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Brownell NK, Ziaeian B, Jackson NJ, Richards AK. Trends in Income Inequities in Cardiovascular Health Among US Adults, 1988-2018. Circ Cardiovasc Qual Outcomes 2024; 17:e010111. [PMID: 38567505 PMCID: PMC11104495 DOI: 10.1161/circoutcomes.123.010111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 02/01/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Mean cardiovascular health has improved over the past several decades in the United States, but it is unclear whether the benefit is shared equitably. This study examined 30-year trends in cardiovascular health using a suite of income equity metrics to provide a comprehensive picture of cardiovascular income equity. METHODS The study evaluated data from the 1988-2018 National Health and Nutrition Examination Survey. Survey groupings were stratified by poverty-to-income ratio (PIR) category, and the mean predicted 10-year risk of a major cardiovascular event or death based on the pooled cohort equations (PCE) was calculated (10-year PCE risk). Equity metrics including the relative and absolute concentration indices and the achievement index-metrics that assess both the prevalence and the distribution of a health measure across different socioeconomic categories-were calculated. RESULTS A total of 26 633 participants aged 40 to 75 years were included (mean age, 53.0-55.5 years; women, 51.9%-53.0%). From 1988-1994 to 2015-2018, the mean 10-year PCE risk improved from 7.8% to 6.4% (P<0.05). The improvement was limited to the 2 highest income categories (10-year PCE risk for PIR 5: 7.7%-5.1%, P<0.05; PIR 3-4.99: 7.6%-6.1%, P<0.05). The 10-year PCE risk for the lowest income category (PIR <1) did not significantly change (8.1%-8.7%). In 1988-1994, the 10-year PCE risk for PIR <1 was 6% higher than PIR 5; by 2015-2018, this relative inequity increased to 70% (P<0.05). When using metrics that account for all income categories, the achievement index improved (8.0%-7.1%, P<0.05); however, the achievement index was consistently higher than the mean 10-year PCE risk, indicating the poor persistently had a greater share of adverse health. CONCLUSIONS In this serial cross-sectional survey of US adults spanning 30 years, the population's mean 10-year PCE risk improved, but the improvement was not felt equally across the income spectrum.
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Affiliation(s)
| | - Boback Ziaeian
- Division of Cardiology (B.Z.), University of California, Los Angeles
| | - Nicholas J. Jackson
- Division of General Internal Medicine and Health Services Research (N.J.J.), University of California, Los Angeles
| | - Adam K. Richards
- Department of Global Health, Milken Institute School of Public Health, The George Washington University, Washington (A.K.R.)
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Højstrup S, Thomsen JH, Prescott E. Disparities in cardiovascular disease and treatment in the Nordic countries. THE LANCET REGIONAL HEALTH. EUROPE 2023; 33:100699. [PMID: 37953994 PMCID: PMC10636266 DOI: 10.1016/j.lanepe.2023.100699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/27/2023] [Accepted: 07/10/2023] [Indexed: 11/14/2023]
Abstract
The Nordic countries, including Denmark, Finland, Iceland, Norway, and Sweden have seen a steep decline in cardiovascular mortality in recent decades. They are among the most egalitarian countries by several measures, and all have universal, publicly funded welfare systems providing healthcare for all citizens. However, despite these seemingly ideal conditions, disparities in access to cardiovascular care and outcomes persist. To address this challenge, The Lancet Region Health-Europe convened experts from a broad range of countries to summarize the current state of knowledge on cardiovascular disease disparities across Europe. This Series Paper presents the main challenges in Nordic countries based on evidence from high-quality nationwide registries. Focusing on major cardiovascular health determinants, areas in need of improvement were identified. There is a need for addressing structural causes underlying these disparities, such as poverty and discrimination, but also to improve access to healthcare in deprived neighborhoods and to address underlying social determinants of health that may mitigate disparities in cardiovascular outcomes. Overall, while the Nordic countries have made great strides in promoting egalitarianism and providing universal healthcare, there is still much work to be done to ensure equitable access to care and improved cardiovascular outcomes for all members of society.
