Socioeconomic status and mortality revisited: an extension of the Brisbane area analysis

[Effect of socioeconomic status on mortality in urban areas: a systematic critical review]

Socioeconomic inequalities cause more disease and death than most risk factors, especially in cities. This systematic review of the scientific evidence included articles in English, Spanish, Portuguese, and Italian and excluded studies with low levels of evidence and those that did not analyze associations between mortality and socioeconomic status in urban settings. Articles were selected by two independent reviewers, and data extraction used evidence tables. A total of 1,509 records were obtained, and 24 were included. All the studies showed higher mortality rates in poorer areas. Six studies showed an association with cardiovascular diseases, four with lung diseases, and three with AIDS, infectious and parasitic diseases, and cirrhosis. The selected studies showed low consistency in the results and important methodological limitations that prevented comparisons between studies or the extraction of relevant conclusions.

Increasing socio-economic inequalities in drug-induced deaths in Australia: 1981-2002

INTRODUCTION AND AIMS

Since the 1990s illicit drug use death rates in Australia have increased markedly. There is a notable gap in knowledge about changing socio-economic inequalities in drug use death rates. Some limited Australian and overseas data point to higher rates of drug death in the lowest socio-economic groups, but the paucity of available studies and their sometimes conflicting findings need to be addressed.

DESIGN AND METHODS

This paper uses data obtained from the Australian Bureau of Statistics (ABS) to examine changes in age-standardised drug-induced mortality rates for Australian males over the period 1981-2002. Socio-economic status was categorised as manual or non-manual work status.

RESULTS

With the rapid increase in drug-induced mortality rates in the 1990s, there was a parallel increase in socio-economic inequalities in drug-induced deaths. The decline in drug death rates from 2000 onwards was associated with a decline in socio-economic inequalities. By 2002, manual workers had drug death rates well over twice the rate of non-manual workers.

DISCUSSION

Three factors are identified which contribute to these socio-economic inequalities in mortality. First, there has been an age shift in deaths evident only for manual workers. Secondly, there has been an increase in availability until 1999 and a relative decline in the cost of the drug, which most often leads to drug death (heroin). Thirdly, there has been a shift to amphetamine use which may lead to significant levels of morbidity, but few deaths.

Do places affect the probability of death in Australia? A multilevel study of area-level disadvantage, individual-level socioeconomic position and all-cause mortality, 1998-2000

BACKGROUND

In Australia, studies finding an association between area-level socioeconomic disadvantage and mortality are often based on aggregate-ecological designs which confound area-level and individual-level sources of socioeconomic variation. Area-level socioeconomic differences in mortality therefore may be an artefact of varying population compositions and not the characteristics of areas as such.

OBJECTIVE

To examine the associations between area-level disadvantage and all-cause mortality before and after adjustment for within-area variation in individual-level socioeconomic position (SEP) using unlinked census and mortality-register data in a multilevel context. Setting, participants and

DESIGN

The study covers the total Australian continent for the period 1998-2000 and is based on decedents aged 25-64 years (n = 43,257). The socioeconomic characteristics of statistical local areas (SLA, n = 1317) were measured using an index of relative socioeconomic disadvantage, and individual-level SEP was measured by occupation.

RESULTS

Living in a disadvantaged SLA was associated with higher all-cause mortality after adjustment for within-SLA variation in occupation. Death rates were highest for blue-collar workers and lowest among white-collar employees. Cross-level interactions showed no convincing evidence that SLA disadvantage modified the extent of inequality in mortality between the occupation groups.

CONCLUSIONS

Multilevel analysis can be used to examine area variation in mortality using unlinked census and mortality data, therefore making it less necessary to use aggregate-ecological designs. In Australia, area-level and individual-level socioeconomic factors make an independent contribution to the probability of premature mortality. Policies and interventions to improve population health and reduce mortality inequalities should focus on places as well as people.

