Pathways between socioeconomic determinants of health

Socioeconomic Determinants and Health Outcomes of Financial Resilience Patterns: A Latent Profile Analysis

BACKGROUND AND OBJECTIVES

Financial resilience describes an actionable financial capability to cope with emergencies and adversities. However, little is known about whether financial resilience patterns impact holistic health outcomes.

METHODS

This study conducted a 3-step latent profile analysis using an urban community sample (n = 3710) from a nationally representative database in China. A multinomial logistic regression model and multiple linear regression models were estimated to examine the proposed argument guided by social determinants of health and resilience theory.

RESULTS

Three latent subgroups were identified to differentiate population heterogeneity with high, moderate, and low financial resilience. Younger generations with lower employment participation, education, income, and assets were significantly less likely to be in moderate and high financial resilience subgroups. After controlling demographics and conventional socioeconomic covariates, financial resilience patterns were significantly negatively associated with mental illness, while positively associated with physical health, subjective happiness, and life satisfaction.

CONCLUSION

Financial resilience could be a strength-based and actionable socioeconomic determinant of health. Research and practical implications are provided for addressing health inequalities. A new target in community health and social welfare is to enhance financial resilience among marginalized populations through family asset-building, financial inclusion policy, financial literacy education, and social capital investment.

Risk of Severe Early Childhood Caries over Time in Low-Income Preschoolers

INTRODUCTION

Early childhood caries (ECC), and the progression to severe ECC (S-ECC), is a serious oral health issue, leading to acute pain, sepsis, tooth loss, and compromised quality of life. Although the association between sociodemographic factors and ECC has been widely discussed, it remains unclear whether the same association exists between inequality and S-ECC.

OBJECTIVES

To investigate the impact of low income on the oral health of preschool children and explore any additional risk factors for developing ECC and S-ECC during follow-up.

METHODS

The study used Taipei Child Development Screening Program data from 2014 to 2019. It included children aged 3 to 5 y who had more than 2 oral exams and completed baseline oral health questionnaires. Low-income children were matched 1:4 with controls by age and gender. Evaluation of ECC and S-ECC used the dmft index during follow-up exams. Generalized estimating equations (GEEs) assessed the impact of household income on ECC and S-ECC risk over time.

RESULTS

Of the 895 participants, 179 were from low-income households. We revealed a significantly higher risk of developing S-ECC (adjusted odds ratio [aOR] 1.99; 95% confidence interval [CI] 1.25-3.17) in children from low-income households, with no significantly increased of risk of developing ECC. Children who consumed sugary beverages >4 times per week showed elevated risks of developing both ECC (aOR 1.77; 95% CI 1.07-2.94) and S-ECC (aOR 1.89; 95% CI 1.13-3.17). Protective factors included children with mothers with a college education (S-ECC: aOR 0.50; 95% CI 0.32-0.79).

CONCLUSION

Children from low-income households have a significant risk of developing S-ECC compared with children from non-low-income households during follow-up. Factors contributing to this risk include lower maternal education, poor maternal oral health, and increased consumption of sugar-sweetened beverages. Policymakers should develop health measures to reduce the prevalence of ECC and S-ECC in children from low-income households whose mothers have lower educational levels and poor oral health.Knowledge Transfer Statement:The results of this study highlight the significant S-ECC risk among preschool children from low-income households in Taipei, with other risk factors including higher consumption of sugar-sweetened beverages, lower maternal education, and poor maternal oral health. Policymakers can use our findings to develop targeted policy and behavioral interventions to reduce S-ECC in vulnerable populations.

Income and work loss in patients with Addison's disease: a nationwide population-based study

OBJECTIVE

Autoimmune Addison's disease (AAD) is associated with reduced health-related quality of life and possibly reduced employability. The aim of this study was to assess differences in income and work loss between patients with AAD and matched comparators.

DESIGN

Nationwide, cross-sectional register-based study.

METHODS

By linking the Swedish Addison Register and national health registers, we identified working age (18-64 years) individuals with AAD and general population comparators (matched 1:5 by sex, age, and county of residence). We assessed differences in taxable earnings and disposable income through quantile regression and differences in work loss through linear regression during 2019.

RESULTS

We identified 1140 cases with AAD and 5700 comparators (mean age 46.1 years, 48.4% men). Type 1 diabetes was prevalent in 15.7% and 1.1%, respectively. Work loss was higher in AAD; adjusted mean difference 14.4 days; 95% CI, 8.6-20. The adjusted median differences in taxable earnings and disposable income were non-significant overall at -617 (95% CI; -2317 to 1083) and -405 (95% CI; -1417 to 607) €. However, significantly lower taxable earnings and disposable income were found among patients with short education: -5303 (95% CI; -9603 to -992) and -3754 (95% CI; -6486 to -1022) €, or concomitant type 1 diabetes: -5808 (95% CI; -9937 to -1690) and -3349 (95% CI; -6203 to -506) €.

