Widening socioeconomic inequalities in mortality in six Western European countries

An innovative visual approach to the simultaneous study of two dimensions of progress in longevity: an application to French and German regions

BACKGROUND

Both enhancing life expectancy and decreasing inequalities in lifespan between social groups are significant goals for public policy. To date, however, methodological tools to study progress in both dimensions simultaneously have been lacking. There is also a consensus that absolute and relative inequalities in lifespan must be studied together.

METHODS

We introduce a novel graphical representation that combines national mortality rates with both absolute and relative measures of social inequality in mortality. To illustrate our approach, we analyze French and German data stratified by place of residence.

RESULTS

For all-age mortality, in France we find a steady pace of decline in both mortality and in regional inequalities in mortality over recent decades. In Germany, substantial progress was made in the 1990s, mostly driven by convergence between eastern and western Germany, followed by a period of slower progress. Age-specific analyses for Germany reveal a worrying divergence in regional trends at ages 35-74 in recent years, which is particularly pronounced among women.

CONCLUSION

Our novel visual approach offers a way to simultaneously examine two dimensions of progress in longevity, and facilitates meaningful comparisons between populations, even when their current mortality rates differ. The applied methods can be easily reproduced in any country for which long-term mortality series stratified by region, or any relevant socioeconomic characteristic, are available. It is useful for both scientific analysis and policy advice.

Forecasting Inequalities in Survival to Retirement Age by Socioeconomic Status in Denmark and Sweden

In Denmark and Sweden, statutory retirement age is indexed to life expectancy to account for mortality improvements in their populations. However, mortality improvements have not been uniform across different sub-populations. Notably, in both countries, individuals of lower socioeconomic status (SES) have experienced slower mortality improvements. As a result, a uniform rise in the statutory retirement age could disproportionally affect these low-SES groups and may unintentionally lead to a reverse redistribution effect, shifting benefits from short-lived low-SES individuals to long-lived high-SES individuals. The aim of this study is twofold: to quantify and contextualise mortality inequalities by SES in Denmark and Sweden, and to assess how indexing retirement age will affect future survival to retirement age by SES in these countries. We used Danish and Swedish registry data (1988-2019), to aggregate individuals aged 50 + based on their demographic characteristics and SES. We computed period life tables by year, sex, and SES to estimate the difference in survival across different SES groups. We then forecast mortality across SES groups to assess how indexing retirement age will affect survival inequalities to retirement age, using two forecasting models-the Mode model and the Li-Lee model. Mortality inequalities are comparable in Denmark and Sweden, even though the latter generally has higher survival. We also find that indexing retirement age to life expectancy will have two main consequences: it will reduce the probability of reaching retirement for all SES groups, particularly those of low SES, and time spent in retirement will be reduced, particularly for those of high SES.

Trends in socioeconomic inequalities in cause-specific premature mortality in Belgium, 1998-2019

BACKGROUND

Higher levels of socioeconomic deprivation have been consistently associated with increased risk of premature mortality, but a detailed analysis by causes of death is lacking in Belgium. We aim to investigate the association between area deprivation and all-cause and cause-specific premature mortality in Belgium over the period 1998-2019.

METHODS

We used the 2001 and 2011 Belgian Indices of Multiple Deprivation to assign statistical sectors, the smallest geographical units in the country, into deprivation deciles. All-cause and cause-specific premature mortality rates, population attributable fraction, and potential years of life lost due to inequality were estimated by period, sex, and deprivation deciles.

RESULTS

Men and women living in the most deprived areas were 1.96 and 1.78 times more likely to die prematurely compared to those living in the least deprived areas over the period under study (1998-2019). About 28% of all premature deaths could be attributed to socioeconomic inequality and about 30% of potential years of life lost would be averted if the whole population of Belgium faced the premature mortality rates of the least deprived areas.

CONCLUSION

Premature mortality rates have declined over time, but inequality has increased due to a faster pace of decrease in the least deprived areas compared to the most deprived areas. As the causes of death related to poor lifestyle choices contribute the most to the inequality gap, more effective, country-level interventions should be put in place to target segments of the population living in the most deprived areas as they are facing disproportionately high risks of dying.

Trends in social inequality in mortality in Denmark 1995-2019: the contribution of smoking- and alcohol-related deaths

BACKGROUND

During the past decades, social inequality in mortality has increased in several countries, including Denmark. Modifiable risk factors, such as smoking and harmful alcohol consumption, have been suggested to moderate the association between socioeconomic position and health-related outcomes. The present study aims to investigate the contribution of smoking- and alcohol-related deaths to the trends in educational inequality in mortality in Denmark 1995-2019 among individuals aged 30-74 years.

METHODS

Nationwide data on mortality and highest attained educational level divided into quartiles were derived from administrative registers. Alcohol-related mortality was directly estimated using information on alcohol-related deaths from death certificates. Smoking-related mortality was indirectly estimated using the Peto-Lopez method. The contribution of smoking- and alcohol-related deaths to the social inequality gap in mortality 1995-2019 was calculated.

RESULTS

Alongside a decrease in all-cause mortality in Denmark 1995-2019, absolute differences in the mortality rate (per 100 000 person-year) between the lowest and the highest educational quartile increased from 494 to 607 among men and from 268 to 376 among women. Among both men and women, smoking- and alcohol-related deaths explained around 60% of the social inequality in mortality and around 50% of the increase in mortality inequality.

CONCLUSION

Smoking and harmful alcohol consumption continue to be important risk factors and causes of social inequality in mortality, with around half of the increase in Denmark 1995-2019 being attributable to smoking- and alcohol-related deaths. Future healthcare planning and policy development should aim at reducing social inequality in modifiable health risk behaviours and their negative consequences.

Impact of sociodemographic and economic determinants of health on COVID-19 infection: incidence variation between reference periods

OBJECTIVES

The COVID-19 pandemic hit Portugal in March 2020, causing widespread disruption to various aspects of society. While extensive research has been conducted on the significance of socio-economic disparities in infection risk, this study aims to enhance our understanding of their evolving relationship over time by analysing four distinct periods in 2020.

STUDY DESIGN AND METHODS

This retrospective observational ecological study included individuals residing in the Primary Healthcare Cluster areas of Almada-Seixal and Western Lisbon and Oeiras, who tested positive for SARS-CoV-2 through a polymerase chain reaction (PCR) test between the 2nd of March and the 8th of November of 2020. Using incidence rates for each specific neighbourhood (n = 29) and period, we explored the relationship between neighbourhood-level socio-economic variables and the risk of infection using negative-binomial regression models.

RESULTS

In the analysed period, a total of 8562 confirmed COVID-19 cases were identified. Overall incidence rates for each period were sequentially 2.74, 5.03, 3.99 and 14.29 COVID-19 cases per 100,000 person-days. Housing overcrowding, illiteracy rate and place of birth were associated with increased risk of infection, while age, congregate living, and employment in the secondary sector exhibited the opposite association. No association was consistent across all time periods.

CONCLUSIONS

Our findings support the idea that the influence of socio-economic determinants of health is not immutable throughout time. In a pandemic context where information, knowledge, beliefs, and behaviours are ever-changing and evolving, a dynamic, inclusive, and adaptable approach to disease control can lead to a more equitable distribution of improved outcomes, benefiting all strata of society.

A cross-sectional study of the association between family conflicts and children's health: Lolland-Falster Health Study

BACKGROUND

Few family interaction processes are more detrimental to children's health than family conflicts. Conflictual relationships in childhood predict a host of adverse health outcomes across the life course. The current study examines associations between household conflicts and the health of children aged 6-12 years and explores to which extent this may vary by socioeconomic status (SES) and multimorbidity (MM) in the household.

METHODS

Cross-sectional study using questionnaire data gathered between 2016 and 2020 as part of the Lolland-Falster Health Study (LOFUS) combined with routine register data on health care use and socio-demography from the Danish nationwide administrative databases. The study sample consisted of 1065 children 6-12 years old, who answered LOFUS4 or LOFUS11, from 777 households for which at least one adult answered LOFUS18. Main outcome was children's health complaints, defined as headache, abdominal pain, back pain, and sleep difficulties. Covariates included MM, SES, and conflicts, all three measured at household level. Multivariable logistic regression models were used.