Does living in a disadvantaged area mean fewer opportunities to purchase fresh fruit and vegetables in the area? Findings from the Brisbane food study

Understanding the particularly low intake of fruits and vegetables among socioeconomically disadvantaged groups is an important issue for public health. This study investigated whether access to retail outlets is similar across areas of varying socioeconomic disadvantage in an Australian urban setting, in terms of distance, the numbers of local shops, and their opening hours. This ecological cross-sectional study used 50 randomly sampled census collection districts and their nearby shopping environment (i.e. within 2.5 km), and generally found minimal or no socioeconomic differences in shopping infrastructure. Important methodological and social/economic issues may explain this contrast with overseas findings.

Mental health and socio-economic variations in Australian suicide

This paper investigates the relationship between suicide rates and prevalence of mental disorder and suicide attempts, across socio-economic status (SES) groups based on area of residence. Australian suicide data (1996-1998) were analysed in conjunction with area-based prevalences of mental disorder derived from the National Survey of Mental Health and Well-Being (1997). Poisson regression models of suicide risk included age, quintile of area-based SES, urban-rural residence, and country of birth (COB), with males and females analysed separately. Analysis focussed on the association between suicide and prevalences of (ICD-10) affective disorders, anxiety disorders, substance use disorders and suicide attempts by SES group. Prevalences of other psychiatric symptomatology, substance use problems, health service utilisation, stressful life-events and personality were also investigated. Significant increasing gradients were evident from high to low SES groups for prevalences of affective disorders, anxiety disorders (females only), and substance use disorders (males only); sub-threshold drug and alcohol problems and depression; and suicide attempts and suicide (males only). Prevalences of mental disorder, other sub-threshold mental health items and suicide attempts were significantly associated with suicide, but in most cases associations were reduced in magnitude and became statistically non-significant after adjustment for COB, urban-rural residence, and SES. For male suicide the relative risk (RR) in the lowest SES group compared to the highest was 1.40 (95% CI 1.29-1.52, p<0.001) for all ages, and 1.46 (95% CI 1.27-1.67, p<0.001) for male youth (20-34 years). This relationship was not substantially modified in males when regression models included prevalences of affective disorders, and other selected mental health variables and demographic factors. From a population perspective, SES remained significantly associated with suicide after controlling for the prevalence of mental disorders and other psychiatric symptomatology. Mental conditions and previous suicidal behaviour may play an intermediary role between SES and suicide, but this study suggests that an independent relationship between suicide and SES also exists.

Gender differences in the relationship of partner's social class to behavioural risk factors and social support in the Whitehall II study

In most countries health inequality in women appears to be greater when their socio-economic position is measured according to the occupation of male partners or spouses than the women's own occupations. Very few studies show social gradients in men's health according to the occupation of their female partners. This paper aims to explore the reasons for the differences in social inequality in cardiovascular disease between men and women by analysing the associations between own or spouses (or partners) socio-economic position and a set of risk factors for prevalent chronic diseases. Study participants were married or cohabiting London based civil servants included in the Whitehall II study. Socio-economic position of study participants was measured according to civil service grade; socio-economic position of the spouses and partners according to the Registrar General's social class schema. Risk factors were smoking, diet, exercise, alcohol consumption, and measures of social support. In no case was risk factor exposure more affected by the socio-economic position of a female partner than that of a male study participant. Wives' social class membership made no difference at all to the likelihood that male Whitehall participants were smokers, or took little exercise. Female participants' exercise and particularly smoking habit was, in contrast, related to their spouse's social class independently of their own grade of employment. Diet quality was affected equally by the socio-economic position of both male and female partners. Unlike the behavioural risk factors, the degree of social support reported by women participants was in general not strongly negatively affected by their husband or partner being in a less advantaged social class. However, non-employment in the husband or partner was associated with relatively lower levels of positive, and higher negative social support, while men with non-working wives or partners were unaffected. Studying gender differences in health inequality highlights some of the problems in health inequality research more broadly. We are brought face to face with the fact that the development of conceptual models that can be applied consistently to aetiology in both men and women are still at an early stage of development. Closer attention is needed to the different processes behind material power and 'emotional power' within the household when investigating gender differences in health and risk factors.