CONCLUSION

Patients with AAD had more work loss, yet overall similar taxable earnings and disposable incomes versus comparators. Patients with AAD with shorter education or type 1 diabetes were most socioeconomically vulnerable.

Education as a social determinant of the health of international migrants and locals in Chile between 2013 and 2022

Background

Education is a recognised social determinant of health and interacts with other determinants including employment and income. International migration may disrupt these interactions. Education in Chile reflects wider socioeconomic inequalities and in the last decade, it has welcomed an increasing number of migrants.

Objective

To analyse education as a social determinant of health among international migrants and locals between 2013 and 2022.

Methods

Observational cross-sectional study based on five versions of the CASEN survey. Education, employment, and income were analysed in relation to healthcare needs for both populations and logistic regression models were estimated for each year. For 2022, the interactions between education and employment were explored in relation to healthcare needs.

Results

International migrants showed a higher education level and employment rate than Chileans, and a smaller proportion reported healthcare needs. After adjusting for demographic and socioeconomic factors, locals aged 19-25 and 26-59 were more likely to report healthcare needs compared to international migrants across multiple years. The effects of education, employment, and income on healthcare needs among locals and international migrants showed fluctuating ORs without marked trends. In 2022, significant differences in healthcare needs were observed among migrants and locals based on interactions between education and employment, with non-overlapping confidence intervals particularly among unemployed, less-educated youth, middle-aged migrants with incomplete basic education, and older individuals.

Conclusions

This study provides an overview of education as a social determinant of health among international migrants and locals for the last decade and call for targeted in-depth analyses on the topic.

Each Indicator of Socioeconomic Status (Education, Occupation, Income, and Household Size) Is Differently Associated with Children's Diets: Results from a Cross-Sectional CroCOSI Study

Background: There has yet to be an agreement on which specific socioeconomic status (SES) indicator most effectively reflects disparities in children's diets. However, children from lower SES backgrounds are particularly vulnerable, as research in other countries indicates that their diets contain fewer fruits and vegetables and more sweetened beverages. This paper aims to evaluate the associations between dietary habits and various SES indicators (education, occupation, income, and household size) among a representative sample of children in Croatia aged 7-10. Methods: Parents of children were asked to complete a questionnaire that contained indicators of their children's dietary habits and socioeconomic status (n = 5608). Associations between SES and children's dietary habits were assessed using logistic regression models. Results: The mother and father's educational attainment were strongly positively associated with breakfast consumption. Children of parents with a lower educational level consumed sweetened beverages, sweet snacks, and fast food slightly more often than children in families with a higher educational background. The mother's education was inversely associated with vegetable and cereal consumption, while the father's education was inversely associated with fruit and bakery product consumption. Meanwhile, household income per unit had a significant influence on the consumption of soft drinks and bakery products. Household size had a significant influence solely on sweet snack consumption. Conclusions: Each SES indicator showed an independent association with at least one particular dietary habit, except for the parent's employment status.

Joint trajectories of physical activity, health, and income before and after statutory retirement: A 22-year follow-up

BACKGROUND

Health behaviors, health, and income change during aging. However, no previous studies have examined, how they develop together over the transition to statutory retirement. We aimed to examine their joint development and to identify the determinants of any distinct trajectories.

METHODS

We studied former employees of the City of Helsinki, Finland, who transitioned to full statutory retirement between 2000 and 2022 (n = 5209, 80% women). We examined five repeated questionnaire surveys to identify any joint developmental patterns in the key indicators of healthy aging and well-being-leisure-time physical activity, health measured by general health perceptions, and household income, over a follow-up of 22 years. We used joint group-based trajectory analysis to identify latent developmental groups. The social and health-related determinants of trajectory group membership are reported as average marginal effects.

RESULTS

We found four distinct joint trajectory groups. Group 1 (22.6%) had consistently poor general health perceptions, less physical activity than the recommended amount, and low income. In Group 2 (34.2%), general health perceptions were first good but then declined, and income was low but slightly increasing. Group 3 (12.3%) had good general health perceptions, a very high level of physical activity, but fluctuating income. In Group 4 (30.9%), general health perceptions were first good but then declined, physical activity was at the recommended level, and income was sharply increasing. People with obesity had a 22 percentage-point (21-24) higher predicted probability of belonging to Group 1 than people with normal weight. They were also more likely to report low education and more physician-diagnosed chronic diseases and mental disorders.