RESULTS

Conflicts were negatively associated with children's health. This was most pronounced for general conflicts in the household, with increased complaints of abdominal pain, back pain, and sleep difficulties. The associations varied when we stratified the households according to MM and SES. Significant associations were found within households without MM for abdominal pain, and within households with MM and low SES, and without MM and with high SES for sleep difficulties. While the higher level of abdominal pain for the above indicated households were found for both internal and external conflicts in the household, the higher level in sleep difficulties was mostly driven by internal conflicts.

CONCLUSION

Children reporting frequent health complaints have a higher future health care use compared with children without such complaints. Our results indicate that growing up in a household with a high conflict level might be a predisposing factor.

Determination of the Level of Cardiovascular Risk in 172,282 Spanish Working Women

Introduction, objectives: Although cardiovascular events have been traditionally associated mainly with men, some data reflect an increase in women, which may even exceed their male counterparts, constituting the leading cause of death in working women in Spain. The objective of this present study was to analyze the level of cardiovascular risk in Spanish working women by assessing the influence of age, type of work, and tobacco consumption.

MATERIAL, METHODS

A descriptive cross-sectional study was carried out in 172,282 working women from different Spanish geographical areas and from different companies between January 2018 and June 2020. A range of variables and risk factors were assessed and various cardiovascular risk scales were used to analyze the data.

RESULTS

An increase in cardiovascular risk was observed in the least qualified work groups, mainly corresponding to blue-collar workers, when using the SCORE or REGICOR risk equation. The prevalence of altered values for all the parameters analyzed (overweight and obesity, hypertension, dyslipidemia, diabetes, fatty liver, hepatic fibrosis, atherogenic indexes, and cardiovascular risk scales) was higher among blue-collar women. Age was the only factor that influenced all the cardiovascular risk scales studied, increasing risk when comparing the group of women aged 50 years and older with the others.

CONCLUSIONS

Aging and belonging to the blue-collar job category meant worse results in the cardiovascular risk scales and in all the parameters analyzed. This is in line with numerous studies that argue that age and zip code are more influential than genetic code.

Subtyping Social Determinants of Health in All of Us: Network Analysis and Visualization Approach

Background

Social determinants of health (SDoH), such as financial resources and housing stability, account for between 30-55% of people's health outcomes. While many studies have identified strong associations among specific SDoH and health outcomes, most people experience multiple SDoH that impact their daily lives. Analysis of this complexity requires the integration of personal, clinical, social, and environmental information from a large cohort of individuals that have been traditionally underrepresented in research, which is only recently being made available through the All of Us research program. However, little is known about the range and response of SDoH in All of Us, and how they co-occur to form subtypes, which are critical for designing targeted interventions.

Objective

To address two research questions: (1) What is the range and response to survey questions related to SDoH in the All of Us dataset? (2) How do SDoH co-occur to form subtypes, and what are their risk for adverse health outcomes?

Methods

For Question-1, an expert panel analyzed the range of SDoH questions across the surveys with respect to the 5 domains in Healthy People 2030 (HP-30), and analyzed their responses across the full All of Us data (n=372,397, V6). For Question-2, we used the following steps: (1) due to the missingness across the surveys, selected all participants with valid and complete SDoH data, and used inverse probability weighting to adjust their imbalance in demographics compared to the full data; (2) an expert panel grouped the SDoH questions into SDoH factors for enabling a more consistent granularity; (3) used bipartite modularity maximization to identify SDoH biclusters, their significance, and their replicability; (4) measured the association of each bicluster to three outcomes (depression, delayed medical care, emergency room visits in the last year) using multiple data types (surveys, electronic health records, and zip codes mapped to Medicaid expansion states); and (5) the expert panel inferred the subtype labels, potential mechanisms that precipitate adverse health outcomes, and interventions to prevent them.

Results

For Question-1, we identified 110 SDoH questions across 4 surveys, which covered all 5 domains in HP-30. However, the results also revealed a large degree of missingness in survey responses (1.76%-84.56%), with later surveys having significantly fewer responses compared to earlier ones, and significant differences in race, ethnicity, and age of participants of those that completed the surveys with SDoH questions, compared to those in the full All of Us dataset. Furthermore, as the SDoH questions varied in granularity, they were categorized by an expert panel into 18 SDoH factors. For Question-2, the subtype analysis (n=12,913, d=18) identified 4 biclusters with significant biclusteredness (Q=0.13, random-Q=0.11, z=7.5, P<0.001), and significant replication (Real-RI=0.88, Random-RI=0.62, P<.001). Furthermore, there were statistically significant associations between specific subtypes and the outcomes, and with Medicaid expansion, each with meaningful interpretations and potential targeted interventions. For example, the subtype Socioeconomic Barriers included the SDoH factors not employed, food insecurity, housing insecurity, low income, low literacy, and low educational attainment, and had a significantly higher odds ratio (OR=4.2, CI=3.5-5.1, P-corr<.001) for depression, when compared to the subtype Sociocultural Barriers. Individuals that match this subtype profile could be screened early for depression and referred to social services for addressing combinations of SDoH such as housing insecurity and low income. Finally, the identified subtypes spanned one or more HP-30 domains revealing the difference between the current knowledge-based SDoH domains, and the data-driven subtypes.

Conclusions

The results revealed that the SDoH subtypes not only had statistically significant clustering and replicability, but also had significant associations with critical adverse health outcomes, which had translational implications for designing targeted SDoH interventions, decision-support systems to alert clinicians of potential risks, and for public policies. Furthermore, these SDoH subtypes spanned multiple SDoH domains defined by HP-30 revealing the complexity of SDoH in the real-world, and aligning with influential SDoH conceptual models such as by Dahlgren-Whitehead. However, the high-degree of missingness warrants repeating the analysis as the data becomes more complete. Consequently we designed our machine learning code to be generalizable and scalable, and made it available on the All of Us workbench, which can be used to periodically rerun the analysis as the dataset grows for analyzing subtypes related to SDoH, and beyond.

Dynamic Changes in the Association Between Education and Health in the United States

Policy Points We reviewed some of the recent advances in education and health, arguing that attention to social contextual factors and the dynamics of social and institutional change provide critical insights into the ways in which the association is embedded in institutional contexts. Based on our findings, we believe incorporating this perspective is fundamentally important to ameliorate current negative trends and inequality in Americans' health and longevity.

Catalogue of socioeconomic disparities and characteristics of 199+ chronic conditions-A nationwide register-based population study

BACKGROUND

Real-world information on socioeconomic differences within and between chronic conditions represents an important data source for treatments and decision-makers executing and prioritising healthcare resources.

AIMS

The aim of this study was to estimate the prevalence and mean of socioeconomic disparities from educational, income, and socioeconomic positions of 199 chronic conditions and disease groups, including sex and age group estimates, for use in planning of care services and prioritisation, by healthcare professionals, decision-makers and researchers.

METHODS

The study population includes all Danish residents 16 years and above, alive on 1 January 2013 (n = 4,555,439). The data was established by linking seven national registers encompassing educational achievements, incomes, socioeconomic positions, hospital- and general practice services, and filled-in out-of-hospital prescriptions. The health register data were used to identify the 199+ chronic conditions. Socioeconomic differences were primarily measured as differences in educational prevalence levels from low to high educational achievements using a ratio. Furthermore, multiple binary logistic regression models were carried out to control for potential confounding and residual correlations of the crude estimates.

RESULTS

The prevalence of having one or more chronic conditions for patients with no educational achievement was 768 per thousand compared to 601.3 for patients with higher educational achievement (ratio 1.3). Across disease groups, the highest educational differences were found within disease group F-mental and behavioural (ratio 2.5), E-endocrine, nutritional and metabolic disease (ratio 2.4), I-diseases of the circulatory system (ratio 2.1) and, K-diseases of the digestive system (ratio 2.1). The highest educational differences among the 29 common diseases were found among schizophrenia (ratio 5.9), hyperkinetic disorders (ratio 5.2), dementia (ratio 4.9), osteoporosis (ratio 3.9), type 2 diabetes (ratio 3.8), chronic obstructive pulmonary disease COPD (ratio 3.3), heart conditions and stroke (ratios ranging from 2.3-3.1).

