Trends in socioeconomic inequalities in self-assessed health in 17 European countries between 1990 and 2010

Hearing and Functioning in Everyday Life Questionnaire: Psychometric Evaluation and Revision

PURPOSE

The aim of the current study was to explore the construct validity and internal consistency reliability of the International Classification of Functioning, Disability and Health (ICF)-based original English version of the Hearing and Functioning in Everyday Life Questionnaire (HFEQ) and to revise the HFEQ based on the results.

METHOD

This study used a cross-sectional survey design. The data were collected using an online survey. Adults with self-reported hearing disability (n = 513) from the United States were included. The ICF components of body functions, activity and participation, and environmental factors were tested as the underlying structure of the HFEQ using confirmatory factor analysis and then adjusted by triangulation with previous content validation.

RESULTS

The results of the current study confirmed the ICF components of body functions, activity and participation, and environmental factors as underlying constructs of the HFEQ. However, after triangulation with previous content validation, fine adjustments were made. The revised version of the HFEQ includes two removed items and a fine-tuned factor structure.

CONCLUSION

The results confirm that the structure of the HFEQ aligns with the ICF, and the overall results indicate that HFEQ has acceptable construct validity and internal consistency.

Association of perceived childhood socio-economic status and health with depressive symptoms among middle-aged and older adults in India: using data from LASI Wave I, 2017-2018

BACKGROUND

Childhood adverse experience has been linked with poor health outcomes across the life course. Nevertheless, whether such an association or direction could be projected to older people's life remains still unclear and needs to generate more evidence, particularly in India. Therefore, this study was conducted to examine the association of childhood socio-economic status and health with depressive symptoms amongst middle- aged and older adults in India.

METHODS

The data for the study was drawn from national representative survey "Longitudinal Ageing Study in India (LASI)" Wave I, 2017-2018 in order to conduct cross-sectional study. Multivariable regression analysis was used to examine the association of childhood socioeconomic status and health with depressive symptoms in the older population.

RESULTS

Poor childhood health was significantly and positively associated with depressive symptoms (AoR: 1.56, CI: 1.19, 2.04). Likewise, respondents who were bedridden for a month during their childhood had high odds of developing depressive symptoms (AoR: 1.16 CI: 1.01, 1.34). In addition to this, the odds of having depressive symptoms increased significantly among the average (AoR: 1.28 CI: 1.08, 1.51) and poor childhood socioeconomic status group (AoR: 1.31 CI: 1.11, 1.55) as compared to the higher socioeconomic category.

CONCLUSIONS

Childhood socioeconomic status and health have a significant role in determining mental health in later life. Results suggest that considering childhood socioeconomic status and health is important while diagnosing depression in older population in order to identify the significant associated factors in early childhood and thus help in preventing depressive symptoms in later life.

Income and professional inequalities in chronic diseases: prevalence and incidence in France

OBJECTIVES

In France, almost nine of 10 deaths are caused by non-communicable diseases, and there is significant social inequality in mortality rates. However, it is not easy to collect robust data on the incidence and prevalence of such diseases according to socio-economic status. Based on data from the link between the primary longitudinal population sample and the national health data system, the aim of our study was to compute the standardised incidence and prevalence of seven major groups of chronic diseases according to socio-economic status.

STUDY DESIGN

Descriptive retrospective cohort study.

METHODS

This was a descriptive retrospective cohort study on a weighted representative sample of the French population, comprising 3.4 million individuals from data collected 2016-2017. Main chronic disease categories include diabetes, cancers, psychiatric disorders, liver and pancreatic diseases, neurological conditions, respiratory and cardiovascular diseases, calculated from the 2016-2017 period by combining health care consumption and diagnoses received during hospitalisations and/or associated with specific full healthcare coverage. Socio-economic status was measured by disposable income from the 2013-2014 tax returns and census-derived socioprofessional groups, and findings were standardised for age and sex.

RESULTS

For all disease categories except cancers, standardised incidence rates showed a gradient favouring the wealthiest, with a risk ratio between the first and tenth standard of living deciles ranging from 1.4 (cardiovascular diseases) to 2.8 (diabetes). Incidence of all disease categories, except cancers, was higher for all groups compared with executives and higher academic professions (risk ratios between workers and executives ranged from 2.0 to 1.3 in psychiatric and cardiovascular diseases, respectively). Conversely, cancer incidence rate followed a flat curve, reduced in the two poorest standard of living deciles, and there were no significant differences between socioprofessional groups. Standardised prevalence rates followed the same patterns, although risk ratios were highest for psychiatric diseases, varying according to sex and disease.

CONCLUSIONS

Deep social inequalities in incidence and prevalence of chronic diseases were observed in a large representative sample of the French population. The reverse social inequalities in cancer incidence and prevalence calls for more detailed research into cancer types and selection mechanisms, the data from which would allow the long-term monitoring of such disparities.

The current state of complex systems research on socioeconomic inequalities in health and health behavior-a systematic scoping review

BACKGROUND

Interest in applying a complex systems approach to understanding socioeconomic inequalities in health is growing, but an overview of existing research on this topic is lacking. In this systematic scoping review, we summarize the current state of the literature, identify shared drivers of multiple health and health behavior outcomes, and highlight areas ripe for future research.

METHODS

SCOPUS, Web of Science, and PubMed databases were searched in April 2023 for peer-reviewed, English-language studies in high-income OECD countries containing a conceptual systems model or simulation model of socioeconomic inequalities in health or health behavior in the adult general population. Two independent reviewers screened abstracts and full texts. Data on study aim, type of model, all model elements, and all relationships were extracted. Model elements were categorized based on the Commission on Social Determinants of Health framework, and relationships between grouped elements were visualized in a summary conceptual systems map.

RESULTS

A total of 42 publications were included; 18 only contained a simulation model, 20 only contained a conceptual model, and 4 contained both types of models. General health outcomes (e.g., health status, well-being) were modeled more often than specific outcomes like obesity. Dietary behavior and physical activity were by far the most commonly modeled health behaviors. Intermediary determinants of health (e.g., material circumstances, social cohesion) were included in nearly all models, whereas structural determinants (e.g., policies, societal values) were included in about a third of models. Using the summary conceptual systems map, we identified 15 shared drivers of socioeconomic inequalities in multiple health and health behavior outcomes.

CONCLUSIONS

The interconnectedness of socioeconomic position, multiple health and health behavior outcomes, and determinants of socioeconomic inequalities in health is clear from this review. Factors central to the complex system as it is currently understood in the literature (e.g., financial strain) may be both efficient and effective policy levers, and factors less well represented in the literature (e.g., sleep, structural determinants) may warrant more research. Our systematic, comprehensive synthesis of the literature may serve as a basis for, among other things, a complex systems framework for socioeconomic inequalities in health.

Socioeconomic inequalities in self-rated health in Japan, 32 European countries and the United States: an international comparative study

AIMS

Japan is known as a country with low self-rated health despite high life expectancy. We compared socioeconomic inequalities in self-rated health in Japan with those in 32 European countries and the US using nationally representative samples.

METHODS

We analysed individual data from the Comprehensive Survey of Living Conditions (Japan), the European Union Statistics on Income and Living Conditions, and the Behavioral Risk Factor Surveillance System (US) in 2016. We used ordered logistic regression models with four ordinal categories of self-rated health as an outcome, and educational level or occupational class as independent variables, controlling for age.

RESULTS

In Japan, about half the population perceived their health as 'fair', which was much higher than in Europe (≈20-40%). The odds ratios of lower self-rated health among less educated men compared with more educated were 1.72 (95% confidence interval (CI) 1.61-1.85) in Japan, and ranged from 1.67 to 4.74 in Europe (pooled; 2.10 (95% CI 2.01-2.20)), and 6.65 (95% CI 6.22-7.12) in the US. The odds ratios of lower self-rated health among less educated women were 1.79 (95% CI 1.65-1.95) in Japan, and ranged from 1.89 to 5.30 in Europe (pooled; 2.43 (95% CI 2.33-2.54)), and 8.82 (95% CI 8.29-9.38) in the US. Socioeconomic inequalities were large when self-rated health was low for European countries, but Japan and the US did not follow the pattern.

CONCLUSIONS

Japan has similar socioeconomic gradient patterns to European countries for self-rated health, and our findings revealed smaller socioeconomic inequalities in self-rated health in Japan compared with those in western countries.

