Social inequalities in health

Early life socioeconomic circumstance and late life brain hyperintensities--a population based cohort study

CONTEXT

There have been many reports confirming the association between lower childhood socioeconomic circumstance and cardiovascular disease but evidence for links with cerebrovascular disease is contradictory. Hyperintensities on brain magnetic resonance imaging are associated with vascular risk factors, cognitive decline, dementia and death. However, the relationship between childhood socioeconomic circumstance and these lesions is unclear.

OBJECTIVE

To test the hypothesis that childhood socioeconomic circumstance is associated with late life hyperintensity burden and that neither adult socioeconomic circumstance nor change in socioeconomic circumstance during life influence this effect.

DESIGN

Cohort study.

SETTING

Community.

PARTICIPANTS

227 community dwelling members of the 1936 Aberdeen Birth Cohort aged 68 years, who were free from dementia.

MAIN OUTCOME MEASURES

Relationship between early life socioeconomic circumstance (paternal occupation) and abundance of late life brain hyperintensities.

RESULTS

We find significant negative correlations between childhood socioeconomic circumstance and white matter hyperintensities (ρ = -0.18, P<0.01), and periventricular hyperintensities (ρ = -0.15, P<0.05), between educational attainment and white matter hyperintensities (ρ = -0.15, P<0.05) and periventricular hyperintensities (ρ = -0.17, P<0.05), and between childhood intelligence and periventricular hyperintensities (ρ = -0.14, P<0.05). The relationship is strongest for childhood socioeconomic circumstance and regional white matter hyperintensities, where there is a step change in increased burden from paternal occupation grades equivalent to a shift from "white collar" to "blue collar" paternal occupation. Significant correlations were also found between hypertension and hyperintensity burden in all brain regions (ρ = 0.15-0.24, P<0.05). In models that include hypertension, the magnitude of the effect of childhood socioeconomic circumstance is similar to and independent from that of hypertension.

CONCLUSIONS

Childhood socioeconomic circumstance predicts the burden of brain white matter hyperintensities aged 68 years. The mechanism underlying this effect is unknown, but may act through fetal and/or early life programming of cerebrovascular disease. Future work to understand this vulnerability will inform strategies to reduce dementia and stroke.

Material hardship and the physical health of school-aged children in low-income households

OBJECTIVES

We examined the relationship between material hardship reported by low-income caregivers and caregivers' assessments of their children's overall health.

METHODS

We used logistic regression techniques to analyze data from 1073 children aged 5 through 11 years whose caregivers participated in multiple waves of the Illinois Families Study.

RESULTS

Caregivers' reports of food hardship were strongly associated with their assessments of their children's health. Other sources of self-reported material hardship were also associated with caregivers' assessments of their children's health, but the effects disappeared when we controlled for caregiver physical health status and mental health status. Proximal measures of material hardship better explained low-income children's health than traditional socioeconomic measures. There were no statistically significant cumulative effects of material hardships above and beyond individual hardship effects.

CONCLUSIONS

Our findings highlight the importance of developing and supporting programs and policies that ensure access to better-quality food, higher quantities of food, and better living conditions for low-income children, as well as health promotion and prevention efforts targeted toward their primary caregivers as ways to reduce health disparities for this population.

Health inequalities in Seville, Spain: use of indicators of social deprivation and mortality in small areas

OBJECTIVES

To analyse the spatial distribution of social structure and mortality in Seville, and to examine the association between various social indicators and mortality.

METHODS

Small areas of the city were typified on the basis of four social indicators, which were used to derive a social index. Overall mortality and cause of death were studied in two age groups (1+years and 1-64 years). Pearson's correlation coefficient was used to examine the relationship between the social indicators and mortality.

RESULTS

Significant social and mortality differences, particularly in premature mortality of males, were found between the areas studied. However, when the basic health zones are grouped together by social level, these differences in mortality are not so clear. The social indicators that correlate most closely with mortality are unemployment and illiteracy. When the social index is used, the correlations are weaker. Premature death from trauma in males presents the highest coefficient of correlation with unemployment and illiteracy.

CONCLUSIONS

The social index used in the present study places less emphasis on material differences than those used by Townsend et al. and Carstairs and Morris. Also, it was not possible to study mortality by individual neighbourhoods in this study. Both factors could have influenced the finding that the correlations between both types of indicator are weaker with the social index than with unemployment and illiteracy.

Socioeconomic differences in children's health: how and why do these relationships change with age?

The effects of socioeconomic status (SES) on health are well documented in adulthood, but far less is known about its effects in childhood. The authors reviewed the literature and found support for a childhood SES effect, whereby each decrease in SES was associated with an increased health risk. The authors explored how this relationship changed as children underwent normal developmental changes and proposed 3 models to describe the temporal patterns. The authors found that a model's capacity to explain SES-health relationships varied across health outcomes. Childhood injury showed stronger relationships with SES at younger ages, whereas smoking showed stronger relationships with SES in adolescence. Finally, the authors proposed a developmental approach to exploring mechanisms that link SES and child health.