CONCLUSIONS

A nationwide catalogue of socioeconomic disparities for 199+ chronic conditions and disease groups is catalogued and provided. The catalogue findings underline a large scope of socioeconomic disparities that exist across most chronic conditions. The data offer essential information on the socioeconomic disparities to inform future socially differentiated treatments, healthcare planning, etiological, economic, and other research areas.

Agent-Based Modelling of Health Inequalities following the Complexity Turn in Public Health: A Systematic Review

There is an increasing focus on the role of complexity in public health and public policy fields which has brought about a methodological shift towards computational approaches. This includes agent-based modelling (ABM), a method used to simulate individuals, their behaviour and interactions with each other, and their social and physical environment. This paper aims to systematically review the use of ABM to simulate the generation or persistence of health inequalities. PubMed, Scopus, and Web of Science (1 January 2013-15 November 2022) were searched, supplemented with manual reference list searching. Twenty studies were included; fourteen of them described models of health behaviours, most commonly relating to diet (n = 7). Six models explored health outcomes, e.g., morbidity, mortality, and depression. All of the included models involved heterogeneous agents and were dynamic, with agents making decisions, growing older, and/or becoming exposed to different health risks. Eighteen models represented physical space and in eleven models, agents interacted with other agents through social networks. ABM is increasingly contributing to our understanding of the socioeconomic inequalities in health. However, to date, the majority of these models focus on the differences in health behaviours. Future research should attempt to investigate the social and economic drivers of health inequalities using ABM.

Difference in Mortality Rates by Occupation in Japanese Male Workers Aged 25 to 64 Years from 1980 to 2015

This study examines the trends in mortality among Japanese working men, across various occupational categories, from 1980 to 2015. A Poisson model of trend, occupational category, and step variable was analysed for eight occupational categories separately, by cause, to explore the trends in mortality. This study found a sharp increase in mortality in the late 1990s, especially among professionals and managers. The overall trends in cancer, ischemic heart disease (IHD), cerebrovascular disease (CVD), and suicide mortality decreased across almost all occupational categories from 1980 to 2015, although there was an increasing trend in cancer of 0.5% among managers. Clerical workers had the greatest relative decrease in mortality rates from cancer (-82.9%), IHD (-81.7%), and CVD (-89.1%). Japan continues to make gains in lowering mortality and extending life expectancy, but its workplace culture must improve to ensure that those working at the heart of the Japanese corporate world can also benefit from Japan's progress in health. Mortality rates in working-aged Japanese men have been declining. However, similar declines are not evident among managers, for whom the mortality rate is remaining stable or slightly increasing. There is a need to address the needs of managers and improve workplace environments for these workers.

Digital transformation: The role of computer use in employee health

This paper studies employee health in the context of digital transformation in Germany. While most studies have focused on mental health, we focus on physical health. Using pooled survey data, we estimate how an increased use of computers in the workplace relates to subjective health and work-related health complaints. We find that employees using the computer frequently report better subjective health and a significantly lower prevalence of back pain and physical exhaustion. After controlling for physical work exposures, the health-promoting effect of computer use is much smaller, suggesting that high computer use is associated with a less physically demanding work environment, which in turn relates to better (physical) health outcomes. While digital transformation seems to foster physical health, there are hints that mental health could deteriorate. Thus, the focus of occupational health is shifting towards the prevention of mental stress.

Health Inequalities in Older Norwegians and the Mediating Role of Social Networks

This study aims to contribute to understanding how social networks serve as an intervening pathway leading to socioeconomic health inequality among older adults in Norway. Longitudinal survey data from the second and the third waves of the Norwegian Life Course, Ageing, and Generation Study were used in this paper. Hayes PROCESS was used to estimate the mediating effect of the contact frequency and the support potential of friends on the impact of social-economic position (SEP) at wave 2 on health outcomes at wave 3. The total indirect effect of the income on physical health observed was 0.04. The total indirect effect of the highest level of education attained on physical health observed was 0.12. The result showed a social-economic gradient in health among older adults in Norway where the social network is a crucial pathway via which SEP influences peoples' health.

Health Disparity Resulting from the Effect of Built Environment on Temperature-Related Mortality in a Subtropical Urban Setting

Whereas previous studies have assessed the overall health impact of temperature in Hong Kong, the aim of this study was to investigate whether the health impact is modified by local temperature of small geographic units, which may be related to the diverse socioeconomic characteristics of these units. The effects of local temperature on non-accidental and cause-specific mortality were analyzed using Bayesian spatial models at a small-area level, adjusting for potential confounders, i.e., area-level air pollutants, socioeconomic status, and green space, as well as spatial dependency. We found that a 10% increase in green space density was associated with an estimated 4.80% decrease in non-accidental mortality risk and a 5.75% decrease in cardiovascular disease mortality risk in Hong Kong, whereas variation in local annual temperature did not significantly contribute to mortality. We also found that the spatial variation of mortality within this city could be explained by the geographic distribution of green space and socioeconomic factors rather than local temperature or air pollution. The findings and methodology of this study may help to further understanding and investigation of social and structural determinants of health disparities, particularly place-based built environment across class-based small geographic units in a city, taking into account the intersection of multiple factors from individual to population levels.

Socioeconomic Status and Risk of Bleeding After Mechanical Aortic Valve Replacement

BACKGROUND

Whether low socioeconomic status (SES) is associated with increased risk of anticoagulation-related adverse events in patients with mechanical heart valves is unknown.

OBJECTIVES

This study sought to investigate the impact of patients' SES on the risk of bleeding after mechanical aortic valve replacement (AVR).

METHODS

This nationwide population-based cohort study included all patients aged 18-70 years who underwent mechanical AVR in Sweden from 1997 to 2018. Data were obtained from the SWEDEHEART register and other national health data registers. The exposure was quartiles of household disposable income. The primary outcome was hospitalization for a bleeding event.

RESULTS

Among 5974 patients, the absolute risk for bleeding after 20 years of follow-up was 20% (95% CI: 17%-24%) in the lowest income quartile (Q1) and 16% (95% CI: 13%-20%) in the highest quartile (Q4). The risk of bleeding decreased with increasing income level and was significantly lower in patients in income level Q3 (HR: 0.77; 95% CI: 0.60-0.99) and Q4 (HR: 0.68; 95% CI: 0.50-0.92) than Q1. The risk of death from intracranial hemorrhage was five times higher in the lowest income quartile than the age- and sex-matched general Swedish population (standardized mortality ratio: 5.0; 95% CI: 3.3-7.4).

CONCLUSIONS

We observed a strong association between SES and risk of bleeding among patients who underwent mechanical AVR. These findings suggest suboptimal anticoagulation treatment in patients with lower SES and the need for strategies to optimize anticoagulation treatment in patients with a mechanical heart valve. (Health-Data Register Studies of Risk and Outcomes in Cardiac Surgery [HARTROCS]; NCT02276950).

Income and outcomes of patients with incident atrial fibrillation

BACKGROUND

Socioeconomic disparities can be associated with adverse outcomes in patients with cardiovascular diseases. The impact of personal income on the outcomes of patients with atrial fibrillation (AF) is unclear.

METHODS

Nationwide observational registry-based study on patients with incident AF in Finland during 2007-2018.

RESULTS

203 154 patients (mean age 73.0±13.5; females 49.0%) were diagnosed with incident AF during the study period. Overall, 16 272 (8.0%) patients experienced first-ever ischaemic stroke and 63 420 (31.2%) died (mean follow-up 4.3±3.3 years). After adjusting for confounding factors, low personal income was associated with increased risk of overall mortality in all age strata and the incidence of first-ever stroke in patients aged <65 years and 65-74 years, but not in those ≥75 years. The magnitude of this effect was greatest in patients aged <65 years. After propensity score matching of patients <65 years in the lowest and highest quintiles of maximum personal annual income, at 10 years, those in the highest income quintile (≥€54 000) had significantly lower risk of first-ever stroke (subdistribution HR 0.495, 95% CI 0.391 to 0.628) and overall mortality (HR 0.307, 95% CI 0.269 to 0.351) compared with patients in the lowest income quintile (≤€12 000).