Predictors of Unmet Healthcare Needs during Economic and Health Crisis in Greece

(1) Background: The aim of this study was to identify predictors of the unmet healthcare needs during the financial and recent health crisis in Greece. (2) Methods: Time series analysis was performed for the years 2008 through 2022 using the Eurostat database. The dependent variable was the percentage of people who reported unmet need for medical care. Demographic, socioeconomic, and health data, as well as health expenditures, were used as independent variables. Correlation analysis and simple linear regression models were conducted to analyze the results. (3) Results: Unmet health needs in Greece increased from the start of the crisis until 2016, as a gradual de-escalation of the crisis was observed. However, in 2019 the country recorded the second highest level of unmet needs for medical care before the health crisis. Limitations in usual activities, reporting bad/very bad health status, being unemployed, and having low income increased the likelihood of unmet needs. Health expenditures (public or private) were also significant determinants of unmet healthcare needs. (4) Conclusions: The increased unmet health needs widen inequalities in health and healthcare access. Therefore, health policies should eliminate barriers which restrict the access to health and enhance healthcare services, developing conditions for citizens' well-being.

Socioeconomic inequalities in sport participation: pattern per sport and time trends - a repeated cross-sectional study

BACKGROUND

Sport participation is an important component of a healthy lifestyle and is known to be more common among privileged individuals. However, few studies examined socio-demographic patterns of participation by type of activity. This study aims at quantifying socio-economic inequalities in sport participation by sport type, and to analyse their trend over 15 years.

METHODS

We used 2005-2019 data from the Bus Santé study, a yearly population-based cross-sectional survey of Geneva adults. Sport participation was defined as reporting at least one sporting activity over the previous week; educational level, household income and occupational position were used as indicators of socio-economic position. Socio-economic inequalities in sport participation, and their trend over time, were examined using the relative and slope indexes of inequality (RII/SII).

RESULTS

Out of 7769 participants (50.8% women, mean age 46 years old), 60% participated in a sporting activity. Results showed that the higher the socioeconomic circumstances, the higher the sport participation (RII = 1.78; 95% Confidence Interval (CI): 1.64-1.92; SII = 0.33; 95%CI: 0.29-0.37 for education). Relative inequalities varied per sport e.g., 0.68 (95%CI: 0.44-1.07) for football and 4.25 (95%CI: 2.68-6.75) for tennis/badminton for education. Yearly absolute inequalities in sport participation tended to increase between 2005 and 2019 for household income, especially among women and older adults.

CONCLUSIONS

We observed strong socio-economic inequalities in sport participation in Geneva, with different magnitude depending on the sport type. These inequalities seemed to increase over the 2005-2019 period. Our results call for tailored measures to promote the participation of socially disadvantaged populations in sporting activities.

Is inconsistent reporting of self-assessed health persistent and systematic? Evidence from the UKHLS

In this paper, we investigate whether individuals provide consistent responses to self-assessed health (SAH) questions in the UK Household Longitudinal Study (UKHLS), and the potential implications for empirical research in case of inconsistent reporting behaviour. We capitalise on an opportunity in the UKHLS, asking respondents the same SAH question twice: with a self-completion and an open interview mode, within the same household interview over four waves. We estimate multivariate models to explore which individual characteristics are systematically relevant for the likelihood and frequency of inconsistent reporting. About 11-24% of those reported a particular SAH category in the self-completion reported inconsistently in the open interview. The probability of inconsistency is systematically associated with individual's demographics, education, income, employment status, cognitive and non-cognitive skills. The same characteristics also predict the frequency of inconsistent reporting across four UKHLS waves. Analysis of the implications of reporting inconsistencies shows no impact of SAH measurement on the association between income and health. A set of dimensions of people's physiological and biological health, captured using biomarkers, is associated equally with both SAH measures, suggesting that the interview mode does not play a role in the relationship between SAH and more objective health measures.

Socioeconomic inequalities in self-assessed health and food consumption: the mediating roles of daily hassles and the perceived importance of health

BACKGROUND

Urgent daily hassles, which are more common among people with a lower socioeconomic position (SEP), might limit one's ability to address less pressing goals, such as goals related to health promotion. Consequently, health goals may be viewed as less focal, which could jeopardize one's health. This study examined an understudied pathway: whether a higher severity of daily hassles resulted in a lower perceived importance of health and whether these two factors sequentially mediate socioeconomic inequalities in self-assessed health (SAH) and food consumption.

METHODS

A cross-sectional survey among 1,330 Dutch adults was conducted in 2019. Participants self-reported SEP (household income, educational level), the severity of eleven daily hassles (e.g., financial hassles, legal hassles), the perceived importance of health (not being ill, living a long life), SAH, and food consumption. Structural equation modeling was used to examine whether daily hassles and the perceived importance of health sequentially mediated income and educational inequalities in SAH, fruit and vegetable consumption (FVC) and snack consumption.

RESULTS

No evidence of sequential mediation through daily hassles and the perceived importance of health was found. Daily hassles individually mediated income inequalities in SAH (indirect effect: 0.04, total effect: 0.06) and in FVC (indirect effect: 0.02, total effect: 0.09). The perceived importance of not being ill and living a long life both individually mediated educational inequalities in SAH (indirect effects: 0.01 and -0.01, respectively, total effect: 0.07).

CONCLUSIONS

Income inequalities in SAH and FVC were explained by daily hassles, and educational inequalities in SAH were explained by the perceived importance of health. Socioeconomic inequalities may not be sequentially explained by a more severe experience of daily hassles and a lower perceived importance of health. Interventions and policies addressing challenging circumstances associated with a low income may improve SAH and healthy food consumption among lower-income groups.

Gender Gap in Unhealthy Life Expectancy: The Role of Education Among Adults Aged 45

Objectives: This paper examines the gender gap in unhealthy life expectancy across education levels and age in Spain to understand the extent to which the gender paradox exists over education and across ages. Methods: Death registrations and vital status were taken from the Spanish Statistical Office, while the three health measures (chronic conditions, bad-self rated health and cognitive impairment) from the 2019 European Health Interview Survey. We used Sullivan's method to compute unhealthy life expectancy by education level. We computed the gender and the education ratios of the proportion of unhealthy life years in each health measure by education and age. Results: At almost all ages and all education levels, women significantly lived longer but in poorer health than men. Marked gender differences are seen across most age-groups, particularly among the low educated. We detected greater health inequalities by education level for women (confirming the gender paradox) and a health gradient due to aging and across the health measures charting the disablement process. Conclusion: The new education distribution might improve the unhealthy life expectancy and might reduce the gender gap in the number of years spent in poor health.

Expanding the Health Information National Trends Survey Research Program Internationally to Examine Global Health Communication Trends: Comparing Health Information Seeking Behaviors in the U.S. and Germany

The Health Information National Trends Survey (HINTS) is a well-established U.S.-based research program administered by the National Cancer Institute to track the public access to and use of health information. This paper introduces a German research initiative, part of the International Studies to Investigate Global Health Information Trends (INSIGHTS) research consortium. This adaptation of the HINTS is important for initiating analyses of global health communication practices and comparing health information seeking behaviors (HISB) across nations to pinpoint potentials and challenges of health information provision and contribute to a deeper understanding of socio-contextual determinants of HISB. First cross-country comparisons revealed that the share of residents seeking for health information is high in the U.S. (80%) and Germany (74%), but different primary sources are used. Whereas a clear majority of U.S. residents chose the Internet to gather health information (74.9%), Germans most often turn to health professionals (48.0%). Socio-structural and health(care)-related predictors were found to contribute to the explanation of HISB in both countries, whereas information-related predictors were only relevant in Germany. The results indicate the need to engage in patient-provider communication to initiate HISB and to improve the access to information for residents with lower socio-economic backgrounds.

Have Health Inequalities Increased during the COVID-19 Pandemic? Evidence from Recent Years for Older European Union Citizens

Reducing inequality is one of the current challenges that most societies are facing. Our aim was to analyze the evolution of inequalities in self-assessed health among older Europeans in a time period spanning the 2008 economic crisis and the COVID-19 health crisis. We used data from Waves 2, 4 and 8 of the Survey of Health, Ageing and Retirement in Europe. We used inequality indices that accept ordinal variables. Our empirical results suggest that average inequality declines over time. Gender significantly influences the results. Some of the countries with the highest level of inequality are Denmark and Sweden, and some with the lowest are Estonia and the Netherlands. Our results may be of interest for the development of public policies to reduce inequalities. Special attention should be paid to vulnerable groups, such as the elderly.