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Affiliation(s)
- Signe Højstrup
- Department of Cardiology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Jakob Hartvig Thomsen
- Department of Cardiology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Eva Prescott
- Department of Cardiology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Copenhagen, Denmark
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Bastos LAVM, Bichara JLP, Nascimento GS, Villela PB, de Oliveira GMM. Mortality from diseases of the circulatory system in Brazil and its relationship with social determinants focusing on vulnerability: an ecological study. BMC Public Health 2022; 22:1947. [PMID: 36266678 PMCID: PMC9583513 DOI: 10.1186/s12889-022-14294-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 09/26/2022] [Indexed: 11/10/2022] Open
Abstract
Background Deaths from diseases of the circulatory system and ischemic heart diseases are declining, but slowly in developing countries, emphasizing its probable relationship with determinants of social vulnerability. Objectives To analyze the temporal progression of mortality rates of diseases of the circulatory system and ischemic heart diseases from 1980 to 2019 and the association of the rates with the Municipal Human Development Index and Social Vulnerability Index in Brazil. Methods We estimated the crude and standardized mortality rates of diseases of the circulatory system and ischemic heart diseases and analyzed the relationship between the obtained data and the Municipal Human Development Index and Social Vulnerability Index. Data on deaths and population were obtained from the DATASUS. The Municipal Human Development Index and the Social Vulnerability Index of each federative unit were extracted from the websites Atlas Brazil and Atlas of Social Vulnerability, respectively. Results The age-standardized mortality rates of diseases of the circulatory system and ischemic heart diseases showed a downward trend nationwide, which was unequal across the federative units. There was an inversely proportional relationship between the standardized mortality rates of diseases of the circulatory system and ischemic heart diseases and the Municipal Human Development Index. The downward mortality trend was observed when the indices were greater than 0.70 and 0.75, respectively. The Social Vulnerability Index was directly proportional to the standardized mortality rates of diseases of the circulatory system and ischemic heart diseases. An upward mortality trend was observed with a Social Vulnerability Index greater than 0.35. Conclusions Social determinants represented by the Municipal Human Development Index and the Social Vulnerability Index were related to mortality from diseases of the circulatory system and ischemic heart diseases across the Brazilian federative units. The units with most development and least social inequalities had the lowest mortality from these causes. The most vulnerable die the most. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-14294-3.
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Affiliation(s)
| | | | | | - Paolo B Villela
- Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Manz KM, Schwettmann L, Mansmann U, Maier W. Area Deprivation and COVID-19 Incidence and Mortality in Bavaria, Germany: A Bayesian Geographical Analysis. Front Public Health 2022; 10:927658. [PMID: 35910894 PMCID: PMC9334899 DOI: 10.3389/fpubh.2022.927658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 06/23/2022] [Indexed: 11/13/2022] Open
Abstract
Background Area deprivation has been shown to be associated with various adverse health outcomes including communicable as well as non-communicable diseases. Our objective was to assess potential associations between area deprivation and COVID-19 standardized incidence and mortality ratios in Bavaria over a period of nearly 2 years. Bavaria is the federal state with the highest infection dynamics in Germany and demographically comparable to several other European countries. Methods In this retrospective, observational ecological study, we estimated the strength of associations between area deprivation and standardized COVID-19 incidence and mortality ratios (SIR and SMR) in Bavaria, Germany. We used official SARS-CoV-2 reporting data aggregated in monthly periods between March 1, 2020 and December 31, 2021. Area deprivation was assessed using the quintiles of the 2015 version of the Bavarian Index of Multiple Deprivation (BIMD 2015) at district level, analyzing the overall index as well as its single domains. Results Deprived districts showed higher SIR and SMR than less deprived districts. Aggregated over the whole period, the SIR increased by 1.04 (95% confidence interval (95% CI): 1.01 to 1.07, p = 0.002), and the SMR by 1.11 (95% CI: 1.07 to 1.16, p < 0.001) per BIMD quintile. This represents a maximum difference of 41% between districts in the most and least deprived quintiles in the SIR and 110% in the SMR. Looking at individual months revealed clear linear association between the BIMD quintiles and the SIR and SMR in the first, second and last quarter of 2021. In the summers of 2020 and 2021, infection activity was low. Conclusions In more deprived areas in Bavaria, Germany, higher incidence and mortality ratios were observed during the COVID-19 pandemic with particularly strong associations during infection waves 3 and 4 in 2020/2021. Only high infection levels reveal the effect of risk factors and socioeconomic inequalities. There may be confounding between the highly deprived areas and border regions in the north and east of Bavaria, making the relationship between area deprivation and infection burden more complex. Vaccination appeared to balance incidence and mortality rates between the most and least deprived districts. Vaccination makes an important contribution to health equality.
