class, coded at 6-month intervals. This was used to simulate two types of life-course data: (1) Theoretical: Life stage (four data-points at key life stages); (2) A-theoretical: Panel data (data-points at regular intervals of varying length). The percentage of life time in disadvantage and the predictive value for limiting longstanding illness (LLI) in later life using the full life-course and simulated data was compared. The presence of 'critical periods' of exposure and the role of trajectories of social class were also investigated. Compared with the full data, the life stage approach estimated a higher percentage of life time in disadvantage and emphasised 'transient' periods in disadvantage (e.g. labour market entry). With varying intervals using the a-theoretical approach, there was no clear pattern. Percentage of life time in manual class was a significant predictor of LLI only when using the four-point life stage approach. Occupational social class at labour market entry was a predictor of LLI in later life, suggesting a 'critical period'. Comparison of trajectories of social class further emphasised the importance of the sequence and timing of exposures to disadvantage in determining later health. We conclude that producing a valid summary of life-course occupational social class does not necessarily require a large number of data-points, particularly if guided by relevant theory, and that such measures can reveal important associations with later health.

Determinants of health-related quality of life in people with Parkinson's disease: a path analysis

PURPOSE

To identify the demographic factors, impairments and activity limitations that contribute to health-related quality of life (HRQOL) in people with idiopathic Parkinson's disease (PD).

METHOD

Two hundred and ten individuals with idiopathic PD who participated in the baseline assessment of a randomized clinical trial were included. The Parkinson's Disease Questionnaire-39 summary index was used to quantify HRQOL. In order to provide greater clarity regarding the determinants of HRQOL, path analysis was used to explore the relationships between the various predictors in relation to the functioning and disability framework of the International Classification of Functioning model.

RESULTS

The two models of HRQOL that were examined in this study had a reasonable fit with the data. Activity limitations were found to be the strongest predictor of HRQOL. Limitations in performing self-care activities contributed the most to HRQOL in Model 1 (β = 0.38; p < 0.05), while limitations in functional mobility had the largest contribution in Model 2 (β = -0.31; p < 0.0005). Self-reported history of falls was also found to have a significant and direct relationship with HRQOL in both models (Model 1 β = -0.11; p < 0.05; Model 2 β = -0.21; p < 0.05).

CONCLUSIONS

Health-related quality of life in PD is associated with self-care limitations, mobility limitations, self-reported history of falls and disease duration. Understanding how these factors are inter-related may assist clinicians focus their assessments and develop strategies that aim to minimize the negative functional and social sequelae of this debilitating disease.

Latent variable model for suicide risk in relation to social capital and socio-economic status

BACKGROUND

There is little evidence on the association between suicide outcomes (ideation, attempts, self-harm) and social capital. This paper investigates such associations using a structural equation model based on health survey data, and allowing for both individual and contextual risk factors.

METHODS

Social capital and other major risk factors for suicide, namely socioeconomic status and social isolation, are modelled as latent variables that are proxied (or measured) by observed indicators or question responses for survey subjects. These latent scales predict suicide risk in the structural component of the model. Also relevant to explaining suicide risk are contextual variables, such as area deprivation and region of residence, as well as the subject's demographic status. The analysis is based on the 2007 Adult Psychiatric Morbidity Survey and includes 7,403 English subjects. A Bayesian modelling strategy is used.

RESULTS

Models with and without social capital as a predictor of suicide risk are applied. A benefit to statistical fit is demonstrated when social capital is added as a predictor. Social capital varies significantly by geographic context variables (neighbourhood deprivation, region), and this impacts on the direct effects of these contextual variables on suicide risk. In particular, area deprivation is not confirmed as a distinct significant influence. The model develops a suicidality risk score incorporating social capital, and the success of this risk score in predicting actual suicide events is demonstrated.

CONCLUSIONS

Social capital as reflected in neighbourhood perceptions is a significant factor affecting risks of different types of self-harm and may mediate the effects of other contextual variables such as area deprivation.

Overqualification and risk of all-cause and cardiovascular mortality: evidence from the Canadian Census Mortality Follow-up Study (1991-2001)

OBJECTIVES

To evaluate whether education, occupation and overqualification (defined as having a level of educational attainment higher than the skill level required for an occupation) are associated with risk of all-cause and cardiovascular disease (CVD) mortality.

METHOD

A prospective study of the association between overqualification and all-cause and CVD mortality was undertaken in the Canadian Census Mortality Follow-up study (1991-2001), a 15% sample of Canadian adults who completed the 1991 census long-form questionnaire (n=1,091,800, 39% women, baseline age 35-64 years). Education, occupation and all confounders (age, income adequacy, marital status, years since immigration, ethnicity, Aboriginal origins, province of residence, and community size) were measured at study baseline, with subsequent follow-up for mortality.