CONCLUSIONS

We identified distinct trajectories in physical activity, general health perceptions, and income over a follow-up of over 20 years. The majority of those who had transitioned to statutory retirement had good general health perceptions but varying levels of physical activity and income. As not all those with a low income had a low level of physical activity or poor general health perceptions, public health interventions should target distinct groups with the most adverse risk factor profiles, to narrow health inequalities during aging.

The inclusion and consideration of cultural differences and health inequalities in physical activity behaviour in the UK - the impact of guidelines and initiatives

Despite widespread attempts from governments and leading health organisations worldwide to promote equity in healthy living medicine, the evidence suggests that attempts to curb worsening public health have been almost entirely ineffective. Despite significant advancements in knowledge, medicine, and technology, as well as the promotion of guidelines and the implementation of numerous global initiatives aimed at addressing health disparities and mitigating the progression of non-communicable diseases (NCDs) worldwide, substantial work remains to be undertaken particularly in addressing inequalities in physical activity. Achieving equitable access to health resources and parity in health outcomes remains a critical and unresolved challenge. Whilst it is recognized that the public health paradigm is broad and complex, with many intersecting and interacting parts, the actions and considerations required to address the urgent and escalating scale of the problem appear at a crossroads of now or never. Throughout this narrative review, we describe the effectiveness of landmark physical activity-related guidelines, policies and national interventions that have been implemented since the turn of the century to address physical activity behaviour in the context of health inequalities.

Unequal weathering: How immigrants' health advantage vanishes over the life-course

The weathering hypothesis implies that there is an interaction between age and race or ethnicity that results in marginalized groups experiencing a more rapid decline in health than the dominant groups. This hypothesis has been tested mostly focusing on racial and ethnic health inequalities, while less is known about weathering by immigration background. This paper aims at contributing to this strand of research by addressing four research questions: is the health of immigrants declining at a faster pace over the life-course, compared to non-immigrants? Do higher levels of education protect immigrants from accelerated ageing compared to non-immigrants? How do income and marital status affect the health trajectories of immigrants and non-immigrants? How do these patterns vary by sex? We use longitudinal survey data to estimate healthy ageing trajectories of immigrants and non-immigrants over the life-course, in the German context. We examine the roles of education, income, and marital status, separately for men and women. We find that immigrants, and especially immigrant women, have a faster health decline than non-immigrants; that high education is linked to higher levels of health, but does not protect immigrants from ageing in poorer health compared to non-immigrants; and that health disparities between immigrants and non-immigrants persist over the life-course net of the socio-economic controls, which appear to be secondary to other unobserved determinants.

Exploring health outcome disparities in African regional economics communities: a multilevel linear mixed-effect analysis

BACKGROUND

In African Regional Economic Communities (RECs), notable and enduring disparities exist in health outcomes. This study investigates the impact of macro-level characteristics of countries on health outcomes disparities within the African Regional Economic groupings. The study used panel data from the World Bank Development Indicators (WDI) and the Worldwide Governance Indicators (WGI), spanning 37 African countries, grouped into eight RECs between 2000 and 2019. We employed infant and under-five mortality rates and life expectancy at birth as indicators of health outcomes.

METHOD

The study used a multilevel linear (ML) mixed-effect approach to examine the influence of country-level factors on health outcome disparities within the eight African RECs recognized by the African Union.

RESULTS

The findings show that higher unemployment rates and HIV incidence exacerbate these disparities, while a growing elderly population and improved access to basic drinking water can mitigate them. Increased internet usage correlates with higher within-regional inequalities in child mortality rates but reduces disparities in life expectant at birth. Urbanization trends contribute to lower-intra-regional inequality in infant mortality rates and life expectancy at birth. Higher domestic government health expenditure as a share of general government spending is linked to reduced disparities in under-five and infant mortality rates. Still, it increases inequalities in life expectancy at birth within the regional groupings. Moreover, a higher proportion of the population below 15 years old and trade gains positively influence regional disparities in life expectancy. Conversely, DTP immunization coverage among children aged 12-23 months is associated with higher within-regional inequality in infant mortality rates.

CONCLUSIONS

Polices aimed at reducing unemployment rates and HIV incidence should be prioritized. In addition, governments should invest in elderly care programs and infrastructure development for water supply. Efforts to promote internet access should be complemented by interventions to enhance child health and healthcare accessibility. Encouraging urban planning policies that prioritize developing healthcare infrastructure and facilitating healthcare access in urban areas is crucial. Furthermore, Governments should increase their health expenditure allocation in general government spending. Promoting strategies to enhance healthcare access and quality for specific demographics, alongside leveraging trade gains to invest in healthcare infrastructure and services, is imperative. Targeted interventions ensuring equitable access to immunization services should also be emphasized.