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Affiliation(s)
- Kirsi Marjaana Manz
- Institute for Medical Information Processing, Biometry and Epidemiology (IBE), Ludwig-Maximilians-Universität (LMU), Munich, Germany
- *Correspondence: Kirsi Marjaana Manz
| | - Lars Schwettmann
- Helmholtz Zentrum München - German Research Center for Environmental Health (GmbH), Institute of Health Economics and Health Care Management, Neuherberg, Germany
- Department of Economics, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Ulrich Mansmann
- Institute for Medical Information Processing, Biometry and Epidemiology (IBE), Ludwig-Maximilians-Universität (LMU), Munich, Germany
- Pettenkofer School of Public Health, Ludwig-Maximilians-Universität (LMU), Munich, Germany
| | - Werner Maier
- Institute for Medical Information Processing, Biometry and Epidemiology (IBE), Ludwig-Maximilians-Universität (LMU), Munich, Germany
- Helmholtz Zentrum München - German Research Center for Environmental Health (GmbH), Institute of Health Economics and Health Care Management, Neuherberg, Germany
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Multiple Socioeconomic Circumstances and Initiation of Cardiovascular Medication among Ageing Employees. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph181910148. [PMID: 34639449 PMCID: PMC8507630 DOI: 10.3390/ijerph181910148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 08/24/2021] [Accepted: 09/22/2021] [Indexed: 12/31/2022]
Abstract
There are persisting socioeconomic differences in cardiovascular diseases, but studies on socioeconomic differences in the initiation of cardiovascular medication are scarce. This study examined the associations between multiple socioeconomic circumstances and cardiovascular medication. The Helsinki Health Study baseline survey (2000-2002) of 40-60-year-old employees was linked with cardiovascular medication data from national registers. The analyses included 5805 employees concerning lipid medication and 4872 employees concerning hypertension medication. Medication purchases were followed for 10 years. The analyses were made using logistic regression, and the odds ratios (ORs) and their 95% confidence intervals (CIs) were calculated for childhood, conventional and material socioeconomic circumstances. Low parental education showed an association with lipid medication among women only (OR 1.34, 95% CI 1.11-1.61), whereas childhood economic difficulties showed more widespread associations. Low education and occupational class were associated with an increased risk of both hypertension (education: OR 1.58, 1.32-1.89; occupational class: 1.31, 1.08-1.59) and lipid medication (education: 1.34, 1.12-1.61; occupational class: 1.38, 1.13-1.67). Rented housing (1.35, 1.18-1.54 for hypertension medication; 1.21, 1.05-1.38 for lipid medication) and current economic difficulties (1.59, 1.28-1.98 for hypertension medication; 1.35, 1.07-1.71 for lipid medication) increased the risk. Several measures of socioeconomic circumstances acting at different stages of the life course were associated with cardiovascular medication, with individuals in disadvantageous socioeconomic circumstances having elevated risks.
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Fors S, Wastesson JW, Morin L. Growing Income-Based Inequalities in Old-Age Life Expectancy in Sweden, 2006-2015. Demography 2021; 58:2117-2138. [PMID: 34528078 DOI: 10.1215/00703370-9456514] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Sweden is known for high life expectancy and economic egalitarianism, yet in recent decades it has lost ground in both respects. This study tracked income inequality in old-age life expectancy and life span variation in Sweden between 2006 and 2015, and examined whether patterns varied across levels of neighborhood deprivation. Income inequality in remaining life expectancy at ages 65, 75, and 85 increased. The gap in life expectancy at age 65 grew by more than a year between the lowest and the highest income quartiles, for both men (from 3.4 years in 2006 to 4.5 years in 2015) and women (from 2.3 to 3.4 years). This widening income gap in old-age life expectancy was driven by different rates of mortality improvement: individuals with higher incomes increased their life expectancy at a faster rate than did those with lower incomes. Women with the lowest incomes experienced no improvement in old-age life expectancy. Furthermore, life span variation increased in the lowest income quartile, while it decreased slightly among those in the highest quartile. Income was found to be a stronger determinant of old-age life expectancy than neighborhood deprivation.
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Affiliation(s)
- Stefan Fors
- Aging Research Center, Karolinska Institutet & Stockholm Universitet, Solna, Sweden.,Center for Epidemiology and Community Medicine, Region Stockholm, Stockholm, Sweden
| | - Jonas W Wastesson
- Aging Research Center, Karolinska Institutet & Stockholm Universitet, Solna, Sweden.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Lucas Morin
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Inserm CIC 1431, CHU Besançon, Besançon, France.,Inserm U1018, High-Dimensional Biostatistics for Drug Safety and Genomics, CESP, Villejuif, France
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Jimenez MP, Wellenius GA, Subramanian SV, Buka S, Eaton C, Gilman SE, Loucks EB. Longitudinal associations of neighborhood socioeconomic status with cardiovascular risk factors: A 46-year follow-up study. Soc Sci Med 2019; 241:112574. [PMID: 31593787 DOI: 10.1016/j.socscimed.2019.112574] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 09/18/2019] [Accepted: 09/24/2019] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Neighborhood characteristics are increasingly recognized as important determinants of cardiovascular disease (CVD) risk. However, longitudinal studies on the health impacts of neighborhood characteristics are rare. We sought to investigate whether neighborhood socioeconomic status (NSES) during birth, childhood and adulthood is associated with CVD risk factors in adulthood. METHODS Using longitudinal data from the New England Family Study (n = 671) with 46-years of follow-up, participants' home addresses were geocoded at birth (mean age = 1.6 months), childhood (mean age = 7.1 years), and adulthood (mean age = 44.2 years) across Massachusetts and Rhode Island in the US from 1961 to 2007. We used multilevel models to evaluate associations of NSES across the life-course with systolic blood pressure, diastolic blood pressure and body mass index (BMI) in adulthood, adjusting for age, sex, race/ethnicity, mother's race, individual SES, and parental SES. RESULTS In fully adjusted models, one standard deviation higher NSES at birth was associated with a 1.9 mmHg lower SBP (95% CI: 3.8, -0.1) and 1.3 mmHg lower DBP (95%CI: 2.6,-0.03) in adulthood; while one standard deviation of higher NSES at adulthood was associated with 0.87 kg/m2 lower BMI (95%CI: 1.7, -0.1). CONCLUSIONS We found that living in a socioeconomically disadvantaged neighborhood early in life and in adulthood was associated with blood pressure and BMI, respectively, two established risk factors for CVD. Our findings support a longitudinal association between exposure to socioeconomically disadvantaged neighborhoods in early life and CVD risk factors in adulthood.