Socio-economic mortality differentials in Sydney over a quarter of a century, 1970-94

OBJECTIVE

To examine trends in socio-economic differentials in all-cause mortality in Sydney over a 25-year period (1970-94).

METHODS

Five measures of single indicators (two for occupation, two for education and one for income) and a composite measure of socio-economic disadvantage based on Census data (the Australian Bureau of Statistics' Index of Relative Socio-Economic Disadvantage) were used as indicators of socio-economic status by local govemment area. The relationship between mortality and socio-economic status was examined using quintiles based on these six measures of socio-economic status.

RESULTS

Socio-economic differentials in mortality were evident for males and females for all periods, and over the 25-year period the relative socio-economic differentials did not decline. For males, the socio-economic status differential in mortality widened, irrespective of socio-economic status indicator used, whereas for females it widened only when certain socio-economic indicators were used: occupation (unemployment measure) and income, but was not significant for the other single indicators or for the composite indicator.

CONCLUSIONS

Sydney trends of widening inequalities are generally similar to those reported for Britain and for other industrialised countries, suggesting that this is a common phenomenon and that policies to reduce health inequalities over the past quarter of a century have not been effective.

Urban cause-specific socioeconomic mortality differences. Which causes of death contribute most?

BACKGROUND

Cause-specific information on socioeconomic differences in health is necessary for a rational public health policy. At the local level, the Municipal Health Service studies these differences in order to support the authorities in policy making.

METHODS

Mortality data of the under 65 age group in The Hague were analysed (1982-1991) at residential area level.

RESULTS

Causes of death with a high socioeconomic gradient among males were: homicide, chronic liver disease, 'other' external causes of injury, diabetes, bronchitis, emphysema and asthma, and motor vehicle accidents; and among females: diabetes, ischaemic heart disease, 'other' diseases of the circulatory system, signs, symptoms and ill-defined conditions, malignant neoplasm of cervix, and 'other' diseases. Main contributors to the mortality differences between the highest and lowest socioeconomic quartiles among males were: ischaemic heart disease (17.3%), 'other' diseases of the circulatory system (10.2%), signs, symptoms and ill-defined conditions (9.0%), 'other' external causes of injury (8.6%), and chronic liver disease (7.2%); and among females: ischaemic heart disease (25.5%), 'other' diseases (20.1%), signs, symptoms and ill-defined conditions (18.6%), 'other' diseases of the circulatory system (11.0%), and diabetes (9.1%). Among females the contributions of malignant neoplasms of breast (-16.3%) and colon (-5.5%) and suicide (-4.3%) were negative.

CONCLUSIONS

The diseases that are the main contributors to urban socioeconomic mortality differences can be influenced by public health policy.

Socioeconomic inequalities in all-cause and specific-cause mortality in Australia: 1985–1987 and 1995–1997

BACKGROUND

Socioeconomic inequalities in mortality have been repeatedly observed in Britain, the US, and Europe, and in some countries there is evidence that the differentials are widening. This study describes trends in socioeconomic mortality inequality in Australia for males and females aged 0-14, 15-24 and 25-64 years over the period 1985-1987 to 1995-1997.

METHODS

Socioeconomic status (SES) was operationalized using the Index of Relative Socioeconomic Disadvantage, an area-based measure developed by the Australian Bureau of Statistics. Mortality differentials were examined using age-standardized rates, and mortality inequality was assessed using rate ratios, gini coefficients, and a measure of excess mortality.

RESULTS

For both periods, and for each sex/age subgroup, death rates were highest in the most disadvantaged areas. The extent and nature of socioeconomic mortality inequality differed for males and females and for each age group: both increases and decreases in mortality inequality were observed, and for some causes, the degree of inequality remained unchanged. If it were possible to reduce death rates among the SES areas to a level equivalent to that of the least disadvantaged area, premature all-cause mortality for males in each age group would be lower by 22%, 28% and 26% respectively, and for females, 35%, 70% and 56%.