Equity is out of fashion? An essay on autonomy and health policy in the individualized society

It is widely recognized that there is a discrepancy between principle and practice with respect to the health equity aim of public policy. This discrepancy is analyzed from two theoretical perspectives: the individualization of society and the fact that individual beliefs and values are connected to one's position in the social structure. These mechanisms influence both the choice of health policy measures and the normative judgements of preventive efforts, both of which tend to be consonant with the views of dominant social groups. In particular, we focus on the treatment of the ethical principle of autonomy and how this is reflected in health policy aimed at influencing health-related behaviour. We examine the current trend towards targeting health information campaigns on certain socio-economic groups and argue that it entails an ethical dilemma. The dominant discourse of the welfare state is contemplated as a means to understand why there tend to be a lack of emphasis on measures that are targeted at socio-economic inequalities. It is argued that there is no substantive basis in the individualized society for perceiving health equity as an independent moral principle and that the driving force behind the professed health equity goal may be in essence utilitarian.

Attitudes to cuts in expenditure and increased fees in health care

The aim of this postal questionnaire study was to measure attitudes to cuts and increased fees in health care in various Finnish population groups. Four groups were identified; a population sample of 2000 subjects, aged 18-70 y; a random sample of 1500 medical doctors of working age; a random sample of 1000 nurses of working age; and a sample of 2200 politicians involved in health and social care administration, mostly at the municipal level (altogether 6700 subjects). The main questionnaire included, among other things, the following questions: (1) Which of 18 specified medical activities at the primary health care level could be cut without causing severe harm to the population? (2) For which of 13 specified medical activities should clients pay at least 50% of the real cost? All the groups indicated the greatest willingness to cut expenditure on health education, occupational health services, hygiene inspection, substance abuse care, rehabilitation services for war veterans, and family planning. All the groups were least willing to make cuts in home care for disabled and elderly people, maternity services and clinics for under-fives. Most respondents in all groups felt that the activities for which clients should pay at least 50% of the cost were visits to physicians, occupational health services and dental services, whereas clinics for under-five and home care for disabled and elderly persons should be kept free of charge. As a conclusion, primary health care and prevention of diseases for small children, mothers, the elderly and disabled persons, were prioritised by all the groups.

Self reported poor health and low educational level predictors for mortality: a population based follow up study of 39,156 people in Sweden

OBJECTIVE

To analyse the relative risk (RR) of mortality for people who reported poor health or had low educational level.

SETTING

Sweden.

DESIGN

A random sample of 39156 people was interviewed face to face by Statistics Sweden from 1979-85. The dependent variable was total mortality. Independent variables were sex, age, marital status, and socioeconomic position, defined as educational level, type of housing tenure, and health status. This study was designed as a follow up study ranging from 1 January 1979 to 31 December 1993. Information on the dependent variables was obtained from the central cause of death register. Respondents were linked to the register by the Swedish personal registration number. Person-years at risk were calculated from the date of the interview until death, or for those who survived, until the end of the follow up period. Data were analysed in relation to gender and age (25-29 years and 60-74 years) in a proportional hazard model in order to estimate RR.

RESULTS

During follow up 2656 men and 1706 women died. Men and women in both age groups who reported poor health status at the interview had a strongly increased risk of dying during the follow up period (RR = 2.05 (95% confidence interval 1.72, 2.31) and RR = 1.91 (1.74, 2.10) for men, and RR = 2.34 (1.94, 2.83) and RR = 1.80 (1.61, 2.02) for women for the younger and older age groups respectively) when simultaneously controlled for age, marital status, education, and housing tenure. Living alone, renting an apartment, and low educational level (< or = 9 years) were also associated with increased mortality risks for men and women in both age groups.

CONCLUSION

Poor self reported health was a strong predictor for total mortality. Furthermore, in Sweden, a country well known for the equality of its income distribution, there are inequalities in health with higher total mortality risks for people with a low educational level and those who are not owner-occupiers.

Psychosocial factors and plasma lipids in black and white young adults: the Coronary Artery Risk Development in Young Adults Study data

These analyses examined the relationship between fasting plasma lipids and several psychosocial factors in a healthy cohort of 5115 black and white men and women between the ages of 18 and 30. Primary analyses were performed within race/gender subgroups and were supplemented with analyses examining consistency of associations across these groups. After controlling for age, high density lipoprotein (HDL) decreased, triglycerides increased, low density lipoprotein (LDL) increased, and the total cholesterol/HDL cholesterol ratio increased with increasing level of education in black men. This pattern is, in general, opposite to that found in other groups, particularly white women, whose lipid profile was found to be less atherogenic the higher the education. These associations were strongly confounded with health behaviors. There was also a positive association between hostility and triglycerides in women but not in men. No significant association with any plasma lipid for either race or gender was found for Type A behavior, social support, or life events. Despite a narrow plasma lipid range in these young adults, these data support the conclusion that increasing education is associated with a less atherogenic plasma lipid profile, except in black men, for whom education is associated with a less favorable plasma lipid profile. Among other psychosocial factors, the only consistent finding was an inverse association between hostility and triglycerides in women.