Working Hours, Sleep Disturbance and Self-Assessed Health in Men and Women: A Multilevel Analysis of 30 Countries in Europe

Objectives

This study examined the gender and cross-country differences in the relationship between working hours and self-assessed health among working men and women in Europe, and further explored the moderating role of sleep disturbance in the relationship.

Methods

We used cross-sectional data from the 6th European Working Condition Survey on 14,603 men and 15,486 women across 30 countries in Europe. A multivariate logistic regression was applied to evaluate the relationship between working hours, sleep disturbance, and self- assessed health. In addition, we employed a two-stage multilevel logistic regression to assess the cross-country variations in the relationship between working hours and self-assessed health.

Results

The study showed a slightly U-shaped relationship between working hours and less-than-good self-assessed health among working adults in Europe (<31 h: aOR = 1.11; 95% CI: 1.00-1.25, 41-50 h: aOR = 0.98; 95% CI: 0.84-1.15, and 50+ h: aOR = 1.31; 95% CI: 1.07-1.59). However, working men had higher odds of reporting less-than-good self-assessed health as compared to women when they devote longer hours to paid work. The results further showed that there are cross-country variations in the association between working hours and less-than-good self-assessed health for both men and women, and that men had slightly lower variations as compared to women. Contrary to expectation, sleep disturbance did not moderate the relationship between working hours and less-than-good self-assessed health for both men and women in Europe.

Conclusions

Although there are gender differences and cross-country variations in the association between working hours and less-than-good self-assessed health, sleep disturbance did not moderate the associations. These findings underscore the importance for strict work time regulation and generous work-family policies that may promote good working conditions and health.

Three-year prediction of depression and anxiety with a single self-rated health item

BACKGROUND

Self-rated health (SRH) is a single question with which general health status is assessed.

AIMS

To study whether SRH (i) is associated with depression and anxiety symptoms, concurrently and after three years, (ii) predicts the course over time for meeting a cutoff for depression and anxiety, and (iii) predicts development of depression and anxiety after three years.

METHOD

Population-based questionnaire data from northern Sweden were used. In total, 2336 individuals participated at baseline and three-year follow-up. The Hospital Anxiety and Depression Scale was used to quantify symptoms of depression and anxiety. Categorical and continuous data were used for analyses to complement each other.

RESULTS

Regarding prevalence, the analyses showed three- to four-fold increased odds for depression and anxiety at three-year follow-up, and two- to three-fold odds for their development at three-year follow-up. SRH at baseline was also found to be a significant, but weak, predictor of depression and anxiety severity and worsening at follow-up as well as being a predictor over time for meeting a cutoff for depression and anxiety.

CONCLUSIONS

Assessment of SRH may be used in general practice to identify individuals who qualify for further evaluation of depression and anxiety.

Social Epidemiology: Past, Present, and Future

In a context where epidemiologic research has been heavily influenced by a biomedical and individualistic approach, the naming of “social epidemiology” allowed explicit emphasis on the social production of disease as a powerful explanatory paradigm and as critically important for interventions to improve population health. This review briefly highlights key substantive areas of focus in social epidemiology over the past 30 years, reflects on major advances and insights, and identifies challenges and possible future directions. Future opportunities for social epidemiology include grounding research in theoretically based and systemic conceptual models of the fundamental social drivers of health; implementing a scientifically rigorous yet realistic approach to drawing conclusions about social causes; using complementary methods to generate valid explanations and identify effective actions; leveraging the power of harmonization, replication, and big data; extending interdisciplinarity and diversity; advancing emerging critical approaches to understanding the health impacts of systemic racism and its policy implications; going global; and embracing a broad approach to generating socially useful research.

Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Inequalities in Health: Methodological Approaches to Spatial Differentiation

The prevalence of inequalities in the general health position of communities can be assessed by using selected determinants. The aims of this article are three-fold: (1) to apply a comprehensive approach to the assessment of inequalities in the general health position of communities, (2) to determine the spatial differentiation of determinants, and (3) to present selected assessment methods and their impact on the results. To present a quantitative assessment of these inequalities in health status in communities, a composite indicator (Health Index) was developed. This Health Index is composed of 8 areas of evaluation and 60 indicators which include, amongst others, determinants of health status and healthcare at district level (LAU 1) in the Czech Republic. The data are evaluated using multicriteria decision-making methods (the WSA and TOPSIS methods). Findings suggest that, when all eight domains are assigned the same weight of one, the spatial differentiation among the districts is similar when using both methods. If different weightings are assigned to the districts, changes occur in both the index values and the rankings of the analyzed districts. For example, the allocation of weightings in both methods results in a rearrangement of the ranking of districts for which the Health Index is around the average.

Health Inequality Analysis in Europe: Exploring the Potential of the EQ-5D as Outcome

Objective: This study explored the additive value of the multi-item EuroQol 5-Dimension 5-Level (EQ-5D-5L) as an outcome measure in health inequality analyses, relative to the single-item EuroQol visual analog scale (EQ VAS). Methods: A sample comprising the general population from Italy, the Netherlands, and United Kingdom (UK) completed the EQ-5D-5L and the EQ VAS. The level of education was selected as a proxy for socio-economic status (SES). EQ-5D-5L level sum scores (LSS) were compared against EQ VAS scores. Stratified and multivariable analyses were used to study the associations between SES and the LSS/EQ VAS relative to the presence of chronic health conditions. Results: A total of 10,172 people participated in this study. In the UK and Netherlands, the LSS was worst for respondents with a low educational level and better for respondents with middle and high educational levels. For Italy, the LSS was best for respondents with a middle educational level compared to respondents with low and high educational levels. The same patterns were observed for the EQ VAS, but differences were slightly smaller. Multivariable analyses showed generally stronger predictive relations in the UK, and with the LSS. The presence of chronic health conditions and being unable to work were independent strong predictors, canceling out the effects of education. Conclusions: In three different European countries, the EQ-5D measures show the presence of education-dependent health inequalities, which are universally explained in regression analysis by independently the presence of chronic health conditions and the inability to work. In stratified analysis, the EQ-5D-5L LSS discriminates slightly better between participants with different levels of SES compared to the EQ VAS.

Quantification of disparities in the distribution of lifestyle and metabolic risk factors, prevalence of non-communicable diseases and related mortality: the Belgian Health Interview Surveys 1997-2018

OBJECTIVES

Comprehensively measure the trends in health disparities by sociodemographic strata in terms of exposure to lifestyle and metabolic risks, and prevalence and mortality of non-communicable diseases (NCDs) during the last 20 years in Belgium.

DESIGN

Cross-sectional analysis of periodic national-representative health interview surveys and vital statistics.

SETTING

Population-based study of adult residents in Belgium between 1997 and 2018.

PARTICIPANTS

Adults aged 25-84 years and resident in Belgium in the years 1997 (7256 adults), 2001 (8665), 2004 (9054), 2008 (7343), 2013 (7704) and 2018 (8358).

MAIN OUTCOME MEASURE

Age-standardised prevalence rates of modifiable lifestyle risks (poor diet, smoking, excessive alcohol use and leisure-time physical inactivity), metabolic risks (high body mass index (BMI), blood pressure and cholesterol levels) and major NCDs (type 2 diabetes mellitus (T2DM), cardiovascular diseases (CVDs), cancer, asthma and chronic obstructive pulmonary disease (COPD)), with their relative health disparities across strata by age, sex, region of residence, nationality, education and income level, and according to high versus low engagement in the four lifestyle risks, calculated from a survey-weighted age-adjusted logistic regression.

RESULTS

Greater avoidable disparities were observed between extremes of education and income strata. The most marked disparities were found for exposure to lifestyle risks (except excessive alcohol use), prevalence of high BMI as well as T2DM, asthma and COPD, with disparities of daily smoking and COPD worsening over time. Still, NCD-specific mortality rates were significantly higher among men (except asthma), residents of Wallonia and Brussels (except cerebrovascular disease), and among the native Belgians (except T2DM and asthma). High engagement in lifestyle risks was generally observed for men, residents of the region Wallonia, and among lower education and income strata. This subgroup (20%) had a worse health profile as compared with those who had a low-risk lifestyle (25%), shown by prevalence ratios varying between 1.1 and 1.6 for metabolic risks, and between 1.8 and 3.7 for CVD, asthma and COPD.