CONCLUSIONS

The mortality burden in the Australian population attributable to socioeconomic inequality is large, and has profound and far-reaching implications in terms of the unnecessary loss of life, the loss of potentially economically productive members of society, and increased costs for the health care system.

Socioeconomic correlates of mortality differentials by local government area in rural northern New South Wales, 1981-1995

OBJECTIVE

Many studies have examined the correlation between socioeconomic status (SES) and mortality in Australia, but little is known about the correlation in rural areas and most studies have not explored the trends in SES differentials in mortality. This ecological study examines this correlation and explores the impact of the national strategies to reduce SES differentials in mortality in a rural area.

METHODS

Mortality data for residents in the New England Health Area, New South Wales (NSW), 1981 to 1995, were analysed. Twenty Local Government Areas (LGAs) in New England were ranked and aggregated into 4 groups according to a composite SES indicator from the 1996 census, and age/sex adjusted mortality rates were calculated for each group and compared. Poisson regression models were used to assess the linear trends in mortality for 1981-95.

RESULTS

A strong relationship between working age adult mortality and SES was found for both sexes. The rates for the most disadvantaged LGAs were significantly higher than the least disadvantaged LGAs for both sexes. The mortality rate was consistently higher for the most disadvantaged LGAs than the least disadvantaged LGAs.

CONCLUSION AND IMPLICATION

Although there has been an overall decline in death for all 4 groups of LGAs, the gap between the most disadvantaged and the least disadvantaged groups has widened over the last 15 years. This widening gap in death rates suggests that the strategies implemented as part of the Health for All initiative to reduce inequalities in mortality differentials have not been effective in this rural area.

The impact of area deprivation on differences in health: does the choice of the geographical classification matter?

OBJECTIVE

Many studies show the average health status in deprived areas to be poorer and the use of health care to be higher, but there is hardly any information on the impact of the geographical classification on the size of these differences. This study examines the impact of the geographical classification on the clustering of poor health per area and on the size of the differences in health by area deprivation.

DESIGN

Data on self reported health regarding 5121 people were analysed using three classifications: neighbourhoods, postcode sectors and boroughs. Multilevel logistic models were used to determine the clustering of poor health per area and the size of the differences in health by area deprivation, without and subsequently with adjustment for individual socioeconomic status.

SETTING

General population aged 16 years and over of Amsterdam, The Netherlands.

MAIN OUTCOME MEASURES

Self rated health, mental symptoms (General Health Questionnaire, 12-item version), physical symptoms and long term functional limitations.

MAIN RESULTS

The clustering of poor health is largest in neighbourhoods and smallest in postcode sectors. Health differences by area deprivation differ only slightly for the three geographical classifications, both with and without adjustment for individual socioeconomic status.

CONCLUSIONS

In this study, the choice of the geographical classification affects the degree of clustering of poor health by area but it has hardly any impact on the size of health differences by area deprivation.

Social integration and mortality in Australia

OBJECTIVE

To investigate the relationship between social integration and mortality at the aggregate level of analysis.

METHOD

The data were compiled from several Australian Bureau of Statistics documents. The unit of analysis was State (Territory)-year. The multivariate regression analysis included data from all States and the Australian Capital Territory for 1990-96. Five indicators of social integration--percentage of people living alone; divorce rate; unemployment rate; proportion of people who are discouraged job seekers; and unionization rate--were used as predictors of nine measures of mortality.

RESULTS

Higher levels of social integration, as measured by all indicators except unionization, were associated with lower mortality rates. In the case of unionization, higher levels were associated with increased mortality rates.

CONCLUSION

Studies concerning the relationship between social integration and health should investigate the 'type' and 'level' of social integration that is conducive to better health.

IMPLICATIONS

To help reduce disparities in health and mortality across communities, public health researchers and policy makers need to closely monitor geographic and temporal trends in social integration measures. Social policies that emphasise investment in social integration or social capital through job creation and training, provision of gainful employment and social services for discouraged and marginalized workers, improved work conditions and social support may lower mortality directly or through their beneficial effects on health-promoting behaviours such as reduced levels of smoking, drinking and physical inactivity.