CONCLUSIONS

Personal annual income has a significant impact on the incidence of first-ever ischaemic stroke and overall mortality among patients with incident AF, particularly among patients of working age. Low-income indicate the need for intervention strategies to improve outcomes of AF.

TRIAL REGISTRATION NUMBER

NCT04645537.

Population variation in social brain morphology: Links to socioeconomic status and health disparity

Health disparity across layers of society involves reasons beyond the healthcare system. Socioeconomic status (SES) shapes people's daily interaction with their social environment and is known to impact various health outcomes. Using generative probabilistic modeling, we investigate health satisfaction and complementary indicators of socioeconomic lifestyle in the human social brain. In a population cohort of ~10,000 UK Biobank participants, our first analysis probed the relationship between health status and subjective social standing (i.e., financial satisfaction). We identified volume effects in participants unhappy with their health in regions of the higher associative cortex, especially the dorsomedial prefrontal cortex (dmPFC) and bilateral temporo-parietal junction (TPJ). Specifically, participants in poor subjective health showed deviations in dmPFC and TPJ volume as a function of financial satisfaction. The second analysis on health status and objective social standing (i.e., household income) revealed volume deviations in regions of the limbic system for individuals feeling unhealthy. In particular, low-SES participants dissatisfied with their health showed deviations in volume distributions in the amygdala and hippocampus bilaterally. Thus, our population-level evidence speaks to the possibility that health status and socioeconomic position have characteristic imprints in social brain differentiation.

The health returns of attending university for the marginally eligible student

A key policy question is whether continued expansion of university education is beneficial for the marginally eligible student. In this paper we exploit an arbitrary university eligibility rule combined with regression discontinuity design to estimate the causal effect of university attendance on healthcare utilization amongst young adults in Sweden. We find that the eligibility rule leads to a clear jump in university attendance of between 10% and 14% points for both males and females. 2SLS estimates find that a 10% point increase in university attendance causes a roughly one percentage point increase in hospital admissions due to mental ill health for males, almost exclusively related to alcohol and narcotics. Our findings for females, however, imply the opposite, suggesting that university attendance decreases hospital admissions related to mental health. The results for males sit in contrast to results from previous studies, and suggest that the effect of university education on health for the male student at the margin of eligibility is different to that of the average student.

Activity and Outcomes of Autologous Stem Cell Transplantation in the Private Sector in Australia

BACKGROUND

Few Australasian Autologous Stem Cell Transplantation (ASCT) programs perform ASCTs in the private sector. Relatively little is known about ASCT outcomes in the private sector, which varies in care delivery models to the public system.

AIMS

We investigated transplantation activity and survival outcomes at Icon Cancer Centre's Brisbane-based private clinical and laboratory ASCT program, over a 23-year period.

METHODS

Retrospective, observational study of all adults who underwent ASCT at Icon between 1996-2018. Main outcome measures were transplant activity, overall survival (OS) and day-100 and 1-year transplant-related mortality (TRM). Outcomes were benchmarked against the Australasian Bone Marrow Transplant Recipient Registry (ABMTRR).

RESULTS

Between 1996-2018, 1676 ASCTs were performed in 1454 patients. From 2010-2018, ASCTs performed at Icon contributed 40% of all South East Queensland ASCTs. In the last 5-years, 21% of Icon's patients were ≥70-years, compared to 5% across Australasia. For the entire cohort, 100-day, and 1-year TRM was 1.1% and 1.7% respectively, whilst for those aged ≥70-years, it was 2.0% and 3.1%. For ASCTs performed between 2014-2018, 100-day and 1-year TRM was 0.8% and 1.4%, which was half the TRM rates reported by the ABMTRR. The 10-year post-transplant OS at Icon was higher than the ABMTRR data, across all disease subtypes.

CONCLUSION

Icon is the largest ASCT contributor in Queensland, with excellent OS and low TRM, demonstrating the critical role of the private sector in the administration of this highly complex therapy. The Icon ASCT program is inclusive of patients aged ≥70-years, demonstrating low and acceptable TRM. This article is protected by copyright. All rights reserved.

A health economic theory of occupational choice, aging, and longevity

In this paper, I propose a life cycle model of occupational choice with endogenous health behavior, aging, and longevity. Health-demanding work leads to a faster accumulation of health deficits and is remunerated with a hazard markup on wages. Health deficit accumulation is also influenced by unhealthy consumption and health care expenditure. I calibrate the model for a 20 year old average American in 2010 and show the following results, among others. Health-demanding work is ceteris paribus preferred by male, young, and healthy individuals with a relatively low level of education. Health demanding work has a negligible effect on health behavior because income and health investment effects largely offset each other, implying that health effects can be attributed almost fully to the direct health burden of work. Better medical technology induces low-skilled individuals to spend a greater part of their life in health-demanding work and thus increases the health gradient of education. High wealth endowments protect against unhealthy occupational choices. I show robustness of the results in an extension of the model with regard to endogenous retirement.

Measuring health-related social deprivation in small areas: development of an index and examination of its association with cancer mortality

BACKGROUND

The small-area deprivation indices are varied across countries due to different social context and data availability. Due to lack of chronic disease-related social deprivation index (SDI) in Hong Kong, China, this study aimed to develop a new SDI and examine its association with cancer mortality.

METHODS

A total of 14 socio-economic variables of 154 large Tertiary Planning Unit groups (LTPUGs) in Hong Kong were obtained from 2016 population by-census. LTPUG-specific all-cause and chronic condition-related mortality and chronic condition inpatient episodes were calculated as health outcomes. Association of socio-economic variables with health outcomes was estimated for variable selection. Candidates for SDI were constructed with selected socio-economic variables and tested for criterion validity using health outcomes. Ecological association between the selected SDI and cancer mortality were examined using zero-inflated negative binomial regression.

RESULTS

A chronic disease-related SDI constructed by six area-level socio-economic variables was selected based on its criterion validity with health outcomes in Hong Kong. It was found that social deprivation was associated with higher cancer mortality during 2011-2016 (most deprived areas: incidence relative risk [IRR] = 1.40, 95% confidence interval [CI]: 1.27-1.55; second most deprived areas: IRR = 1.34, 95%CI: 1.21-1.48; least deprived areas as reference), and the cancer mortality gap became larger in more recent years. Excess cancer death related to social deprivation was found to have increased through 2011-2016.

CONCLUSIONS

Our newly developed SDI is a valid and routinely available measurement of social deprivation in small areas and is useful in resource allocation and policy-making for public health purpose in communities. There is a potential large improvement in cancer mortality by offering relevant policies and interventions to reduce health-related deprivation. Further studies can be done to design strategies to reduce the expanding health inequalities between more and less deprived areas.

The asymmetric experience of gains and losses in job security on health

Is workers' health more sensitive to losses than gains in job security? I address this question using the 1999 rise in the French Delalande tax as a quasi-natural experiment. The tax design allows to separately identify the causal impact of exogenous gains and losses in job security on workers' health. Difference-in-differences estimation results show that a greater job insecurity reduces significantly self-reported health. At the same time, more job security does not translate into a higher level of self-reported health.

Socioeconomic position and healthy ageing: A systematic review of cross-sectional and longitudinal studies

BACKGROUND

The association between socioeconomic position (SEP) and health is well-established. However, the association between SEP and healthy ageing as a multidimensional construct is unclear.

METHODS

We conducted a systematic review of peer-reviewed cross-sectional and longitudinal studies on the associations between SEP and multidimensional healthy ageing measures. Studies were identified from a systematic search across major electronic databases from inception to February 2021.

RESULTS

Fourthy-five articles met inclusion criteria (26 cross-sectional and 19 longitudinal studies). There was no consistency in method of operationalizing healthy ageing across studies, domains included in the healthy ageing measures, or in the definition and number of levels of SEP indicators. Overall, regardless of heterogeneity between studies, a positive association between educational level (85.0 % of studies) and income/wealth (81.4 % of studies) and healthy ageing was evident. Regarding occupational position, evidence from 11 studies was inconclusive. The number of studies including home ownership, parenteral SEP, or composite SEP scores was insufficient to be able to draw a conclusion.