CONCLUSIONS

Improving population health, including promoting greater health equity, requires approaches to be tailored to high-risk groups with actions tackling driving root causes of disparities seen by social factors and unhealthy lifestyle.

Trends in the Social Class Inequalities in Disability and Self-Rated Health: Repeated Cross-Sectional Surveys from Finland and Sweden 2001-2018

Objectives: To assess time trends in the social class inequalities and in total inequality in disability and self-rated health (SRH) in two oldest old populations.

Methods: The data came from the Finnish Vitality 90+ Study (2001, 2003, 2007, 2010, 2014 and 2018; n = 5,440) and from the Swedish Panel Study of Living Conditions of the Oldest Old (2002, 2004, 2011 and 2014; n = 1,645). Inequalities in mobility and activities of daily living (ADL) disability and SRH were examined cross-sectionally and over time using relative and absolute measures.

Results: Lower social classes had greater mobility and ADL disability and worse SRH than higher social classes and the inequalities tended to increase over time. Findings were remarkably similar in both studies and with absolute and relative measures. Total inequality, referring to the variance in health outcome in the total population, remained stable or decreased.

Conclusion: The study suggests that the earlier findings of improved mobility and ADL are largely driven by the positive development in higher social classes while findings of decline in SRH are related to the worsening of SRH in lower social classes

Trends in absolute and relative educational inequalities in health during times of labour market restructuring in coastal areas: The HUNT Study, Norway

BACKGROUND

Restructuring labour markets offers natural population-level experiments of great social epidemiological interest. Many coastal areas have endured substantial restructuring of their local labour markets following declines in small-scale fishing and transitions to new employment opportunities. It is unknown how educational inequalities in health have developed in formerly fishery-dependent communities during such restructuring. In this study, we compare trends in social inequalities in health in Norwegian coastal areas with adjacent geographical areas between 1984 and 2019.

METHODS

We used cross-sectional population-based data from the Trøndelag Health Study (HUNT), collected four times: HUNT1 (1984-86), HUNT2 (1995-97), HUNT3 (2006-08) and HUNT4 (2017-19). Adults above 30 years of age were included. Using Poisson regression, we calculated absolute and relative educational inequalities in self-rated health, using slope (SII) and relative (RII) indices of inequality.

RESULTS

Trends in absolute and relative inequalities in rural coastal health were generally more favourable than in adjacent geographical areas. We found a statistically significant trend of declining relative educational inequalities in self-rated health in the rural coastal population from HUNT1 to HUNT4. Absolute inequalities overall increased from HUNT1 to HUNT4, although a declining trend followed HUNT2. Nonetheless, the rural coastal population exhibited the highest prevalence of poor self-rated health across the four decades.

CONCLUSIONS

Although absolute educational inequalities in self-rated health widened in all geographical areas, the smallest increase was in rural coastal areas. Relative educational inequalities narrowed in this rural coastal population. Considering the concurrent processes of large-scale investments in the Norwegian public sector and welfare schemes, increased fishing fleet safety, and employment opportunities in aquaculture, our findings do not suggest that potential positive effects on public health of this restructuring have benefitted inhabitants with higher educational attainment more than inhabitants with lower educational attainment in this rural coastal population.

Trends and socioeconomic inequalities in self-rated health in Japan, 1986-2016

INTRODUCTION

Despite having very high life expectancy, Japan has relatively poor self-rated health, compared to other high-income countries. We studied trends and socioeconomic inequalities in self-rated health in Japan using nationally representative data.

METHODS

The Comprehensive Survey of Living Conditions was analyzed, every 3 years (n ≈ 0.6-0.8 million/year) from 1986 to 2016. Whereas previous studies dichotomized self-rated health as an outcome, we used four categories: very good, good, fair, and bad/very bad. Proportional odds ordinal logistic regression models are used, with ordinal scale self-rated health as an outcome, and age category, survey year and occupational class or educational level as independent variables.

RESULTS

In 2016, the age-adjusted percentages for self-rated health categorized as very good, good, fair, and bad/very bad, were 24.0, 17.1, 48.7, and 10.2% among working-age men, and 21.6, 17.5, 49.4, and 11.5% among working-age women, respectively. With 1986 as the reference year, the odds ratios (ORs) of less good self-rated health were lowest in 1995 (0.69; 95% Confidence Interval [95% CI]: 0.66-0.71 of working-age men), and highest in 2010 (1.23 [95% CI: 1.19-1.27]). The ORs of male, lower non-manual workers (compared to upper non-manual) increased from 1.12 (95% CI: 1.07-1.17) in 2010 to 1.20 (95% CI: 1.15-1.26) in 2016. Between 2010 and 2016, the ORs of working-age men with middle and low levels of education (compared to a high level of education) increased from 1.22 (95% CI: 1.18-1.27) to 1.34 (95% CI: 1.29-1.38), and from 1.47 (95% CI: 1.39-1.56) to 1.75 (95% CI: 1.63-1.88), respectively. The ORs of working-age women with middle and low levels of education also increased from 1.22 (95% CI: 1.17-1.28) to 1.32 (95% CI: 1.26-1.37), and from 1.74 (95% CI: 1.61-1.88) to 2.03 (95% CI: 1.87-2.21) during the same period.

CONCLUSION

Japan has the unique feature that approximately 50% of the survey respondents rated their self-rated health as fair, but with important variations over time and between socioeconomic groups. In-depth studies of the role of socioeconomic conditions may shed light on the reasons for the high prevalence of poor self-rated health in Japan.

Lifetime socioeconomic determinants of health trajectories among older adults

Drawing on life course theory and research, we explored how socioeconomic circumstances during childhood and adulthood shape self-reported health trajectories among older Mexican adults. We used data from the Mexican Health and Aging Study panel survey (2001-2015) and used sequence analysis to estimate types of self-reported health trajectories in older adulthood. We then explored the association between those health trajectories and socioeconomic determinants at different life stages, including education, occupation, employment, economic status, parental education, and adverse living conditions and illnesses during childhood. Our contributions are threefold. First, we identified four types of health trajectories for men and eight for women, representing a more nuanced longitudinal health status profile than previously shown. Second, we found that childhood and adult socioeconomic circumstances influence self-reported health trajectories at older age. Third, our results suggest there is no simple monotonic relationship between life course circumstances and self-reported health trajectories.

Socio-economic inequality in long-term care: a comparison of three time periods in the Netherlands

As a result of the rapid ageing of societies, meeting the demands for long-term care has become increasingly difficult. In the Netherlands, informal care is recognised as a key element to compensate for cut-backs in formal care provision. Formal, informal and privately paid long-term care services, however, are not used equally across socio-economic status (SES) groups and whether these inequalities have been reduced or exacerbated over time has not been researched. This study investigates to what extent educational and income inequalities in the use of formal, informal and privately paid care have changed over time. Data from the Longitudinal Aging Study Amsterdam (LASA) was used from three points in time: 1995 (N = 787), 2005 (N = 550) and 2015 (N = 473). Participants were between 75 and 85 years of age and living independently. The results indicate that lower SES groups are consistently more likely to use formal and informal care, and less likely to use privately paid care compared to higher SES groups. An increase in inequality was only found in the use of informal care; while informal care use is stable among lower SES groups, it decreases steeply among higher SES groups. These findings highlight the importance of education for explaining variation and changes over time in care use. Governmental efforts to mobilise informal care-givers might be outweighed by trends towards less long-term care.

The Effect of Socio-Economic Status on Health Information Literacy among Urban Older Adults: Evidence from Western China

The present study aimed to observe the effect of socio-economic status on health information literacy and to identify whether there is a social gradient for health information literacy among urban older adults in Western China. This study employed a cross-sectional research design, and 812 urban participants aged 60 and older were enrolled in Western China. In the current study, only 16.7% of urban older adults reported having adequate health information literacy. Binary logistic regression analysis showed that socio-economic status factors including educational attainment, ethnicity, and financial strain were significantly and tightly associated with health information literacy. Additionally, other factors including suffering from chronic diseases, information-seeking activity, reading magazines and books, and watching television were also significantly linked to health information literacy. Consistent with existing studies, the findings indicate the health information literacy deficit and demonstrate the crucial impact of socio-economic status on health information literacy, which implies a social gradient in health information literacy. The importance of other factors related to health information literacy are discussed as well. The results suggest that reducing the health information literacy deficit and social gradient in health information literacy must be considered as an important priority when developing public health and health education strategies, programs, and actions among urban older adults in Western China.