Suicide in urban New South Wales, Australia 1985-1994: socio-economic and migrant interactions

Variation of suicide with socio-economic status (SES) in urban NSW (Australia) during 1985-1994, by sex and country or region of birth, was examined using Poisson regression analysis of vital statistics and population data (age >¿ approximately 15 yr). Quintiles of SES were defined by municipality of residence and comparisons of suicide by SES were adjusted for age and country (or region) of birth (COB), and examined by COB. Risk of suicide in females was 28% that of males for all adults and 21% for youth (age 15-24 yr). Suicide risk was lower in males from southern Europe, Middle East and Asia, and higher in northern and eastern European males, compared to the Australian-born. Risks for suicide increased significantly with decreasing SES in males, but not in females. The relationship of male suicide and SES was stronger when controlled for COB. For males, the relative risk of suicide, adjusted for age and COB, was 66% higher in the lowest SES quintile compared to the highest quintile. and 39% higher for youth (age 15-24 yr). For male suicide, the population attributable fraction for SES (less than the highest quintile) was 27%. Analysis of SES differentials in male suicide according to COB indicated a significant inverse suicide gradient in relation to SES for the Australian-born and those born in New Zealand and the United Kingdom or Eire, but not in non-English speaking COB groups, except for Asia. For Australian-born males, suicide risk was 71% higher in the lowest SES group (compared to the highest), adjusted for age. These findings indicate that SES plays an important role in male suicide rates among the Australian-born and migrants from English-speaking countries and Asia, and among youth; but not in female suicide, nor suicide in most non-English speaking migrant groups. Reduction in SES differentials through economic and social policies may reduce male suicide in lower SES groups and should be seen to be at least as important as individual level interventions.

Disadvantage and male cancer incidence and mortality in New South Wales 1985-1993

Male premature mortality variations from cancers by socioeconomic status and marital status were analysed for the period 1986-1989 and 1990-1993 for New South Wales. Cancer incidence and mortality were also surveyed by statistical local areas within metropolitan Sydney between 1985-1991 and correlation and regression analyses were undertaken with socioeconomic indicators and the modified Jarman 8 disadvantage indicator. Martial status variations were found with most major cancers, with not currently married men being more at risk. Cancers of the oesophagus, oral cavity, pancreas, bladder, kidney, liver and trachea, bronchus and lung were more associated with manual occupations and the disadvantage indicator, while cancer of the colon and melanoma were more associated spatially and occupationally with higher socioeconomic status. An unexpected finding with mortality was an occupational status bipolarity with several cancers, notably with managerial and manual workers. There are implications for the more precise targeting of populations at risk.

Food insufficiency in Queensland

To investigate the prevalence of food insufficiency and factors associated with it, two questions assessing household and individual food insufficiency were included in 13 regional health surveys conducted in Queensland in 1993. The surveys used computer-assisted telephone interviewing methodology. Of the 10,451 people interviewed, 9.7 per cent and 6.4 per cent reported household and individual food insufficiency, respectively, and 11.3 per cent reported at least one type. Prevalence was significantly higher in women than men and in urban than rural residents, and decreased monotonically with increasing age from 16.6 per cent in 18- to 30-year-olds to 1.7 per cent in over-70-year-olds. Higher prevalence also was associated with lower income, unemployment, single or separated, divorced or widowed status versus married (or de facto), one-adult households, and shared accommodation. Lower prevalence was associated with more education in those aged 50 and under but not in those over 50 years. Using logistic regression to control simultaneously for important sociodemographic factors, we found that risk of food insufficiency was most highly associated with age and income (threefold risk), unemployment and shared accommodation (twofold risk) and one-adult households, and being single versus separated, widowed or divorced (one-and-a-half-fold risk). Some differences in risks existed between men and women and between rural and urban residents, although none excluded the role of chance. Association of the items with lower reported fruit, vegetable and meat intake, poorer health status, and greater underweight supports their validity.