CONCLUSIONS

There is evidence that socioeconomic inequalities, as assessed by educational level and income/wealth, are associated with healthy ageing. These findings, and the broader evidence base on SEP and healthy ageing, highlight the importance of addressing inequality through integrated health and social policies and strategies.

Patient-reported outcomes, sociodemographic and clinical factors are associated with 1-year mortality in patients with ischemic heart disease-findings from the DenHeart cohort study

PURPOSE

In patients with ischemic heart disease, the objectives were (1) to explore associations between patient-reported outcomes, sociodemographic, and clinical factors at discharge and 1-year all-cause mortality and (2) to investigate the discriminant predictive performance of the applied patient-reported outcome instruments on 1-year all-cause mortality.

METHODS

Data from the Danish national DenHeart cohort study were used. Eligible patients (n = 13,476) were invited to complete a questionnaire-package, of which 7167 (53%) responded. Questionnaires included the 12-item Short form health survey (SF-12), Hospital anxiety and depression scale (HADS), EQ-5D, HeartQoL, Edmonton symptom assessment scale (ESAS), and ancillary questions on, e.g., social support. Clinical and demographic characteristics were obtained from registers, as were data on mortality. Comparative analyses were used to investigate differences in patient-reported outcomes. Mortality associations were explored using multifactorially adjusted Cox regression analyses. Predictive performance was analyzed using receiver operating characteristics (ROC).

RESULTS

Patient-reported outcomes at discharge differed among those alive versus those deceased at one year, e.g., depression (HADS-Depression ≥ 8) 19% vs. 44% (p < 0.001). Associations with 1-year mortality included feeling unsafe about returning home from the hospital; hazard ratio (HR) 2.07 (95% CI 1.2-3.61); high comorbidity level, HR 3.6 (95% CI 2.7-4.8); and being unmarried, HR 1.60 (95% CI 1.33-1.93). Best predictive performance was observed for SF-12 physical component summary (Area under the curve (AUC) 0.706).

CONCLUSION

Patient-reported health, sociodemographic, and clinical factors are associated with 1-year mortality. We propose systematic screening with robust predictive tools to identify patients at risk and healthcare initiatives to explore and offer effective treatment to modify patient-reported health indicators.

Beyond Behaviour: How Health Inequality Theory Can Enhance Our Understanding of the 'Alcohol-Harm Paradox'

There are large socioeconomic inequalities in alcohol-related harm. The alcohol harm paradox (AHP) is the consistent finding that lower socioeconomic groups consume the same or less as higher socioeconomic groups yet experience greater rates of harm. To date, alcohol researchers have predominantly taken an individualised behavioural approach to understand the AHP. This paper calls for a new approach which draws on theories of health inequality, specifically the social determinants of health, fundamental cause theory, political economy of health and eco-social models. These theories consist of several interwoven causal mechanisms, including genetic inheritance, the role of social networks, the unequal availability of wealth and other resources, the psychosocial experience of lower socioeconomic position, and the accumulation of these experiences over time. To date, research exploring the causes of the AHP has often lacked clear theoretical underpinning. Drawing on these theoretical approaches in alcohol research would not only address this gap but would also result in a structured effort to identify the causes of the AHP. Given the present lack of clear evidence in favour of any specific theory, it is difficult to conclude whether one theory should take primacy in future research efforts. However, drawing on any of these theories would shift how we think about the causes of the paradox, from health behaviour in isolation to the wider context of complex interacting mechanisms between individuals and their environment. Meanwhile, computer simulations have the potential to test the competing theoretical perspectives, both in the abstract and empirically via synthesis of the disparate existing evidence base. Overall, making greater use of existing theoretical frameworks in alcohol epidemiology would offer novel insights into the AHP and generate knowledge of how to intervene to mitigate inequalities in alcohol-related harm.

Explaining socioeconomic disparities in health behaviours: A review of biopsychological pathways involving stress and inflammation

The purpose of this article was to explore how individuals' position in a socioeconomic hierarchy is related to health behaviours that are related to socioeconomic disparities in health. We identified research which shows that: (a) low socioeconomic status (SES) is associated with living in harsh environments, (b) harsh environments are related to increased levels of stress and inflammation, (c) stress and inflammation impact neural systems involved in self-control by sensitising the impulsive system and desensitising the reflective system, (d) the effects are inflated valuations of small immediate rewards and deflated valuations of larger delayed rewards, (e) these effects are observed as increased delay discounting, and (f) delay discounting is positively associated with practicing more unhealthy behaviours. The results are discussed within an adaptive evolutionary framework which lays out how the stress response system, and its interaction with the immune system and brain systems for decision-making and behaviours, provides the biopsychological mechanisms and regulatory shifts that make widespread conditional adaptability possible. Consequences for policy work, interventions, and future research are discussed.

Can changes in education alter future population ageing in Asia and Europe?

While population ageing is rising, the educational composition of the elderly remains rather heterogeneous. This study assesses the educational differences in future population ageing in Asia and Europe, and how future population ageing in Asia and Europe would change if the educational composition of its populations changed. A comparative population ageing measure (the Comparative Prospective Old-Age Threshold [CPOAT]) was used, which recalculates old-age thresholds after accounting for differences in life expectancy, and the likelihood of adults surviving to higher ages. Combined data from projected age- and sex-specific life-tables (from the United Nations) and projected age- and sex-specific survival ratios by different levels of education (from the Wittgenstein Centre for Demography and Global Human Capital) were used to construct projected life-tables (2015-2020, …, 2045-2050) by educational level and sex for different regions of Asia and Europe. Based on these life-tables, future comparative prospective old-age thresholds by educational level and sex were calculated. It was found that in both Asia and Europe, and among both men and women, the projected old-age thresholds are higher for higher educated people than for less-educated people. While Europe has a larger projected share of elderly in the population than Asia, Europe's older population is better educated. In alternative future scenarios in which populations hypothetically have higher levels of education, the projected shares of elderly in the population decrease across all regions of Asia and Europe, but more so in Asia. The results highlight the effectiveness of investing in education as a policy response to the challenges associated with population ageing in Asia and Europe. Such investments are more effective in the Asian regions, where the educational infrastructure is less developed.

Evolution of inequalities in the coronavirus pandemics in Portugal: an ecological study

Background

Previous literature shows systematic differences in health according to socioeconomic status (SES). However, there is no clear evidence that the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection might be different across SES in Portugal. This work identifies the coronavirus disease 2019 (COVID-19) worst-affected municipalities at four different time points in Portugal measured by prevalence of cases, and seeks to determine if these worst-affected areas are associated with SES.

Methods

The worst-affected areas were defined using the spatial scan statistic for the cumulative number of cases per municipality. The likelihood of being in a worst-affected area was then modelled using logistic regressions, as a function of area-based SES and health services supply. The analyses were repeated at four different time points of the COVID-19 pandemic: 1 April, 1 May, 1 June, and 1 July, corresponding to two moments before and during the confinement period and two moments thereafter.

Results

Twenty municipalities were identified as worst-affected areas in all four time points, most in the coastal area in the Northern part of the country. The areas of lower unemployment were less likely to be a worst-affected area on the 1 April [adjusted odds ratio (AOR) = 0.36 (0.14–0.91)], 1 May [AOR = 0.03 (0.00–0.41)] and 1 July [AOR = 0.40 (0.16–1.05)].

Conclusion

This study shows a relationship between being in a worst-affected area and unemployment. Governments and public health authorities should formulate measures and be prepared to protect the most vulnerable groups.

Mortality in mental health patients of the Emilia-Romagna region of Italy: A registry-based study

Evidence from previous research demonstrated a gap in mortality between patients with mental disorders and the general population. However, a more exhaustive assessment is required to address this public health issue. The aim of this study was to provide comprehensive analysis of mortality examining all causes of death and all psychiatric diagnoses. We conducted a 10-year retrospective cohort study, including all in and out patients registered in the Mental Health Registry of Emilia-Romagna, Italy. Standardized mortality ratios (SMRs) were calculated. The cohort consisted of 137,351 patients 11,236 of whom died during the study period and the overall SMR was 1.99. 85.9 % of excess mortality was attributable to a broad range of natural causes. Diseases of circulatory and respiratory systems as well as neoplasms were the principal contributors to the mortality gap. All psychiatric conditions led to a higher risk of death. The greatest excess was due to neoplasms in depressed and neurotic patients and to cardiovascular diseases in patients with schizophrenia and personality disorders. Our results highlight the need for close collaboration between mental and primary health care services with the aim of reducing excess mortality as a result of medical diseases among all patients suffering from psychiatric condition.