Self-rated health status and associated factors in Ilam, west of Iran: results of a population-based cross-sectional study

Background

Self-rated health (SRH) is a single-item subjective indicator that asks individuals to assess their overall health and acts as a good indicator to reveal general health status. This study aimed to determine the SRH status and determining factors.

Methods

This was a population-based cross sectional study conducted in Ilam city (West of Iran) in 2023. A total of 1,370 people were invited to participate in the study using multi-stage stratified cluster random sampling method. Demographic and SRH status data were collected by face-to-face interview. SRH was indicated by a single question in five scales of very good, good, fair, poor and very poor. Multiple ordinal logistic regression was used for data analysis.

Results

The 59.38% (95% CI: 56.76 to 62) participants reported a good SRH status. By ordinal multiple logistic regression, odds ratio (OR) and 95% confidence interval (CI) was calculated and based on that, female gender [OR: 1.68 (1.29 to 2.20)], not having insurance coverage [OR: 1.35; (1.01 to 1.80)], history of job loss [OR: 1.72; (1.28 to 2.31)], hopelessness for the future [OR: 5.07; (3.96 to 6.49)], and having underlying diseases [OR: 2.95; (2.25 to 3.88)], were positively associated with poor SRH status. The Kurd race [OR: 0.45; (0.25 to 0.78)], higher economic status [OR: 0.72; (0.54 to 0.96)] and use of health care service [OR: 0.68; (0.53 to 0.88)] were negatively associated with poor SRH status. The most effective variables for poor SRH status were hopelessness about the future and suffering from underlying diseases.

Conclusion

It is important to devise corrective measures and effective public health policies to address causes and factors associated with poor SRH. It is also necessary for local health officials to allocate financial resources and introduce other kinds of supportive initiatives to provide targeted support for those who are struggling with poverty and suffering chronic diseases.

Changes in socioeconomic differences in fruit and vegetable consumption among statutorily retiring women: A longitudinal cohort study

OBJECTIVES

Socioeconomic differences in fruit and vegetable (F&V) consumption are recognized, but little is known about how these differences develop when moving from mid-life to older adulthood. We investigated the longitudinal changes in socioeconomic differences in F&V consumption in an ageing Finnish cohort, using occupational class as a measure of socioeconomic position. Additionally, we examined whether socioeconomic differences in F&V consumption changed over retirement transition.

DESIGN

An observational longitudinal cohort study with a 15-17-year follow-up.

SETTING AND PARTICIPANTS

The survey data used in this study were collected in four phases: 2000-02, 2007, 2012 and 2017. We included 2719 women who were 40-60-year-old in Phase 1. All participants transitioned to statutory retirement during the follow-up.

MEASUREMENTS

F&V consumption was measured in each phase as a part of a food frequency questionnaire (FFQ) and determined by the number of F&V consumption times per 4 weeks. We used linear mixed modeling for the analyses, and used age, marital status, education, income and BMI as covariates.

RESULTS

We found marked differences between occupational classes in F&V consumption. Semi-professionals used F&V most often and manual workers least often. In Phase 1, semi-professionals had 14.5 consumption times more per 4 weeks than manual workers, which is equivalent to ca. 0.5 daily consumption times. Differences between occupational classes showed a transient decrease in the beginning of the follow-up, followed by an increasing trend towards the last study phase. However, these changes were modest and overall differences between occupational classes changed only little over the follow-up period. Retirement did not markedly contribute to occupational class differences in F&V consumption.

CONCLUSIONS

Our findings suggest that the socioeconomic differences in F&V consumption seen in mid-life persist in older adulthood and over retirement transition. The results imply that means to reduce socioeconomic differences in F&V use should be actively sought to support healthy ageing and reduce socioeconomic health differences in ageing populations. Workplace could be a fruitful ground for targeting these interventions.

Development of a territory-wide household-based composite index for measuring relative distribution of households by economic status in individual small areas throughout Hong Kong

BACKGROUND

Many countries have developed their country/nation-wide multidimensional area-based index on deprivation or socioeconomic status for resource allocation, service planning and research. However, whether each geographical unit proxied by a single index is sufficiently small to contain a relatively homogeneous population remains questionable. Globally, this is the first study that presents the distribution of domestic households by the territory-wide economic status index decile groups within each of the 2,252 small subunit groups (SSUGs) throughout Hong Kong, with a median study population of 1,300 and a median area of 42,400 m2.