Relation between parasuicide, suicide, psychiatric admissions, and socioeconomic deprivation

OBJECTIVE

To examine the relations between parasuicide, suicide, psychiatric inpatient admissions, and socioeconomic deprivation.

DESIGN

Ecological analysis with data from routine information systems and the 1991 census.

SETTING

24 localities in the area covered by the Bristol and District Health Authority (population 817,000), consisting of aggregations of neighbouring wards, with an average population of 34,000.

SUBJECTS

6089 subjects aged over 10 years admitted to hospital after parasuicide between April 1990 and March 1994; 997 suicides occurring 1982-91; 4763 subjects aged 10-64 years admitted with acute psychiatric illness between April 1990 and March 1994.

RESULTS

Localities varied significantly in standardised admission ratios for parasuicide and standardised mortality ratios for suicide (P < 0.001). Spearman's rank correlation coefficient between the standardised mortality ratio for suicide and standardised admission ratio for parasuicide was 0.73 (95% confidence interval 0.46 to 0.88). Correlation between parasuicide and Townsend score was 0.86 (0.70 to 0.94) and between suicide and Townsend score 0.73 (0.46 to 0.88). The partial correlation coefficient between suicide and parasuicide after the Townsend score was adjusted for was 0.29 (-0.13 to 0.62). The correlation between standardised admission ratio for parasuicide and standardised admission ratio for psychiatric illness was 0.76 (0.51 to 0.89) and between standardised mortality ratio for suicide and standardised admission ratio for psychiatric illness was 0.72 (0.45 to 0.87).

CONCLUSION

A strong ecological association exists between suicide and parasuicide, with socioeconomic deprivation accounting for much of this relation. This strong association provides supporting evidence for the importance of social policy measures in attaining Health of the Nation targets on mental health.

Cancer prevention: setting the scene

Each year in the United Kingdom there are over 300,000 new cases of cancer and nearly 165,000 deaths from cancer. It is widely believed that as many as four fifths of all cancers are preventable by means that are already available. The Health of the Nation and the Europe Against Cancer programme have set targets and strategies for reducing the risk of cancer. An approach based on the whole population will achieve the greatest reductions in morbidity and mortality. Complementary to this is the individual approach, which can be based in primary care and targeted at high risk subjects. Health promotion and screening in primary care are not in themselves self evidently valuable. Their effectiveness must be tested rigorously and scientifically. Furthermore, because of limited time and resources, health education in primary care should be focused on interventions that are likely to achieve the greatest benefit, such as helping people to stop smoking.

Geographical mapping of diabetic patients from the deprived inner city shows less insulin therapy and more hyperglycaemia

To determine whether or not economic and social deprivation were associated with different diabetic treatment and metabolic control, data of patients from deprived inner city wards and prosperous wards were compared. A database was obtained for 1528 patients attending our hospital Diabetes Care Centre. Demographic data and postcodes were used to construct geographical maps of disease and deprivation. Blood glucose and glycated haemoglobin were measured. Inner city patients were less likely to be taking insulin, but if they were, they were more likely to have higher blood glucose values (p = 0.02) and higher glycated haemoglobin values (p = 0.02), compared to patients from prosperous wards. Insulin-treated patients from socially and economically deprived wards had worse diabetic control than patients from more prosperous wards. The study emphasizes the needs to target deprived patients for education and motivation to understand diabetes, and to optimize metabolic control.

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

Using the methodology of an earlier study of socioeconomic mortality gradients, we partitioned Brisbane City into five strata of equal size on the basis of suburb scores derived from aggregate socioeconomic census data. Numbers of deaths by stratum, age, sex and cause were obtained from mortality files. For almost all causes, mortality gradients had not changed between 1976-1979 and 1980-1987. A new category, medically-preventable death under age 65, had lower rates in higher-ranking suburbs. Potential years of life lost (PYLL) per unit of population, age-standardised, were also computed by stratum and cause. External causes of death were the main contributors to PYLL among men, with a strong socioeconomic gradient, while neoplasms were most important among women, with little evidence of a social class effect. It is estimated that, in urban Australia, the annual number of additional deaths under age 65 due to socioeconomic circumstances is over 2000 for males and over 1000 for females. This study provides a baseline against which the programs of health advancement initiated in the mid-1980s may be evaluated, or conversely, the effects of societal changes assessed.