Inequality of opportunities in health and death: an investigation from birth to middle age in Great Britain

Objective

We assess the existence of unfair inequalities in health and death using the normative framework of inequality of opportunities, from birth to middle age in Great Britain.

Methods

We use data from the 1958 National Child Development Study, which provides a unique opportunity to observe individual health from birth to the age of 54, including the occurrence of mortality. We measure health status combining self-assessed health and mortality. We compare and statistically test the differences between the cumulative distribution functions of health status at each age according to one childhood circumstance beyond people’s control: the father’s occupation.

Results

At all ages, individuals born to a ‘professional’, ‘senior manager or technician’ father report a better health status and have a lower mortality rate than individuals born to ‘skilled’, ‘partly skilled’ or ‘unskilled’ manual workers and individuals without a father at birth. The gap in the probability to report good health between individuals born into high social backgrounds compared with low, increases from 12 percentage points at age 23 to 26 at age 54. Health gaps are even more marked in health states at the bottom of the health distribution when mortality is combined with self-assessed health.

Conclusions

There is increasing inequality of opportunities in health over the lifespan in Great Britain. The tag of social background intensifies as individuals get older. Finally, there is added analytical value to combining mortality with self-assessed health when measuring health inequalities.

Contrasts in alcohol-related mortality in Czechia and Lithuania: Analysis of time trends and educational differences

INTRODUCTION AND AIMS

Globally, Czechia and Lithuania are among the top-ranking countries in terms of high alcohol consumption. This study highlights notable contrasts in temporal trends in alcohol-related mortality and identifies country-specific patterns in educational differences.

DESIGN AND METHODS

The study uses harmonised cause-of-death series from the Human Cause of Death Database. Mortality disparities by education were assessed using census-linked mortality data. Directly standardised death rates were used to estimate levels of national and group-specific mortality. Relative and absolute mortality differences by education were assessed by range-type measures (Poisson regression mortality ratios and rate differences) and Gini-type measures.

RESULTS

Between 1994-1995 and 2016, the absolute difference between Czechia and Lithuania in terms of alcohol-related age-standardised death rates (per 1 000 000) decreased from 450 for males and 130 for females to 76 in males and 11 in females. In both countries, alcohol-related mortality was markedly higher among persons of lower education levels. Lithuanian males experienced the highest absolute inequalities measured by rate difference between the low and high educated (740 per million), while Lithuanian females showed the most pronounced relative inequalities (6.70-fold difference between low and high educated). The corresponding figures were less than half for Czechia.

DISCUSSION AND CONCLUSIONS

Reducing educational disparities in alcohol-related mortality within both countries would have a substantial impact on overall levels. Policies aimed at targeting the lowest priced and illegal alcohols and reducing levels of harmful drinking should be a priority, especially in Lithuania.

A randomized controlled trial testing a virtual perspective-taking intervention to reduce race and socioeconomic status disparities in pain care

We conducted a randomized controlled trial of an individually tailored, virtual perspective-taking intervention to reduce race and socioeconomic status (SES) disparities in providers' pain treatment decisions. Physician residents and fellows (n = 436) were recruited from across the United States for this two-part online study. Providers first completed a bias assessment task in which they made treatment decisions for virtual patients with chronic pain who varied by race (black/white) and SES (low/high). Providers who demonstrated a treatment bias were randomized to the intervention or control group. The intervention consisted of personalized feedback about their bias, real-time dynamic interactions with virtual patients, and videos depicting how pain impacts the patients' lives. Treatment bias was re-assessed 1 week later. Compared with the control group, providers who received the tailored intervention had 85% lower odds of demonstrating a treatment bias against black patients and 76% lower odds of demonstrating a treatment bias against low SES patients at follow-up. Providers who received the intervention for racial bias also showed increased compassion for patients compared with providers in the control condition. Group differences did not emerge for provider comfort in treating patients. Results suggest an online intervention that is tailored to providers according to their individual treatment biases, delivers feedback about these biases, and provides opportunities for increased contact with black and low SES patients, can produce substantial changes in providers' treatment decisions, resulting in more equitable pain care. Future studies should examine how these effects translate to real-world patient care and the optimal timing/dose of the intervention.

Occupational categories and cardiovascular diseases incidences: a cohort study in Iranian population

Introduction

In spite of traditional cardiovascular risk factor, the different occupations can play an important role in cardiovascular disease (CVDs) incidence. We aimed to assess the correlation between the occupational classes, based on the International Standard Classification of Occupation (ISCO), and CVDs in Iran as a developing country.

Methods

We followed the 2440 men, aged 35-65 years and without history of CVDs over fourteen years; 2001 to 2015 during the Isfahan Cohort Study. ISCO was used to classify occupations into 10 categories. Incidence rates of ischemic heart diseases and stroke were recorded. Socioeconomic demographic data including marital state, income and place of living and metabolic risk factors were also recorded.

Results

The mean age was 46.97 ± 8.31 years old. 272 cardiovascular events (CVEs) were recorded that unstable angina was the highest recorded with 49% prevalence and the fatal stroke had the lowest outbreak (1%). The unemployed/jobless group and elementary occupations (9th ISCO category) had higher and lower relative frequency in CVEs respectively. There was non-significant decrease in CVEs in all of categories except of 4^th (clerical support workers) and 10th (armed forces) groups in comparison to unemployed/jobless subjects (P > 0.05). After considering of the group 7 as a reference group (most absolute CVEs frequency), in fully adjustment analysis group 4 had significant risk for CVEs (P = 0.04).

Conclusions

This study indicates that working as clerical support workers (4^th ISCO category) is associated with higher significant risk for IHD and stroke incidence in comparison to craft and related trades workers (7^th group of ISCO).

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.

District-Level Life Expectancy in Germany

BACKGROUND

Identifying regions with low life expectancy is important to policy makers, in particular for allocating resources in the health system. Life expectancy estimates for small regions are, however, often unreliable and lead to statistical uncertainties when the underlying populations are relatively small.

METHODS

We combine the most recent German data available (2015-2017) with a Bayesian model that includes several methodological advances. This allows us to estimate male and female life expectancy with good precision for all 402 German districts and to quantify the uncertainty of those estimates.

RESULTS

Across districts, life expectancy varies between 75.8 and 81.2 years for men and from 81.8 to 85.7 years for women. The spatial pattern is similar for women and men. Rural districts in eastern Germany and some districts of the Ruhr region have relatively low life expectancy. Districts with relatively high life expectancies cluster in Baden-Wuerttemberg and southern Bavaria. Exploratory analysis shows that average income, population density, and number of physicians per 100 000 inhabitants are not strongly correlated with life expectancy at district level. In contrast, indicators that point to particularly disadvantaged segments of the population (unemployment rate, welfare benefits) are better predictors of life expectancy.

CONCLUSIONS

We do not find a consistent urban-rural gap in life expectancy. Our results suggest that policies that improve living standards for poorer segment of the population are the most likely to reduce the existing differences in life expectancy.

Geographic and socioeconomic disparity in cardiovascular risk factors in Indonesia: analysis of the Basic Health Research 2018

Background

Cardiovascular diseases (CVDs) accounted for over 17 million deaths and 353 million disability-adjusted life years lost in 2016. The risk factors are also high and increasing with high blood pressure, smoking, and high body mass index contributed to up to 212 million disability-adjusted life years in 2016. To help reduce the burden, it is crucial to understand the geographic and socioeconomic disparities in CVD risk factors.

Methods

Employing both geospatial and quantitative analyses, we analyzed the disparities in the prevalence of smoking, physical inactivity, obesity, hypertension, and diabetes in Indonesia. CVD data was from Riskesdas 2018, and socioeconomic data was from the World Bank.