METHODS

The index development involved 248,000 anonymized sampled household-based data collected from the population census, representing 2·66 million domestic households and 6·93 million population in mid-2021. Our composite index comprises seven variables under income-/wealth-related and housing-related domains with weights determined using the analytic hierarchy process. After ranking all households from the most to the least well-off according to the numeric/ordinal value of each variable and then calculating their weighted rank scores, they were segregated into ten deciles from D1 (top 10% most well-off) to D10 (bottom 10%). Their relative distribution was summarized in a three-dimensional ternary plot to distinguish patterns across the 2,252 SSUGs within the 18 administrative districts.

RESULTS

In Hong Kong, of the 2,252 SSUGs, only one-quarter contain a homogeneous composition of households with similar economic status, while the other three-quarters are heterogeneous to varying extents. Of the 18 administrative districts, only two are concentrated with more homogeneously well-off SSUGs.

CONCLUSIONS

Small-sized geographical units may contain a heterogeneous composition of households with diverse economic statuses, underlying the need for more precise information to quantify their relative distribution. Results of this study are disseminated via an online interactive map dashboard ( https://experience.arcgis.com/experience/‌b4c7643feb9043eb94b3add386c4b71c /) which can serve as a versatile planning tool capable of performing analysis at different varying geographic scales for community-based resource prioritization, service planning and research across different domains.

Social Determinants and Consequences of Pain: Toward Multilevel, Intersectional, and Life Course Perspectives

Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain remain rarely addressed in the context of pain prevention and management. In this review, we aim to 1) examine the broad scope of social determinants and consequences of pain and their interactions across multiple levels of organization, and 2) provide a framework synthesizing existing concepts and potential areas for future work on social aspects of pain, drawing upon socioecological, intersectional, and life course approaches. Integrating interdisciplinary theory and evidence, we outline pathways through which multilevel social factors and pain may affect each other over time. We also provide a brief summary of intrapersonal aspects of pain, which are thought to operate at the interface between individuals and the social context. Progressing from micro- to macrolevel factors, we illustrate how social determinants of pain can directly or indirectly contribute to pain experiences, expression, risk, prognosis, and impact across populations. We consider 1) at the interpersonal level, the roles of social comparison, social relatedness, social support, social exclusion, empathy, and interpersonal conflict; 2) at the group or community level, the roles of intimacy groups, task groups, social categories, and loose associations; and 3) at the societal level, the roles of political, economic, and cultural systems, as well as their policies and practices. We present examples of multilevel consequences of pain across these levels and discuss opportunities to reduce the burden and inequities of pain by expanding multilevel social approaches in pain research and practice. PERSPECTIVE: Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain are often unclearly defined, hindering their use in pain prevention, management, and research. We summarize the scope of social aspects of pain and provide a framework synthesizing existing concepts and potential areas for future work.

Does social need fulfillment moderate the association between socioeconomic status and health risk behaviours during pregnancy?

Socioeconomic differences in health risk behaviours during pregnancy may be influenced by social relations. In this study, we aimed to investigate if social need fulfillment moderates the association between socioeconomic status (SES) and health risk behaviours (smoking and/or alcohol consumption) during pregnancy. We used baseline data from the Lifelines Cohort Study merged with data from the Lifelines Reproductive Origin of Adult Health and Disease (ROAHD) cohort. Education level was used to determine SES, categorized into low, middle, and high, with middle SES as the reference category. Social need fulfillment was taken as indicator for social relations and was measured with the validated Social Production Function Instrument for the Level of Well-being scale. The dependent variable was smoking and/or alcohol consumption during pregnancy. Univariable and multivariable logistic regression analysis was conducted to assess the association of SES and social need fulfillment with health risk behaviours and to test for effect modification. We included 1107 pregnant women. The results showed that women with a high SES had statistically significantly lower odds of health risk behaviours during pregnancy. The interaction effect between SES and social need fulfillment on health risk behaviours was not statistically significant, indicating that no moderation effect is present. The results indicate that social need fulfillment does not modify the effect of SES on health risk behaviours during pregnancy. However, in literature, social relations are identified as an important influence on health risk behaviours. More research is needed to identify which measure of social relations is the most relevant regarding the association with health risk behaviours.

A Cross-Sectional Study Investigating Associations between Personality Traits, Glycemic Control, and BMI in Persons with Diabetes: Lolland-Falster Health Study, Denmark

There is a growing focus on person-centered care, emphasizing the importance of respecting inter-individual differences and implementing individualized treatment initiatives. Prior research has established an association between personality traits, body mass index, and health-related behaviors. The aim of this study was to explore the potential of personality trait assessments in identifying individuals at risk of glycemic dysregulation and increasing BMI. This cross-sectional study used a dataset comprising 140 participants with diabetes who completed the Big Five personality trait questionnaire from the Lolland-Falster Health Study. Logistic regression was used to investigate associations between personality traits, glycemic control, and BMI ≥ 25. No significant associations between personality traits and glycemic control were found. There was a significant association between agreeableness and lower odds of BMI ≥ 25 in the unadjusted analysis (OR 0.54 (0.34-0.86)), which persisted after adjusting for sex, age, and education (OR 0.54 (0.33-0.89)). No significant association between glycemic control and personality traits was observed in this small sample study. However, higher levels of agreeableness were associated with a lower likelihood of having a BMI of ≥25. This preliminary study suggests that integrating personality assessments could help identify individuals at risk of increasing BMI. These findings highlight the potential of using personality traits to guide targeted interventions, offering a direction for future research.