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Affiliation(s)
- Marcia P Jimenez
- Department of Epidemiology, Brown University School of Public Health, 121 S Main St, Providence, RI 02903, USA.
| | - Gregory A Wellenius
- Department of Epidemiology, Brown University School of Public Health, 121 S Main St, Providence, RI 02903, USA
| | - S V Subramanian
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA
| | - Stephen Buka
- Department of Epidemiology, Brown University School of Public Health, 121 S Main St, Providence, RI 02903, USA
| | - Charles Eaton
- Department of Epidemiology, Brown University School of Public Health, 121 S Main St, Providence, RI 02903, USA; Department of Family Medicine, Warren Alpert Medical School of Brown University, 222 Richmond St, Providence, RI 02903, USA
| | - Stephen E Gilman
- Social and Behavioral Sciences Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA; Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Eric B Loucks
- Department of Epidemiology, Brown University School of Public Health, 121 S Main St, Providence, RI 02903, USA
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Quiel L, Moreno Velásquez I, Gómez B, Motta J, Herrera-Ballesteros V. Social determinants and cardiovascular disease mortality in Panama, 2012-2016. BMC Public Health 2019; 19:199. [PMID: 30770742 PMCID: PMC6377740 DOI: 10.1186/s12889-019-6508-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 02/04/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The aims of this study were to determine the geographic and time variation of social determinants of health (SDH) and cardiovascular disease (CVD) mortality in Panama from 2012 to 2016, and to identify which of the SDH has the strongest correlation with a socioeconomic index (SEI). METHODS We conducted an ecological study obtaining mortality from the National Mortality Register and socioeconomic variables derived from the National Household Survey (NHS). The International Classification of Diseases 10th revision codes I20-I25 and I60-I69 were used for ischemic heart disease (IHD) and stroke, respectively. Standardized age-adjusted mortality rates were calculated by direct method. Mortality rates and socioeconomic variables were evaluated together in a panel data model. A SEI was developed from factorial analysis by principal components with a polychoric correlation matrix. Provinces and regions were categorized in tertiles according to median value of the SEI score. RESULTS The NHS evaluated an average of 15,919 households per year. The mean of age throughout the study period was 41 years. The average monthly income increased, from US$ (SD) 331.94 (5.38) in 2012, to 406.24 (5.81) in 2016, whereas the social security health coverage remained in a range of 57-58%. The mean number of school years was twelve. Significant geographical and temporal variations in social determinants and mortality rates were observed throughout the country. Colon, categorized in the middle tertile according to the SEI, presented higher IHD mortality rates. Darién (in the lowest SEI tertile) Colón and Herrera had higher stroke mortality rates. The SEI categorized indigenous territories in the lowest tertile. Total years of education was the strongest correlated variable with the SEI, when we excluded the population living in indigenous territories. However, when this population was included, social security coverage had the strongest correlation with the SEI. CONCLUSION We observed geographical and temporal disparities in SDH and CVD mortality rates. Further epidemiological studies are warranted in the provinces of Colón, Darien, Herrera and Los Santos to explore in-depth the higher CVD mortality rates observed in these provinces.
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Affiliation(s)
- Luis Quiel
- Gorgas Memorial Institute for Health Studies, Panama City, Panama
| | | | - Beatriz Gómez
- Gorgas Memorial Institute for Health Studies, Panama City, Panama
| | - Jorge Motta
- Gorgas Memorial Institute for Health Studies, Panama City, Panama
- National Secretariat for Science and Technology, Panama City, Panama
| | - Víctor Herrera-Ballesteros
- Gorgas Memorial Institute for Health Studies, Panama City, Panama
- Department of Research and Health Technology Assessment,, Gorgas Memorial Institute for Health Studies, Panama City, Panama
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