Socioeconomic inequalities in self-assessed health and mental health in Barcelona, 2001-2016

OBJECTIVE

Previous research has found persistent socioeconomic inequalities in health outcomes at the national level, with different patterns after the economic crisis. However, inequalities in urban areas are also important. This study analyses socioeconomic inequalities in self-assessed health and mental health in the city of Barcelona.

METHOD

Repeated cross-sectional design using quinquennial data from the Barcelona Health Surveys carried out in 2001, 2006, 2011 and 2016 for the population older than 22 years. Robust Poisson regressions models were used to compute socioeconomic gradients and relative (RII) and slope indexes of inequality (SII) by occupational social class, with stratification by sex. RII and SII were also obtained with further adjustment by employment situation.

RESULTS

A consistent socioeconomic gradient was found for all years except for 2011. Relative and absolute inequalities followed a V-shape, showing a drop during the economic crisis but widening thereafter to recover pre-crisis figures for self-assessed health and widening for mental health, in both relative and absolute terms in 2016. Adjustment for employment situation reduces inequalities but a large part of these inequalities remains, with variability across years.

CONCLUSIONS

The lasting effects of the 2008 economic crisis and the austerity programmes imposed since then may have contributed to the persistence of socioeconomic inequalities in self-assessed health and the widening of those for mental health.

Trends in inequalities in disability in Europe between 2002 and 2017

BACKGROUND

Monitoring socioeconomic inequalities in population health is important in order to reduce them. We aim to determine if educational inequalities in Global Activity Limitation Indicator (GALI) disability have changed between 2002 and 2017 in Europe (26 countries).

METHODS

We used logistic regression to quantify the annual change in disability prevalence by education, as well as the annual change in prevalence difference and ratio, both for the pooled sample and each country, as reported in the European Union Statistics on Income and Living Conditions (EU-SILC) and the European Social Survey (ESS) for individuals aged 30-79 years.

RESULTS

In EU-SILC, disability prevalence tended to decrease among the high educated. As a result, both the prevalence difference and the prevalence ratio between the low and high educated increased over time. There were no discernible trends in the ESS. However, there was substantial heterogeneity between countries in the magnitude and direction of these changes, but without clear geographical patterns and without consistency between surveys.

CONCLUSIONS

Socioeconomic inequalities in disability appear to have increased over time in Europe between 2002 and 2017 as per EU-SILC, and have persisted as measured by the ESS. Efforts to further harmonise disability instruments in international surveys are important, and so are studies to better understand international differences in disability trends and inequalities.

Life stage-specific trends in educational inequalities in health-related quality of life and self-rated health between 2002 and 2016 in Germany: findings from the German Socio-Economic Panel Study (GSOEP)

OBJECTIVES

While evidence suggests persisting health inequalities, research on whether these trends may vary according to different stages of life has rarely been considered. Against this backdrop, we analysed life stage-specific trends in educational inequalities in health-related quality of life (HRQOL) and poor self-rated health (SRH) for individuals in 'later working life' (50-64 years), 'young seniors' (65-79 years) and persons of 'old age' (80+ years).

METHODS

We used survey data from the German Socio-Economic Panel Study comprising the period from 2002 to 2016. The sample consists of 26 074 respondents (160 888 person-years) aged 50 years and older. Health was assessed using the mental and physical component summary scale (MCS/PCS) of the HRQOL questionnaire (12-Item Short Form Health Survey V.2) and the single item SRH. To estimate educational health inequalities, we calculated the regression-based Slope Index of Inequality (SII) and Relative Index of Inequality (RII). Time trends in inequalities were assessed by the inclusion of a two-way interaction term between school education and time.

RESULTS

With increasing age, educational inequalities in PCS and poor SRH decreased whereas they rose in MCS. Over time, health inequalities decreased in men aged 65-79 years (MCSSII=2.76, 95% CI 0.41 to 5.11; MCSRII=1.05, 95% CI 1.01 to 1.10; PCSSII=2.12, 95% CI -0.27to 4.51; PCSRII=1.05, 95% CI 1.00 to 1.11; poor SRHSII=-0.10, 95% CI -0.19 to 0.01; poor SRHRII=0.73, 95% CI 0.48 to 1.13) and among women of that age for MCS (MCSSII=2.82, 95% CI 0.16 to 5.50; MCSRII=1.06, 95% CI 1.01 to 1.12). In contrast, health inequalities widened in the 'later working life' among women (PCSSII=-2.98, 95% CI -4.86 to -1.11; PCSRII=0.94, 95% CI 0.90 to 0.98; poor SRHSII=0.07, 95% CI 0.00 to 0.14) while remained largely stable at old age for both genders.

CONCLUSIONS

We found distinctive patterns of health inequality trends depending on gender and life stage. Our findings suggest to adopt a differentiated view on health inequality trends and to pursue research that explores their underlying determinants.

Ranking populations in terms of inequality of health opportunity: A flexible latent type approach

We offer a flexible latent type approach to rank populations according to unequal health opportunities. Building upon the latent-class method, an approch increasingly adopted to estimate health inequalities, our contribution is to let the number of socioeconomic groups considered vary to obtain an opportunity-inequality curve for a population that gives how the between-type inequality varies with the number of types. A population A is said to have less inequality of opportunity than population B if its curve is statistically below that of population B. This version of the latent class approach allows for a robust ranking of 31 European countries regarding inequality of opportunity in health.

Inequality in hospitalization due to non-communicable diseases in Sweden: Age-cohort analysis of the Uppsala Birth Cohort Multigenerational Study

We aimed to investigate cohort differences in age trajectories of hospitalization due to non-communicable conditions, and if these varied by paternal socioeconomic position. We used the Uppsala Birth Cohort Multigenerational Study—including virtually complete information on medical diagnoses.

Our sample constituted 28,448 individuals (103,262 observations). The outcome was five-year prevalence of hospitalization due to major non-communicable conditions in 1989–2008. The exposures were age (19–91), year-of-birth (1915–1929; 1938–1972), gender (man vs woman), and parental socioeconomic position (low, medium, and high). We used multilevel logit models to examine associations between exposures and the hospitalization outcome.

Younger cohorts had a higher prevalence of hospitalization at overlapping ages than those born earlier, with inter-cohort differences emerging from early-adulthood and increasing with age. For instance, at age 40 predicted probability of hospitalization increased across birth-cohorts—from 1.2% (born in 1948-52) to 2.0% (born in 1963-67)—whereas at age 50 it was 2.9% for those born in 1938-42 compared with 4.6% among participants born in 1953-57. Those with medium and low socioeconomic position had 13.0% and 20.0% higher odds of experiencing hospitalization during the observation period, respectively—when age, year-of-birth and gender were accounted for.

We found that no progress was made in reducing the socioeconomic inequalities in hospitalization across cohorts born between 1915 and 1972. Hence, more effective policies and interventions are needed to reduce the overall burden of morbidity—particularly among the most vulnerable.

•

What is already known on this subject?

•

The evidence on trends in morbidity in Sweden is mainly cross-sectional and focused on individual conditions.

•

Rates of various indicators of morbidity (e.g. poor mobility, psychological distress, disability) have increased over time.

•

What this study adds.

•

Successively younger birth cohorts had a higher prevalence of hospitalization, with differences emerging in early-adulthood.

•

Those in medium and low parental socioeconomic position (vs high) had 13% and 20% higher odds of hospitalization.

•

No progress was made in reducing the socioeconomic inequalities across cohorts born between 1915 and 1972.

Socioeconomic pathways to inequalities in mental and functional health: a comparative study of three birth cohorts

Background

Although the educational expansion is often seen as a mechanism that might reduce health inequalities, socioeconomic inequalities in health (SEIH) have persisted or increased over the past decades. Theories suggest that this persistence could be due to a changing role of education as a ‘gatekeeper’ to access other socioeconomic resources such as occupation and income that are also associated with health outcomes. To test this, we examine whether the mediating role of occupation and income in the education–health relationship differs between three cohorts of 55–64 year old adults.

Methods

We used cross-sectional data from three cohorts of 988, 1002, and 1023 adults born in 1928/37, 1938/47 and 1948/57 and observed in 1992/93, 2002/03, 2012/13 respectively, who participated in the Longitudinal Aging Study Amsterdam, the Netherlands. We used multigroup structural equation modelling to compare the strength of indirect effects of education via occupational skill level and income to functional limitations and depressive symptoms between cohorts.