Examining geographical inequalities for malaria outcomes and spending on malaria in 40 malaria-endemic countries, 2010-2020

BACKGROUND

While substantial gains have been made in the fight against malaria over the past 20 years, malaria morbidity and mortality are marked by inequality. The equitable elimination of malaria within countries will be determined in part by greater spending on malaria interventions, and how those investments are allocated. This study aims to identify potential drivers of malaria outcome inequality and to demonstrate how spending through different mechanisms might lead to greater health equity.

METHODS

Using the Gini index, subnational estimates of malaria incidence and mortality rates from 2010 to 2020 were used to quantify the degree of inequality in malaria burden within countries with incidence rates above 5000 cases per 100,000 people in 2020. Estimates of Gini indices represent within-country distributions of disease burden, with high values corresponding to inequitable distributions of malaria burden within a country. Time series analyses were used to quantify associations of malaria inequality with malaria spending, controlling for country socioeconomic and population characteristics.

RESULTS

Between 2010 and 2020, varying levels of inequality in malaria burden within malaria-endemic countries was found. In 2020, values of the Gini index ranged from 0.06 to 0.73 for incidence, 0.07 to 0.73 for mortality, and 0.00 to 0.36 for case fatality. Greater total malaria spending, spending on health systems strengthening for malaria, healthcare access and quality, and national malaria incidence were associated with reductions in malaria outcomes inequality within countries. In addition, government expenditure on malaria, aggregated government and donor spending on treatment, and maternal educational attainment were also associated with changes in malaria outcome inequality among countries with the greatest malaria burden.

CONCLUSIONS

The findings from this study suggest that prioritizing health systems strengthening in malaria spending and malaria spending in general especially from governments will help to reduce inequality of the malaria burden within countries. Given heterogeneity in outcomes in countries currently fighting to control malaria, and the challenges in increasing both domestic and international funding allocated to control and eliminate malaria, the efficient targeting of limited resources is critical to attain global malaria eradication goals.

Association between the health vulnerability of family members and concern about the contagion of COVID-19 in Peruvian residents after the pandemic

Background

The COVID-19 pandemic has created additional challenges for family health. Worry, fear, and anxiety associated with this disease can affect the perception of family health. The study's objective was to analyze the factors associated with health vulnerability of family members in the Peruvian population after pandemic.

Methods

Observational, cross-sectional, and analytical study. Sampling was nonprobabilistic. The sample consisted of 519 residents who met the following inclusion criteria: Peruvian resident, of both genders, over 18 years of age, who lives with their family, and who agrees to participate in the study. For data collection, the "SALUFAM" and "PRE-COVID-19" scales were used, which measure the health vulnerability of family members and concern about the contagion of COVID-19, respectively. Data collection was done between January and March, 2023.

Results

Living in the Coast region increases by 3.299 times (95% CI = 1.55-9.28; p = 0.003) the probability of lower family health vulnerability compared to residents from the Jungle region. In the same way, having a low concern about the contagion of COVID-19 increases 2.77 times (95% CI = 1.02-7.53; p = 0.044) the probability of less vulnerability to family health, unlike participants who are highly concerned about the contagion of COVID-19.

Conclusions

It should be necessary to design prevention and family health promotion strategies according to the geographical region; it is also essential to provide education on the risks and the importance of prevention measures for COVID-19, regardless of their initial level of concern.

Occupational stressors and mental illness in healthcare work: An intersection between gender, race, and class

BACKGROUND

Previous studies have supported the relevance of using broad and complex approaches, including multiple explanatory categories, to analyze mental disorders in the working population. This study aimed to assess the direct and indirect effects of gender, race, social class, and occupational stressors on mental health.

METHODS

A cross-sectional study used a random sample of 3343 health workers. The effort-reward imbalance (ERI) scale measured occupational stressors. The World Health Organization Self-Reporting Questionnaire (SRQ-20) evaluated common mental disorders (CMDs) as outcomes. The role of gender, race/color, and class determinants (level of schooling and income) in the relationship between occupational stressors and CMD was assessed. Structural equation modeling was used to determine associations and effects.