Results

Our findings show a very high prevalence of CVD risk factors with the prevalence of smoking, physical activity, obesity, hypertension ranged from 28 to 33%. Results also show the geographic disparity in CVD risk factors in all five Indonesian regions. Moreover, results show socioeconomic disparity with the prevalence of obesity, hypertension, and diabetes are higher among urban and the richest and most educated districts while that physical inactivity and smoking is higher among rural and the least educated districts.

Conclusion

The CVD burden is high and increasing in particularly among urban areas and districts with higher income and education levels. While the government needs to continue tackling the persistent burden from maternal mortality and infectious diseases, they need to put more effort into the prevention and control of CVDs and their risk factors.

Reward Responsiveness in the Adolescent Brain Cognitive Development (ABCD) Study: African Americans' Diminished Returns of Parental Education

(1) Background: Reward responsiveness (RR) is a risk factor for high-risk behaviors such as aggressive behaviors and early sexual initiation, which are all reported to be higher in African American and low socioeconomic status adolescents. At the same time, parental education is one of the main drivers of reward responsiveness among adolescents. It is still unknown if some of this racial and economic gap is attributed to weaker effects of parental education for African Americans, a pattern also called minorities' diminished returns (MDRs). (2) Aim: We compared non-Hispanic White and African American adolescents for the effects of parent education on adolescents RR, a psychological and cognitive construct that is closely associated with high-risk behaviors such as the use of drugs, alcohol, and tobacco. (3) Methods: This was a cross-sectional analysis that included 7072 adolescents from the adolescent brain cognitive development (ABCD) study. The independent variable was parent education. The main outcome as adolescents' RR measured by the behavioral inhibition system (BIS) and behavioral activation system (BAS) measure. (4) Results: In the overall sample, high parent education was associated with lower levels of RR. In the overall sample, we found a statistically significant interaction between race and parent education on adolescents' RR. The observed statistical interaction term suggested that high parent education is associated with a weaker effect on RR for African American than non-Hispanic White adolescents. In race-stratified models, high parent education was only associated with lower RR for non-Hispanic White but not African American adolescents. (5) Conclusion: Parent education reduces RR for non-Hispanic White but not African American adolescents. To minimize the racial gap in brain development and risk-taking behaviors, we need to address societal barriers that diminish the returns of parent education and resources in African American families. We need public and social policies that target structural and societal barriers, such as the unequal distribution of opportunities and resources. To meet such an aim, we need to reduce the negative effects of social stratification, segregation, racism, and discrimination in the daily lives of African American parents and families. Through an approach like this, African American families and parents can effectively mobilize their resources and utilize their human capital to secure the best possible tangible outcomes for their adolescents.

Mortality inequalities by occupational status and type of job in men and women: results from the Rome Longitudinal Study

OBJECTIVES

Socioeconomic inequalities have a strong impact on population health all over the world. Occupational status is a powerful determinant of health in rich societies. We aimed at investigating the association between occupation and mortality in a large metropolitan study.

DESIGN

Cohort study.

SETTING

Rome, capital of Italy.

PARTICIPANTS

We used the Rome Longitudinal Study, the administrative cohort of residents in Rome at the 2001 general census, followed until 2015. We selected residents aged 15-65 years at baseline. For each subject, we had information on sex, age and occupation (occupational status and type of job) according to the Italian General Census recognition.

MAIN OUTCOME MEASURES

We investigated all-cause, cancer, cardiovascular and accidental mortality, major causes of death in the working-age population. We used Cox proportional hazards models to investigate the association between occupation and all-cause and cause-specific mortality in men and women.

RESULTS

We selected 1 466 726 subjects (52.1% women). 42 715 men and 29 915 women died during the follow-up. In men, 47.8% of deaths were due to cancer, 26.7% to cardiovascular causes and 6.4% to accidents, whereas in women 57.8% of deaths were due to cancer, 19.3% to cardiovascular causes and 3.5% to accidents. We found an association between occupational variables and mortality, more evident in men than in women. Compared with employed, unemployed had a higher risk of mortality for all causes with an HR=1.99 (95% CI 1.92 to 2.06) in men and an HR=1.49 (95% CI 1.39 to 1.60) in women. Compared with high-qualified non-manual workers, non-specialised manual workers had a higher mortality risk (HR=1.68, 95% CI 1.59 to 1.77 and HR=1.30, 95% CI 1.20 to 1.40, for men and women, respectively).

CONCLUSIONS

This study shows the importance of occupational variables as social health determinants and provides evidence for policy-makers on the necessity of integrated and preventive policies aimed at improving the safety of the living and the working environment.

When Did the Health Gradient Emerge? Social Class and Adult Mortality in Southern Sweden, 1813-2015

Across today's developed world, there is a clear mortality gradient by socioeconomic status for all ages. It is often taken for granted that this gradient was as strong-or even stronger-in the past when social transfers were rudimentary and health care systems were less developed. Some studies based on cross-sectional data have supported this view, but others based on longitudinal data found that this was not the case. If there was no gradient in the past, when did it emerge? To answer this question, we examine social class differences in adult mortality for men and women in southern Sweden over a 200-year period, using unique individual-level register data. We find a systematic class gradient in adult mortality emerging at ages 30-59 only after 1950 for women and after 1970 for men, and in subsequent periods also observable for ages 60-89. Given that the mortality gradient emerged when Sweden transitioned into a modern welfare state with substantial social transfers and a universal health care system, this finding points to lifestyle and psychosocial factors as likely determinants.

Association of Parental Socioeconomic Status and Newborn Telomere Length

IMPORTANCE

Low socioeconomic status is associated with higher all-cause mortality and risks for aging-related diseases. Biological aging is a potential process underlying health conditions related to social disadvantages, which may be present from birth onward.

OBJECTIVE

To evaluate the association of parental socioeconomic status with telomere length (TL) at birth, a marker of biological aging.

DESIGN, SETTING, AND PARTICIPANTS

This prospective birth cohort study was conducted among 1504 mother-newborn pairs in Belgium recruited between February 1, 2010, and July 1, 2017.

EXPOSURES

Parental socioeconomic measures, including maternal educational level, occupation, paternal educational level, and neighborhood income based on median annual household income.

MAIN OUTCOMES AND MEASURES

Mean relative TL was measured in cord blood and placental tissue. By constructing a principal component, an integrative socioeconomic measure was derived that integrates parental socioeconomic status and neighborhood income. Multivariable adjusted regression analyses were performed to associate the integrative socioeconomic measure and TL at birth.

RESULTS

In 1026 newborns (517 boys; mean [SD] gestational age, 39.2 [1.4] weeks), a higher socioeconomic status was associated with longer cord blood TL and placental TL. Each unit increment in the integrative socioeconomic status measure was associated with 2.1% (95% CI, 0.9%-3.4%; P < .001) longer cord blood TL in boys, while no association was observed for girls (0.5% longer cord blood TL; 95% CI, -0.9% to 1.8%; P = .50). The sex-specific socioeconomic status interaction revealed a stronger association in boys compared with newborn girls (1.6%; 95% CI, 0.02%-3.3%; P = .047 for interaction). In placental tissue, higher socioeconomic status was associated with 1.8% (95% CI, 0.3%-3.3%; P = .02) longer TL in newborn boys but not in girls (0.4% longer TL; 95% CI, -1.2% to 2.0%; P = .63). For placental tissue, no sex and socioeconomic status interaction on TL was observed (1.4%; 95% CI, -0.5% to 3.4%; P = .16 for interaction).

CONCLUSIONS AND RELEVANCE

This study suggests that parental socioeconomic status is associated with newborn TL, especially in boys. The results indicate that familial social economic factors are associated with the potential cellular longevity of the next generation, with a potential higher transgenerational vulnerability for newborn boys.