Duration of general practice consultations: association with patient occupational and educational status

Past studies have demonstrated that the majority of health care visits are made to general practitioners, and that socio-economically disadvantaged individuals are significantly more likely to use such services. Relatively little is known, however, about the quality of general practice care provided to patients of different socio-economic status. The specific aims of the study were to determine whether an association existed between consultation duration and patient educational and occupational status, and if an association was evident, to determine the extent of association after taking into account a range of identified confounding variables and the effect of a clustered sample design. Consecutive consultations from a randomly selected sample of general practitioners were audiotaped and their durations measured electronically. Patient education and occupational status were obtained by questionnaire. Information concerning a range of additional patient, practitioner and consultation variables was also assessed in order to identify possible confounders of the association between consultation duration and patient occupational and educational status. No association was evident between consultation duration and level of patient educational qualification. Independent of identified confounding variables and the effect of a clustered sample design, general practitioners spent less time with those patients employed in unskilled occupations. Unskilled patients received 2.1 min or 21% less time per consultation than patients in professional occupations. The odds of patients in unskilled occupations receiving a long consultation (> 10 min) were 26% less than the odds of patients in professional occupations. The finding of an occupational status differential in the duration of general practice consultations suggests that socio-economically disadvantaged patients may not be receiving the health care they require. Further research is required to confirm these findings and to identify whether similar differentials are evident in more specific elements of general practice care.

Practitioner provision of preventive care in general practice consultations: association with patient educational and occupational status

Socio-economically disadvantaged individuals experience significantly greater mortality and morbidity relative to advantaged individuals. General practitioners have been suggested to occupy a position which has the capacity to ameliorate the health consequences of socio-economic disadvantage. Community studies of preventive care status suggest, however, that socio-economically disadvantaged individuals are less likely to receive appropriate preventive care. Using a convenience sample of 22 general practitioners, 579 consultations were audiotaped to determine whether practitioner provision of preventive care was associated with the educational and occupational status of patients. Practitioner provision of preventive care was assessed in terms of: the proportion of consultations in which discussion of at least one preventive care topic occurred; the number of preventive care topics discussed; and the proportion of consultations in which each of six specific preventive care topic were discussed. Practitioners were significantly less likely to discuss at least one preventive care topic with patients of high occupational status. No significant differences were observed between patient groups in the number of preventive care topics, discussed, and in the likelihood of receiving preventive care discussion concerning each of six preventive topics. However, a consistent trend of practitioners being less likely to discuss preventive care topics with patients of high educational or occupational status was evident for all outcome variables. The pattern of results suggests that previously reported findings of socio-economically disadvantaged individuals having a poorer preventive care status may not be attributable to differentials in practitioner's provision of preventive care. Greater attention should therefore be given to identifying and resolving barriers other than practitioner-based barriers to preventive care provision if these differentials in preventive care status are to be reduced.

Socioeconomic differentials in cancer incidence and mortality in urban New South Wales, 1987-1991

Cancer incidence and mortality in urban residents of New South Wales (NSW), 1987 to 1991, were analyzed according to socioeconomic status (SES) for males (m) and females (f). Incidence rates displaying a negative gradient with SES at P < 0.01 included: cancers of the mouth and pharynx (m), oesophagus (m), stomach (m,f), liver (m), pancreas (m), larynx (m), lung (m,f), cervix, kidney (m,f) and all cancers combined (m). Negative mortality gradients at P < 0.01 were observed for mouth and pharynx (m), stomach (m,f), rectum (m), liver (m), larynx (m), lung (m,f) and cervix, and all cancers (m,f). Those sites for which incidence showed a positive gradient with SES included: colon (m,f), melanoma (m,f), breast (f), prostate and testis. For cancer mortality for specific sites no significant (P < 0.01) positive gradients were observed, although for melanoma (m,f) a positive gradient at P < 0.05 was found. Mortality for all cancers considered together in both sexes was significantly higher in the low SES group compared to the high SES group. This is partly because the more-fatal cancers are more common in the lower SES groups. Diet, tobacco use, reproductive factors, occupational and sun exposures are likely to be associated with the patterns observed but are not investigated in this study. Variations in health care between SES groups may also be partly responsible for some of the differences.