RESULTS

Occupational stressors were directly associated with CMD and mediated the relationship between income and CMD. Gender was directly associated with occupational stressors, income, and domestic overload. Race was associated with education and with CMD through indirect paths mediated by class indicators. Class indicators contributed to increasing exposure to occupational stressors and the occurrence of CMD.

CONCLUSION

The results highlight the relevance of gender, race/color, and class in understanding the unequal distribution of work stressors and mental illness in health workers.

Validity of self-reported educational level in the Tromsø Study

BACKGROUND

Self-reported data on educational level have been collected for decades in the Tromsø Study, but their validity has yet to be established.

AIM

To investigate the completeness and correctness of self-reported educational level in the Tromsø Study, using data from Statistics Norway. In addition, we explored the consequence of using these two data sources on educational trends in cardiometabolic diseases.

METHODS

We compared self-reported and Statistics Norway-recorded educational level (primary, upper secondary, college/university <4 years, and college/university ⩾4 years) among 20,615 participants in the seventh survey of the Tromsø Study (Tromsø7, 2015-2016). Sensitivity, positive predictive value and weighted kappa were used to measure the validity of self-reported educational level in three age groups (40-52, 53-62, 63-99 years). Multivariable logistic regression was used to compare educational trends in cardiometabolic diseases between self-reported and Statistics Norway-recorded educational level.

RESULTS

Sensitivity of self-reported educational level was highest among those with a college/university education of 4 years or more (⩾97% in all age groups and both sexes). Sensitivity for primary educational level ranged from 67% to 92% (all age groups and both sexes). The lowest positive predictive value was observed among women with a college/university education of 4 years or more (29-46%). Weighted kappa was substantial (0.52-0.59) among men and moderate to substantial (0.41-0.51) among women. Educational trends in the risk of cardiometabolic diseases were less pronounced when self-reported educational level was used.

CONCLUSIONS

Self-reported educational level in Tromsø7 is adequately complete and correct. Self-reported data may produce weaker associations between educational level and cardiometabolic diseases than registry-based data.

Factors affecting unmet medical needs of patients with diabetes: A population-based study

AIMS

The purpose of this study was to identify unmet medical needs and related factors in patients with diabetes.

DESIGN

A cross-sectional study.

METHODS

Participants included 2269 diabetes patients aged >19 years by using data from the National Health and Nutrition Examination Surveys. A complex sample design multiple logistic regression analysis was performed.

RESULTS

The study found that 8.7% of diabetes patients experienced unmet medical needs, and it was found to be higher for those who thought their self-assessed health status was unhealthy and often felt stressed in their daily life. Gender and education level had a moderating effect on income level on unmet medical needs experience.

CONCLUSION

These findings have important implications for nursing practice in the management of diabetes. Nurses can develop targeted interventions that address the specific needs of patients who are at risk for unmet medical needs, particularly those from low-income backgrounds. By considering the factors that contribute to unmet medical needs and the moderating effect of income level, nurses can improve patient outcomes and reduce the burden of diabetes.

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.

A holistic model of health inequalities for health policy and state administration: a case study in the regions of the Czech Republic

BACKGROUND

Health inequities exist within and between societies at different hierarchical levels. Despite overall improvements in health status in European Union countries, disparities persist among socially, economically, and societally disadvantaged individuals. This study aims to develop a holistic model of health determinants, examining the complex relationship between various determinants of health inequalities and their association with health condition.

METHODS

Health inequalities and conditions were assessed at the territorial level of Local Administrative Units (LAU1) in the Czech Republic. A dataset of 57 indicators was created, categorized into seven determinants of health and one health condition category. The necessary data were obtained from publicly available databases. Comparisons were made between 2001-2003 and 2016-2019. Various methods were employed, including composite indicator creation, correlation analysis, the Wilcoxon test, aggregate index calculation, cluster analysis, and data visualization using the LISA method.

RESULTS

The correlation matrix revealed strong relationships between health inequality categories in both periods. The most significant associations were observed between Economic status and social protection and Education in the first period. However, dependencies weakened in the later period, approaching values of approximately 0.50. The Wilcoxon test confirmed variations in determinant values over time, except for three specific determinants. Data visualization identified persistently adverse or worsening health inequalities in specific LAU1, focusing on categories such as Economic status and social protection, Education, Demographic situation, Environmental status, Individual living status, and Road safety and crime. The health condition indices showed no significant change over time, while the aggregate index of health inequalities improved with widened differences.