Results

Absolute educational inequalities in functional limitations increased for men and women in later cohorts, and in depressive symptoms only for men. Relative inequalities in functional limitations increased only for women and in depressive symptoms only for men. The indirect effect of education via income on both health outcomes was weaker in the most recent birth cohort compared to the earlier cohorts. In contrast, the indirect effect of education via occupation on functional limitations was stronger in the most recent cohort compared to the earlier cohorts. These differences were mainly due to a decreasing direct effect of education on income and an increasing direct effect of education on occupational skill level, rather than to changes in the direct effects of occupation and income on health.

Conclusions

The role of education in determining inequalities in health appears to have changed across cohorts. While education became a less important determinant of income, it became a more important determinant of occupational level. This changing role of education in producing health inequalities should be considered in research and policy.

Explaining socioeconomic inequalities in self-reported health outcomes: The mediating role of perceived life stress, financial self-reliance, psychological capital, and time perspective orientations

Objective

The main aim of the current study was to investigate what role perceived life stress, psychological capital (PsyCap), financial self-reliance and time perspective orientations play in explaining socioeconomic health inequalities, specifically self-perceived health and self-reported physical health conditions.

Methods

Individuals (total n = 600) aged 16+ years from a general Dutch population sample (LISS panel) completed an online questionnaire measuring three different SEP indicators (highest achieved educational level, personal monthly disposable income and being in paid employment), perceived life stress, PsyCap, financial self-reliance, time perspective, self-perceived health, and self-reported physical health conditions. Structural equation modelling using a cross-sectional design was used to test the mediation paths from SEP indicators to self-perceived health and self-reported physical health conditions through perceived life stress, PsyCap, financial self-reliance and time perspective orientations.

Results

Highest achieved educational level and being in paid employment showed to play a role in the social stratification within self-reported and self-perceived health outcomes, whereas this was not found for personal monthly disposable income. The association between a lower highest achieved educational level and lower self-perceived health was mediated by lower PsyCap and higher perceived life stress levels. The association between a lower highest achieved educational level and higher levels of self-reported physical health conditions was mediated by less financial self-reliance and higher perceived life stress levels. Although no mediating role was found for time perspective orientations in the association between the measured SEP indicators and health outcomes, negative time perspective orientations were associated with either self-perceived health or self-reported physical health conditions.

Conclusions

reserves (PsyCap and financial self-reliance) and perceived life stress seem to play a larger role in explaining the health gradient in achieved educational level than time perspective orientations. Prevention efforts trying to reduce the SEP-health gradient should focus on a) increasing reserves and lowering perceived life stress levels for individuals with a low achieved educational level, and b) reducing unemployment and narrowing opportunity gaps in education for people with a low SEP.

To what extent do socioeconomic inequalities in SRH reflect inequalities in burden of disease? The HELIUS study

BACKGROUND

Self-rated health (SRH), an attractive measure for health monitoring, shows persistent inequalities with regard to socioeconomic status (SES). However, knowledge on the extent to which inequalities in SRH reflect inequalities in disease burden is lacking.

METHODS

Data come from the multi-ethnic HEalthy LIfe in an Urban Setting study (Dutch, South-Asian Surinamese, African Surinamese, Ghanaian, Turkish or Moroccan origin, N = 19 379, aged 18-70). SES was defined by educational and occupational level. Disease burden was operationalized as chronic diseases, physical and mental functioning (measured with SF-12) and depressive symptoms (measured with PHQ-9). We applied logistic regression analyses and reported average marginal effects (AME).

RESULTS

Dutch origin participants with low educational or low occupational level had higher probabilities of reporting fair/poor SRH, compared to the highest levels (AME = 0.20 95% CI: 0.13;0.27; and 0.12 (0.09;0.15), respectively). Associations were attenuated after adjusting for all disease burden indicators, to AME = 0.03 (0.01;0.04) and AME = 0.02 (-0.00;0.04). In all the non-Dutch origin groups, a larger part of the inequalities remained after adjustment.

CONCLUSION

Socioeconomic inequalities in SRH are for a large part explained by higher disease burden in lower socioeconomic groups, but less so in those with non-Dutch origin. Future research should examine if our conclusions also hold for trend data on inequalities in SRH.

How health inequality affect responses to the COVID-19 pandemic in Sub-Saharan Africa

The COVID-19 outbreak has infected millions of people across the world, caused hundreds of thousands of deaths, and collapsed national economies. Recognizing the importance of handwashing in preventing the spread of COVID-19, concerns have arisen about the condition of millions of Africans who lack access to hygiene facilities and clean water services. This paper compiles evidence from the WHO-UNICEF data to show the health disparities that limit the capacity of African countries to effectively address the COVID-19 disease along with recommendations for addressing the challenge.

Work characteristics and health in older workers: Educational inequalities

To be able to extend working lives, maintaining good health in older workers is important. The aim of the present study was to identify which work characteristics are associated with physical and mental health outcomes in older workers in the Netherlands, and particularly whether there are educational differences in these associations. We used longitudinal tobit and ordered logistic regression analyses to examine the associations between physical demands, psychosocial demands, variation in tasks, autonomy, and job strain and self-rated health (SRH), functional limitations, and depressive symptoms. We included interaction terms between the work characteristics and education to examine effect modification by education. We found that high physical demands, low variation in tasks, low autonomy, and high job strain were associated with poorer physical and mental health. We found evidence for educational differences in the exposure to these work characteristics, as well as in the strengths of their associations with health, with lower educated workers being disadvantaged. The associations between physical demands (SRH: OR = 3.70 (95%CI:1.92;7.11); functional limitations: B = 1.27 (95%CI:.47;2.07)), autonomy (SRH: OR = .42(95%CI:.26;.69)), and job strain (active job; SRH: OR = .25 (95%CI:.09;.69); functional limitations: B = -1.51 (95%CI:-2.68;-.34), and health were strongest in the lower educated workers. In order to maintain good health in older workers and reduce health inequalities, it is recommended to implement workplace interventions to improve working conditions, especially among the lower educated workers.

Is quality of life impairment associated with chronic diseases dependent on educational level?

BACKGROUND

Previous research indicates that quality of life impairment as a result of chronic diseases differs between socioeconomic groups, but the pattern seems to vary between health-related quality of life (HRQOL) outcomes. We tested for a one-item and a multi-item outcome whether associations between diseases and HRQOL varied between educational levels.

METHODS

Data come from Dutch participants of HELIUS (N =4615, aged 18-70). Education was defined as low, middle or high. Myocardial infarction, angina pectoris, hypertension, diabetes, obesity and depressed mood were measured using physical examination and/or self-report. Outcomes were fair/poor self-rated health (SRH) and physical (PCS) and mental (MCS) SF-12 scores. Interaction terms and relative excess risk due to interaction (RERI) were used as measures of additive interaction.

RESULTS

SRH and PCS were worst in lower educated participants, whereas MCS was worst in middle educated participants. Out of thirty-six interactions tested, four were statistically significant, with risks of poor HRQOL being both larger and smaller in low vs. high education groups. Obesity was associated with smaller risk of fair/poor SRH in low vs. high educated [RERI=-2.49 (-4.66; -0.33)]. Depressed mood was associated with more [b=-3.34 (-6.14; -0.54)] and hypertension with less reduction in PCS [b=1.23 (0.18; 2.27)] in middle vs. high educated. Depressed mood was highly associated with MCS, but less so in middle vs. high educated [b=4.09 (0.72; 7.47)].

CONCLUSION

Despite a higher prevalence of diseases in low education groups, if measured in absolute terms, most diseases were not associated with larger impairment of HRQOL in lower vs. higher educated groups, regardless of the outcome measure used.