Prevalence and frequency of health service use: associations with occupational prestige and educational attainment

The accessibility of health care services has been suggested to be one factor with the potential to ameliorate the health effects of socioeconomic disadvantage. From a randomly selected sample of households in the Lower Hunter Valley region, 2623 adults were surveyed in 1987-88 to identify their reported use of medical, allied and alternative health services during the previous four weeks. There was a higher prevalence of use of the 'usual' general practitioner and medical services among educationally disadvantaged respondents only. No significant differences were evident between educational or between occupational groups in the prevalence of use of either alternative services or health services generally. Fewer occupationally disadvantaged respondents reported using allied health services. There was no difference in the number of health services used. Disadvantaged respondents were more likely to use medical services exclusively. Only educationally disadvantaged service users reported using any health, medical or general practitioner services more frequently than expected. In contrast, only occupationally disadvantaged service users reported using allied health services (and allied health services other than dentists) more frequently. The lack of consistent differentials in use across health services in favour of disadvantaged respondents suggests that a number of health care services may not be responding to the greater need for health care among disadvantaged members of the community.

Socioeconomic indices and suicide rate in Queensland

Suicides identified from a suicide register were classified according to socioeconomic indices of statistical local areas. Suicide rates were correlated with socioeconomic disadvantage, as measured by the proportion of persons of low income, low education and high unemployment living in an area. Suicide rates were inversely related to the proportion of families on high income, who owned their homes and who had large houses. Suicide rates of older people (55 years and over) were least influenced by these factors. For females, only the most disadvantaged areas had higher suicide rates. In other age and sex groupings, relationships were mostly linear.

Cardiovascular risk factors in Australia: trends in socioeconomic inequalities

STUDY OBJECTIVE

To examine trends in socioeconomic inequalities in cardiovascular risk factors using educational attainment to indicate socioeconomic status.

DESIGN

Behavioural data, physical measurements, blood pressure, and lipid determination collected in three, successive multicentre cross sectional community surveys conducted in 1980, 1983, and 1989.

SETTING

The six state capital cities of Australia; Sydney, Melbourne, Brisbane, Adelaide, Perth, and Hobart.

PARTICIPANTS

A total of 19,315 randomly selected respondents stratified by age (25-44, 45-64) and sex.

RESULTS

During the 1980s, average blood pressure declined for each level of educational attainment. Dietary messages to reduce the intake of saturated fat had little effect on the lipid profile of any population group. Height and educational attainment were positively associated. Women increased in weight from between 2 to 4 kg depending on age and educational attainment while older men experienced increases of around 2.5 kg regardless of educational attainment. Advice to avoid salt was adopted across the spectrum of educational attainment but with no suggestion that the socioeconomic gradient, which favoured the more highly educated, was diminishing. Men of all education levels responded positively to the anti-smoking initiatives of the 1980s but the relative disadvantage of those of lower education was maintained. Among women, the decline in smoking was less among those in the low education group. The prevalence of moderate to heavy drinkers was higher in men of lower educational attainment but declined significantly over the period. Walking for recreation or exercise became more popular, especially among older men of low education, while the prevalence of aerobic exercise and vigorous exercise remained largely unchanged. Overall, the clear socioeconomic gradient between leisure time physical activity and education attainment remained.

CONCLUSIONS

The lower socioeconomic group has improved its risk factor profile but its relative disadvantage compared with the higher socioeconomic group persists. Health promotion activities in Australia seem to have been effective in reaching the lower socioeconomic groups but the challenge to reduce inequalities remains. The steady increase in educational attainment in Australia may have been an important factor in the general improvement in the nation's risk factor profile and in the decrease in mortality from coronary heart disease.