RESULTS

Sex-specific age-adjusted Cox proportional hazards models showed an inverse association between education and all-cause mortality (women: hazard ratio (HR)=1.55, 95% confidence interval (CI): 1.45-1.66; men: HR=1.94, 95% CI: 1.87-2.01, for <high school vs. university degree). In addition, age-adjusted occupation was inversely associated with all-cause mortality (women: HR=1.42, 95% CI: 1.32-1.53; men: HR=1.86, 95% CI: 1.78-1.95, for unskilled vs. professional occupation). Similar social gradients were observed for CVD mortality. Overqualification was not associated with risk of all-cause or CVD mortality, demonstrated by non-statistically significant interaction terms between education and occupation.

CONCLUSIONS

Increasingly, Canadians are pursuing high levels of education; however, the occupational distribution in the labour market has not changed to the same extent. Results from this study suggest that the resulting increase in workers who are overqualified for their occupation will not lead to increased all-cause or CVD mortality.

Tracking exposure to child poverty during the first 10 years of life in a Quebec birth cohort

OBJECTIVES

Early childhood poverty is associated with adult chronic diseases. The objectives of this study were to examine patterns of exposure to poverty during the first 10 years of life in the Quebec Longitudinal Study of Child Development (QLSCD) cohort according to three measures of poverty and to explore family characteristics associated with different poverty exposures.

METHOD

Data from 1,334 participants from the QLSCD were collected annually at home from ages 5 months through 10 years. Household income (previous 12 months) and sources of income were recorded at each data round. Poverty status was operationalized as 1) living below the low income cut-off of Statistics Canada, 2) receiving social welfare and 3) being in the lowest quintile of socio-economic status. We plotted trends in the prevalence of child poverty over time. We used latent class growth modelling to identify subgroups with similar poverty trajectories. Duration of poverty according to each measure was computed separately for early childhood, middle childhood, and the entire 10 years of life.

RESULTS

Four trajectories of poverty were identified: stable poor, decreasing likelihood, increasing likelihood, and never poor. The three measures of poverty do not cover the same population, yet the characteristics of those identified as poor are similar. Children of non-European, immigrant mothers were most likely to be poor, and there was a higher likelihood of children from single-parent families to live in chronic poverty during the first 10 years.

CONCLUSION

A large proportion of children are exposed to poverty before 10 years of age. More effective public policies could reduce child poverty.

Examining the relationship between psychosocial working conditions, physical work demands, and leisure time physical activity in Canada

OBJECTIVE

To examine the effects of psychosocial working conditions and physical work demands on leisure time physical activity (LTPA).

METHODS

Using path analysis, direct and indirect effects of self-reported working conditions on LTPA levels were assessed in a representative sample of 4167 workers from the 2000 to 2001 Canadian National Population Health Survey.

RESULTS

Higher levels of skill discretion and decision latitude were associated with higher LTPA. Physical work demands had opposite effects among men versus women, and skill discretion had a stronger effect among women than among men. Job security had a stronger effect on older workers and those without children younger than 13 years.

CONCLUSIONS

The results support the influence of the work environment on LTPA and suggest that certain work conditions should be targeted in future interventions seeking to impact participation in physical activity.

Early life financial adversity and respiratory function in midlife: a prospective birth cohort study

Data from the 1958 National Child Development Study (1958-2004) were used in a prospective study of the relation of financial adversity in childhood to lung function in midlife. It was hypothesized that such a relation would be found and would be mediated partly by early housing deprivation, partly by continuities in social disadvantage, and partly by smoking. These hypotheses were confirmed. The mediating variables explained nearly two-thirds of the observed relation. The strongest individual pathway from early financial hardship to adult lung function was through poor housing in childhood. Poor housing increased the risk of educational failure, which in turn was strongly related to less-advantaged social class. Lack of educational qualifications and less-advantaged social class independently increased the risk of higher levels of smoking. Mediating variables therefore acted in part as indicators of environmental exposures and in part through their links to adult smoking. Early financial adversity is associated with adult lung function partly through poor housing and partly through pathways involving continuities in social disadvantage and the associated environmental exposures and behaviors.

Distal and variably proximal causes: education, obesity, and health

Medical sociologists hold that social conditions generate disparities across a host of health conditions through exposure to a variety of more proximate risk factors. Though distal and proximal causes jointly influence disease, the nature of risk accumulation may differ appreciably by the link of a proximal cause to the outcome in question. This paper employs a representative sample of over 3000 American older adults to examine whether position in the educational gradient amplifies the effect of obesity on two health outcomes. Results indicate that educational inequalities amplify the effect of high body mass index on disability (unstandardized coefficients across education groups range from -.05 [ns] to .26 [p < .01] among overweight respondents yet reach .17 [ns] to .73 [p < .001] among severely obese adults), but fail to amplify the consequences of severe obesity in the case of C-reactive protein (CRP) levels. Instead, educational gradients in CRP are most pronounced at lower levels of body mass. Sex-specific analyses further clarify these patterns, as the connections between CRP and body mass are particularly strong among women. We conclude that risk accumulation processes differ based on the proximity of causes to the health outcome under examination.