Cautionary tails of grip strength in health inequality studies: An analysis from the Canadian longitudinal study on aging

Self-rated health is widely used in studies of the socioeconomic gradient of health in community-based populations. Its subjectivity may lead to under- or over-estimation of a true underlying socioeconomic gradient and has increased interest in searching for alternative, objective measures of health. Grip strength has emerged as one such alternative for community-based older populations, yet no study has directly assessed the relationship between these two measures and compared their associations with socioeconomic status and health behaviours. Using 26,754 participants aged 45-85 years in the baseline data of the Canadian Longitudinal Study on Aging Comprehensive Cohort, we estimated adjusted-grip strength through indirect standardization using age, sex, height, weight, and their square terms and used ANOVA to assess the variance of adjusted-grip strength within and between each self-rated health category. We ran four separate logistic regression models, examining unhealthy tails (those reporting poor health vs. not and those at the bottom 8th percentile of adjusted-grip strength vs. above) and healthy tails (those reporting excellent health vs. not and those at the top 20th percentile of adjusted-grip strength vs. below). Stronger adjusted-grip strength correlated with better self-rated health, but only 2% of the total variance of adjusted-grip strength was explained by variance between the self-rated health categories. While self-rated health largely showed the expected socioeconomic gradients and positive relationships with health enhancing behaviours, adjusted-grip strength showed no clear, consistent associations with either socioeconomic or health behaviour variables. The results give caution about using grip strength as an objective alternative to self-rated health in studies of social inequalities in health. Empirical approaches demand careful considerations as to which dimensions of health and corresponding measures of health are most relevant to the context being studied.

Education, immigration and rising mental health inequality in Sweden

Educational and income gradients in health are well established in the literature but there is need for a better understanding of how mental health inequalities change over time, and what drives the development. We aim to study how psychiatric diagnosis and its income-related inequality have changed over time in Sweden and to make a first attempt at disentangling the development by decomposing any changes in terms of changes in two important demographic characteristics: education and migration background. We use administrative patient data to study psychiatric inpatient diagnosis in the years 1994 and 2011. The study population comprises all individuals aged 31-64 years living in Sweden. Income-related inequalities are measured by the Concentration Index (CI). We decompose changes in the probability of receiving a diagnosis and changes in income-related inequality over time to understand the role of changing demographics. Our results show that over the study period the probability of receiving a psychiatric inpatient diagnosis increased by 12.6%, while the relative and absolute income-related inequalities in diagnosis increased by 48.2% and 66.7% respectively. In 2011, more than half of psychiatric inpatients were found among the poorest fifth of the population. The decomposition results suggest that changes in education and migration background have not played a substantial role in determining these increases. Education levels increased substantially over the study period which would be expected to protect against mental ill-health. Instead, we find that diagnoses have become more concentrated amongst the lowest educated individuals and the lowest income families, groups who appear to be increasingly disadvantaged. The growing proportion of individuals with foreign background in Sweden does, in fact, predict small increases in the probability of diagnosis, while the impact on diagnosis inequality varies depending on the definition of foreign background.

Cold-related symptoms and performance degradation among Thai poultry industry workers with reference to vulnerable groups: a cross-sectional study

Background

Few studies have examined cold-related symptoms among cold workplace workers in Thailand. This study aimed to determine the prevalence of cold-related cardiorespiratory, circulatory, and general symptoms and performance degradation among Thai chicken industry workers and identify vulnerable groups.

Methods

Overall, 422 workers aged from 18 to 57 years at four chicken meat factories in Thailand were interviewed for cold-related symptoms and complaints. The results were expressed in terms of model-based adjusted prevalence and prevalence differences (PDs) in percentage points (pp) with 95% confidence intervals (CIs).

Results

In total, 76.1% of the respondents reported cold-related respiratory symptoms, 24.6% reported cardiac symptoms, 68.6% reported circulatory symptoms, and 72.1% reported general symptoms. In addition, 82.7% of the respondents reported performance degradation. Cold-related respiratory symptoms increased by PD 29.0 pp. (95% CI 23.4–34.6) from the lowest to the highest educational group, with a similar pattern observed in performance degradation. Forklift drivers and storage and manufacturing workers complained of cold-related respiratory symptoms more than office staff (PD 22.1 pp., 95% CI 12.8–31.3; 12.0 pp., 95% CI 2.4–21.6; and 17.5 pp., 95% CI 11.5–23.6, respectively); they also reported more performance degradation (PD 24.1 pp., 95% CI 17.0–31.2; 19.8 pp., 95% CI 14.1–25.6; and 14.8 pp., 95% CI 8.0–22.6, respectively). Weekly alcohol consumers reported more performance problems owing to cold (PD 18.2 pp., 95% CI 13.9–22.6) than non-consumers of alcohol. Cardiac and circulation symptoms were more common in women than men (PD 10.0 pp., 95% CI 1.1–18.9; and 8.4 pp., 95% CI 0.5–16.4, respectively). The age trend in performance issues was curved, with the highest prevalence among those aged 35–44 years, while the oldest workers (45–57 years) perceived less cold-related symptoms, particularly thirst.

Conclusions

Cold-related symptoms and performance degradation were found to be common in this industry, with vulnerable groups comprising of highly educated workers, forklift drivers, storage and manufacturing workers, weekly alcohol consumers, aging workers, and women. The results demonstrate a need for further research on the adequacy of protection provided against the cold, particularly given that global warming will increase the contrast between cold workplaces and outdoor heat.

Educational Inequalities in Self-Rated Health in Europe and South Korea

While numerous comparative works on the magnitude of health inequalities in Europe have been conducted, there is a paucity of research that encompasses non-European nations such as Asian countries. This study was conducted to compare Europe and Korea in terms of educational health inequalities, with poor self-rated health (SRH) as the outcome variable. The European Union Statistics on Income and Living Conditions and the Korea National Health and Nutrition Examination Survey in 2017 were used (31 countries). Adult men and women aged 20+ years were included (207,245 men and 238,007 women). The age-standardized, sex-specific prevalence of poor SRH by educational level was computed. The slope index of inequality (SII) and relative index of inequality (RII) were calculated. The prevalence of poor SRH was higher in Korea than in other countries for both low/middle- and highly educated individuals. Among highly educated Koreans, the proportion of less healthy women was higher than that of less healthy men. Korea’s SII was the highest for men (15.7%) and the ninth-highest for women (10.4%). In contrast, Korea’s RII was the third-lowest for men (3.27), and the lowest among women (1.98). This high-SII–low-RII mix seems to have been generated by the high level of baseline poor SRH.

Improving the health of workers with a low socioeconomic position: Intervention Mapping as a useful method for adaptation of the Participatory Approach

Background

Workers with a low socioeconomic position (SEP) have a higher risk for health problems and premature dropout from the workforce. Unfavorable working conditions and unhealthy behaviors are more prevalent among this group of workers. The Participatory Approach (PA), is an evidence-based method to identify and solve problems at the workplace related to health issues of the worker. Health problems among workers with a low SEP are usually caused by an interplay of problems in and outside the workplace. To solve health problems on multiple life domains for workers with a low SEP we aim to adapt this approach to a broader perspective.

Methods

An Intervention Mapping (IM) protocol was used to adapt the PA. First, a needs assessment was conducted combining literature with data from interviews and focus groups with workers with a low SEP, employers and occupational health professionals (OHPs). Based on the needs assessment a program goal and performance and change objectives were defined, which resulted in methods and practical strategies to solve problems on multiple life domains. Based on the results of these steps, the PA was adapted and an implementation and evaluation plan were developed.

Results

The needs assessment confirmed that an interplay of problems on multiple life domains affect work functioning and health of workers with a low SEP. Moreover, they perceived difficulties with solving problems or used passive or avoidant coping styles towards these problems. The program goal is to identify and solve problems on multiple life domains that affect healthy functioning at work. To achieve this workers need support from OHPs to solve problems. The PA protocol and materials were adapted using theoretical concepts of the Self-Determination Theory (SDT), which resulted in the Grip on Health intervention. For OHPs a training was developed on how to implement this intervention in practice. The intervention will be evaluated in a pilot implementation study among workers with a low SEP and other relevant stakeholders.

Conclusions

IM was a valuable tool for the adaptation of the PA to better support workers with a low SEP to improve their work functioning and health from a broader perspective.

Towards an equitable digital public health era: promoting equity through a health literacy perspective

Digital technologies shape the way in which individuals and health systems interact to promote health and treat illness. Their propensity to exacerbate inequalities is increasingly being highlighted as a concern for public health. Personal, contextual and technological factors all interact and determine uptake and consequent use of digital technologies for health. This article reviews evidence on the impact of digital technologies on health equity. Health literacy is presented as a lens through which to approach research and policy on access, uptake and use of digital technologies. In the short term, based on our review of published literature, we conclude that it is likely that digital technologies will increase health inequities associated with increased age, lower level of educational attainment and lower socio-economic status. Geographical inequity may increase as a result of poor infrastructure but may decrease if digital technologies can be effectively widely deployed to compensate for health workforce and health system deficiencies. Programmes to enhance health and digital literacy and monitoring of access, utilization and impact across all groups in society can help to ensure that digital technologies act to reduce rather than reproduce or exacerbate existent health inequalities.