The impact of educational attainment on cardiorespiratory fitness and metabolic syndrome in Korean adults

The aim of this study was to evaluate the relationship between educational attainment and cardiorespiratory fitness (CRF) as a predictor of metabolic syndrome in a Korean population.In this single-center, retrospective cross-sectional study, 988 healthy adults (601 men and 387 women) who underwent regular health check-up in Seoul St. Mary's Hospital were analyzed. Educational attainment was categorized into 3 groups according to their final grade of educational course: middle or high school (≤12 years of education), college or university (12-16 years of education), and postgraduate (≥16 years of education). CRF was assessed by cardiopulmonary exercise testing, biceps strength, hand grip strength, bioelectrical impedance analysis, and echocardiography. Metabolic syndrome was diagnosed according to the 3rd report of the National Cholesterol Education Program.Among the subjects, 357 (36.1%) had metabolic syndrome. The postgraduate group had significantly higher peak oxygen consumption (VO2), biceps strength, hand grip strength, and peak expiratory flow than other groups (all P < .001). This group showed better left ventricular diastolic function, in terms of deceleration time of mitral inflow, maximal tricuspid valve regurgitation velocity, and left atrial volume index than other groups. Peak VO2 (%) was significantly correlated with all the parameters of metabolic syndrome, including insulin resistance (r = -0.106, P = .002), waist circumference (r = -0.387, P < .001), triglyceride (r = -0.109, P = .001), high density lipoprotein-cholesterol (r = 0.219, P < .001), systolic blood pressure (r = -0.143, P < .001), and diastolic blood pressure (r = -0.177, P < .001). And Peak VO2 (%) was found to be a predictor of metabolic syndrome (adjusted β = .988, P < .001). However, the level of education was not able to predict metabolic syndrome (postgraduate group; β = .955, P = .801).Although the postgraduate group had better CRF than other groups, the educational attainment could not exclusively predict metabolic syndrome in this study. Further research is needed to reveal the socioeconomic mechanism of developing metabolic syndrome.

Non-compensatory aggregation method to measure social and material deprivation in an urban area: relationship with premature mortality

Health inequalities exist between nations, regions, and even smaller units. In societies where social and economic structures change rapidly and continuously, analysis of health socioeconomic determinants plays a fundamental role to provide proper policy answers. This study aims to measure accurately two different conceptions of deprivation by developing two different indexes using non-compensatory among sub-indicators aggregation methods. The proposed indicators are compared with premature mortality to verify deprivation's effect on health status. The results show that materially deprived areas are not necessarily socially deprived and vice versa. Material deprivation has a positive statistical co-graduation with premature mortality, while social deprivation has no association with premature mortality.

Educational inequality in patient-reported outcomes but not mortality among cardiac patients: Results from the national DenHeart survey with register follow-up

Aims: This study aimed to explore whether educational level is associated with mental and physical health status, anxiety and depression symptoms and quality of life at hospital discharge and predicts cardiac events and all-cause mortality 1 year after hospital discharge in patients with ischaemic heart disease, arrhythmias, heart failure or heart valve disease. Methods: The DenHeart survey is cross-sectional and combined with data from national registers. Information on educational level and co-morbidity at hospital discharge and cardiac events and mortality 1-year post-discharge was obtained from registers. Patient-reported outcomes included SF-12, Hospital Anxiety and Depression Scale and HeartQoL. Multivariate linear and logistic regression and Cox proportional hazards regression models were used. Results: A total of 13,145 patients were included. A significant educational gradient was found in patient-reported mental and physical health status, anxiety and depression symptoms and quality of life, with lower educational groups reporting worse outcomes in adjusted analyses. No association was found between educational level and risk of cardiac events or all-cause mortality within 1 year after hospital discharge in adjusted analyses. Conclusions: In a large population of patients with cardiac disease a significant educational gradient was found in mental and physical health and quality of life at hospital discharge. There was, however, no association between educational level and risk of cardiac events or mortality 1 year after hospital discharge.

Understanding America: Unequal Economic Returns of Years of Schooling in Whites and Blacks

BACKGROUND

Higher schooling is associated with higher economic wellbeing. Marginalization-related Diminished Returns (MDRs) framework, however, refers to smaller returns of schooling for non-Hispanic Blacks (NHBs) compared to non-Hispanic Whites (NHWs).

AIM

Using a national sample of American adults, the current study compared NHBs and NHWs for the effects of each incremental increase in the years of schooling (gradient of educational level) on economic wellbeing of American adults.

METHODS

Data came from the Understanding America Study (UAS), a national online survey with a nationally representative sample. A total of 5715 adults (18+ years old) were included. From this number, 4,826 (84.4%) were NHWs, and 889 (15.6%) were NHBs. Years of schooling was the independent variable. Economic wellbeing was the main outcome. Age and gender were the covariates. Race was the moderator.

RESULTS

Overall, each additional year of schooling was associated with higher economic wellbeing, net of age, and gender. A statistically significant interaction was found between race and years of schooling on the outcome, indicating a smaller boosting effect of any incremental increase in the years of education on the economic wellbeing of NHBs compared to NHWs.

CONCLUSION

In line with MDRs, highly educated Black people experience low economic wellbeing. The MDRs of education on economic wellbeing may be why highly educated, and middle-class Black Americans still report poor health. Policy solutions should address multi-level causes of MDR-related health disparities.

Socioeconomic differences in mortality among 27 million economically active Germans: a cross-sectional analysis of the German Pension Fund data

OBJECTIVES

To assess disparities in mortality by socioeconomic status in Germany.

DESIGN AND PARTICIPANTS

We analyse a large administrative dataset of the German Pension Fund (DRV), including 27 million person-years of exposure and 42 000 deaths in 2013. The data cover the economically active population, stratified by sex and by East and West.

OUTCOME MEASURES

Age-standardised mortality rates and Poisson regression mortality rate ratios (MRRs).

RESULTS

The risk of dying increases with decreasing income: the MRRs of the lowest to the highest income quintile are 4.66 (95% CI 4.48 to 4.85) among men and 3.06 (95% CI 2.90 to 3.23) among women. The impact of income attenuates after controlling for education and other explanatory variables, especially for females. In the fully controlled model for females, individual income is a weaker predictor of mortality, but there is a clear educational mortality gradient. In the fully controlled model, the MRRs of the unemployed to the employed are 2.09 (95% CI 2.03 to 2.15) among men and 2.01 (95% CI 1.92 to 2.10) among women. The risk of dying is around half as high among foreigners as among German citizens. The socioeconomic disparities are greater among East than West German men.

CONCLUSIONS

Low socioeconomic status is a major determinant of excess adult mortality in Germany. The persisting East-West differences in male adult mortality can be explained by the higher socioeconomic status of men living in the West, rather than by contextual differences between East and West. These differences can be further monitored using DRV data.

Changing educational gradient in long-term care-free life expectancy among German men, 1997-2012

BACKGROUND

The inverse association between mortality and individual socioeconomic status is well-documented. Due to the lack of appropriate data, little is known about the nature of this association among individuals with long-term care (LTC) needs.

OBJECTIVES

We aim to fill in this knowledge gap by estimating life expectancy (LE), life expectancy without (CFLE) and with (CLE) long-term care by education for older German men; and by assessing the trends in the education-LE/CFLE/CLE gradient over time.

DATA AND METHODS

We apply survival analysis and Gompertz regression to German Socioeconomic Panel data (1997-2012) to estimate the mortality levels and to construct the life tables for three educational categories. Using the administrative data from the health insurance, we adjust mortality rates upward to account for the institutionalized population. We estimate age-specific LTC prevalence from the German Microcensus data (2004, 2012) and compute life expectancy with and without LTC by employing Sullivan's method. Slope and Relative Indices of Inequality are computed to evaluate the magnitude of educational inequalities in CFLE.

RESULTS

There is a clear and growing educational gradient in LE and CFLE among older men in Germany. In 2004, LE at age 65 among men with low education was 14.2 years, or 3.3 years lower than among highly educated individuals. The CFLE of these two educational categories ranged from 13.6 to almost 17 years. The gradient increased over time and in 2012 the difference constituted 4.6 years. The gaps between educational groups were not pronounced for CLE. The declining health ratio of years without LTC to remaining LE suggests the expansion of LTC needs, irrespective of the educational level.

CONCLUSIONS

Growing inequalities by educational status among older German men with care needs demand the attention of policy-makers. Prompt actions are needed to increase the survival chances of the most vulnerable groups.