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.

Socio-economic status, self-rated health and mental health: the mediation effect of social participation on early-late midlife and older adults

Background

Socioeconomic status (SES) is a major determinant of diverse health outcomes, among these are self-rated-health and mental health. Yet the mechanisms underlying the SES—health relation are not fully explored. Socioeconomic inequalities in health and mental health may form along several pathways. One is social participation which is linked to better self-rated-health and mental health. We examined (1) whether various social participation practices, including the usage of information and communication technology, relate to a unidimensional or multidimensional phenomenon (2) the relationship among SES, social participation, self-rated-health and mental health; (3) whether social participation and mental health mediates the association between SES and self-rated-health; (4) whether social participation and self-rated-health mediates the links between SES and mental health.

Method

Cross-sectional data for individuals aged 35 and older were taken from the Israeli Social Survey for 2016 (N = 4848). Social participation practices included connection with family and friends, self-perceived-support, self-perceived trust, volunteering, civic and political involvement, and information and communication technology usage. An exploratory factor analysis was conducted for all social participation practices. We then constructed structural Equation Modeling (SEM) to explore paths of relations among SES, social participation, self-rated-health and mental health.

Results

We found disparities in self-rated health and mental health across SES. Social participation practice, ‘frequency of meeting with friends’, mediated the links between SES-self-rated health and SES-mental health. Formal social participation practices along with internet usage mediated the SES- self-rated health link. Informal social participation practices and self-perceived trust mediated the SES-mental health link. Mental health mediated the SES- self-rated health link and self-rated health mediated the SES-mental health link.

Conclusion

The links between SES and the two health constructs were enhanced by common and distinct social participation practices. Enhancement of social participation practices among low SES individuals is recommended. Social participation should be a prominent aspect of preventive medicine practice and health promotion interventions. Policy makers are called to support such programs as an important way to promote public health.

Are self-reported health inequalities widening by income? An analysis of British pseudo birth cohorts born, 1920-1970

INTRODUCTION

The health of the British population has been shown to be worsening by self-reported health and improving by self-reported limiting illness for those born before and after 1945. Little is known about the inequality in health difference across British birth cohorts by income.

METHODS

Repeated cross-sections from the British General Household Survey, 1979-2011, are used to create pseudo birth cohorts born, 1920-1970, and their gender stratified, age-adjusted limiting illness and self-rated health (SRH) are estimated by household income tertiles. Absolute and relative differences between the poorest and richest income groups are reported.

RESULTS

Absolute inequalities in limiting illness between the richest and poorest households have doubled in women and increased by one and a half times in men for those born in 1920-1922 compared with those born in 1968-1970. Relative inequalities in limiting illness increased by a half in women and doubled in men. Absolute inequalities in SRH between the richest and poorest households increased by almost half in women and more than half in men and relative inequalities increased by 18% in women and 14% in men for those born in 1920-1922 compared with those born in 1968-1970.

CONCLUSION

Inequalities in self-reported health at the same age by household income have widened for successively later-born British cohorts.

36-year trends in educational inequalities in self-rated health among Finnish adults

Health inequalities exist across countries and populations, but little is known about their long-term trends and even less about factors shaping the trends. We examined the magnitude of absolute and relative educational inequalities in self-rated health over 36 years among Finnish adults, considering individual covariates and macro-economic fluctuations. Our data were derived from representative annual cross-sectional surveys in 1979-2014 conducted among adult men and women. Participants aged 25-64 were included and nine periods used (n = 8870-14235). Our health outcome was less-than-good self-rated health (SRH) and our socioeconomic indicator was completed years of education as a continuous variable. Educational inequalities in self-rated health were analysed using the relative index of inequality (RII) and the slope index of inequality (SII). Nine time-variant sociodemographic and health-related covariates were included in the analyses. Linear trends suggested stable or slightly curvilinear overall trends in both absolute and relative health equalities over 36 years. Among men, absolute and relative inequalities narrowed immediately after economic recession in Finland in 1993-1994. Among women, inequalities narrowed during financial crisis in 2008-2009. Adjusting for most covariates reduced the magnitude of inequalities throughout the nine periods, but affected little the temporal patterning of health inequalities. Educational inequalities in self-rated health remained during 36 years in Finland. While among men and women health inequalities narrowed during and after recessions, they widened soon back to the pre-recession level. The perseverance of the trends calls for novel and powerful measures to tackle health inequalities.

Self-rated health and smoking among physicians and general population with higher education in Estonia: results from cross-sectional studies in 2002 and 2014

Background

Poor self-rated health (SRH) and smoking have consistently been shown to be related to mortality. The aim of this study was to explore SRH and smoking among physicians and general population with higher education in Estonia in 2002 and 2014 and to analyse the association of SRH with smoking and sociodemographic factors.

Methods

This study was based on cross-sectional postal surveys among physicians and general population with higher education in Estonia n in 2002 and 2014. Calculation of age-standardized prevalence of SRH and current smoking with 95% confidence intervals (CI) was performed. Multivariate logistic regression analysis was used to measure association between SRH (at-least-good vs less-than good) and smoking status, study year, age group, ethnicity, and marital status. Fully adjusted odds ratios (OR) with 95% CI were computed.

Results

Age-standardized prevalence of at-least-good SRH was 71.3 and 80.6% among male physicians, 68.4 and 83.1% among female physicians, 45.4 and 67.4% among men with higher education, and 44.7 and 63.1% among women with higher education in 2002 and 2014, respectively. Age-standardized prevalence of current smoking was 26.0 and 15.6% among male physicians, 10.2 and 5.9% among female physicians, 38.7 and 22.2% among men with higher education, and 20.9 and 16.4% among women with higher education in 2002 and 2014, respectively. There was no significant gender difference in at-least-good SRH, but prevalence of current smoking was significantly higher among men in both study groups in 2002 and 2014. Compared to year 2002, odds to have at-least-good SRH was higher in 2014 (OR = 1.64; 95% CI 1.16-2.31 among male and OR = 2.36; 95% CI 2.02-2.75 among female physicians, OR = 1.49; 95% CI 1.07-2.07 among men and OR = 2.40; 95% CI 1.84-3.13). Odds to have at-least-good SRH was significantly higher among non-smokers (except female physicians), in the youngest age group, and among Estonians.

Conclusions

This study gave an overview of differences in SRH and smoking between two target groups with higher education in two timepoints highlighting the importance of addressing smoking cessation counselling and health promotion campaigns in the population by different subgroups in Estonia.

Patterns of long-term conditions in older age and subsequent mortality: a national study of inequalities in health

Background

Multiple long-term health conditions in older people are associated with increased mortality. The study aims to identify patterns of long-term health in a national ageing population using a census-based self-reported indicator of long-term health conditions. We assessed associations with subsequent mortality and socio-economic and demographic risk factors.

Methods

Using linked administrative data from the Northern Ireland Mortality Study, we assessed the presence of latent classes of morbidity in self-reported data on 11 long-term health conditions in a population aged 65 or more (N = 244 349). These classes were associated with demographic and socio-economic predictors using multi-nomial logistic regression. In a 3.75-year follow-up, all-cause and cause-specific mortality were regressed on morbidity patterns.

Results

Four latent classes of long-term ill-health conditions were derived, and labelled: ‘low impairment’; ‘pain/mobility’; ‘cognitive/mental’; ‘sensory impairment’. Groupings reflecting higher levels of long-term ill-health were associated with class-specific increases in all-cause and cause-specific mortality. Strongest effects were found for the ‘cognitive/mental’ group, which predicted all-cause mortality [hazard ratio (HR) = 2.96: 95% confidence interval (CI) = 2.83, 3.10) as well as some cause-specific mortality (i.e. dementia-related death: HR = 10.78: 95% CI = 9.39, 12.15). Class membership was predicted by a range of socio-demographic factors. Lower socio-economic status was associated with poorer health.

Conclusion

Results indicate that long-term ill-health clusters in specific patterns, which are both predicted by socio-demographic factors and are themselves predictive of mortality in the elderly. The syndromic nature of long-term ill-health and functioning in ageing populations has implications for healthcare planning and public health policy in older populations.