CONCLUSION

Spatial inequalities in health persist in the Czech Republic, influenced by economic, social, demographic, and environmental factors, as well as local healthcare accessibility. Both inner and outer peripheries exhibit poor health outcomes, challenging the assumption that urban areas fare better. The combination of poverty and vulnerabilities exacerbates these inequalities. Despite the low rates of social exclusion and poverty, regional health inequalities persist in the long term. Effectively addressing health inequalities requires interdisciplinary collaboration and evidence-based policy interventions. Efforts should focus on creating supportive social and physical environments, strengthening the healthcare system, and fostering cooperation with non-medical disciplines.

Built and social indices for hazards in Children's environments

Leveraging the capabilities of the Historical Spatial Data Infrastructure (HSDI) and composite indices we explore the importance of children's built and social environments on health. We apply contemporary GIS methods to a set of 2000 historical school records contextualized within an existing HSDI to establish seven variables measuring the relative quality of each child's built and social environments. We then combined these variables to create a composite index that assesses acute (short-term) health risks generated by their environments. Our results show that higher acute index values significantly correlated with higher presence of disease in the home. Further, higher income significantly correlated with lower acute index values, indicating that the relative quality of children's environments in our study area were constrained by familial wealth. This work demonstrates the importance of analyzing multiple activity spaces when assessing built and social environments, as well as the importance of spatial microdata.

Performing up to Nordic principles? Geographic and socioeconomic equity in ambulatory care sensitive conditions among older adults in capital areas of Denmark, Finland and Sweden in 2000-2015

BACKGROUND

Denmark, Finland and Sweden pursue equity in health for their citizens through universal health care. However, it is unclear if these services reach the older adult population equally across different socioeconomic positions or living areas. Thus, we assessed geographic and socioeconomic equity in primary health care (PHC) performance among the older adults in the capital areas of Denmark (Copenhagen), Finland (Helsinki) and Sweden (Stockholm) in 2000-2015. Hospitalisations for ambulatory care sensitive conditions (ACSC) were applied as a proxy for PHC performance.

METHODS

We acquired individual level ACSCs for those aged ≥ 45 in 2000-2015 from national hospitalisation registers. To identify whether the disparities varied by age, we applied three age groups (those aged 45-64, 65-75 and ≥ 75). Socioeconomic disparities in ACSCs were described with incidence rate ratios (IRR) and annual rates by education, income and living-alone; and then analysed with biennial concentration indices by income. Geographic disparities were described with biennial ACSC rates by small areas and analysed with two-level Poisson multilevel models. These models provided small area estimates of IRRs of ACSCs in 2000 and their slopes for development over time, between which Pearson correlations were calculated within each capital area. Finally, these models were adjusted for income to distinguish between geographic and socioeconomic disparities.

RESULTS

Copenhagen had the highest IRR of ACSCs among those aged 45-64, and Helsinki among those aged ≥ 75. Over time IRRs decreased among those aged ≥ 45, but only in Helsinki among those aged ≥ 75. All concentration indices slightly favoured the affluent population but in Stockholm were mainly non-significant. Among those aged ≥ 75, Pearson correlations were low in Copenhagen (-0.14; p = 0.424) but high in both Helsinki (-0.74; < 0.001) and Stockholm (-0.62; < 0.001) - with only little change when adjusted for income. Among those aged ≥ 45 the respective correlations were rather similar, except for a strong correlation in Copenhagen (-0.51, 0.001) after income adjustment.

CONCLUSIONS

While socioeconomic disparities in PHC performance persisted among older adults in the three Nordic capital areas, geographic disparities narrowed in both Helsinki and Stockholm but persisted in Copenhagen. Our findings suggest that the Danish PHC incorporated the negative effects of socio-economic segregation to a lesser degree.

A united approach to promoting healthy living behaviours and associated health outcomes: a global call for policymakers and decisionmakers

Chronic disease pandemics have challenged societies and public health throughout history and remain ever-present. Despite increased knowledge, awareness and advancements in medicine, technology, and global initiatives the state of global health is declining. The coronavirus disease 2019 (COVID-19) pandemic has compounded the current perilous state of global health, and the long-term impact is yet to be realised. A coordinated global infrastructure could add substantial benefits to public health and yield prominent and consistent policy resulting in impactful change. To achieve global impact, research priorities that address multi-disciplinary social, environmental, and clinical must be supported by unified approaches that maximise public health. We present a call to action for established public health organisations and governments globally to consider the lessons from the COVID-19 pandemic and unite with true collaborative efforts to address current, longstanding, and growing challenges to public health.

Social position and functional somatic disorders: The DanFunD study

BACKGROUND AND AIM

It is generally accepted that functional somatic disorders (FSDs) are a product of biological, psychological, and social factors. Social position might be part of this complex, but the literature on this issue is currently heterogeneous and inconsistent. The aim of the present study was - in a population-based cohort - to test the hypothesis that lower social position would be associated with higher a risk of FSD.

METHOD

The association between social position and FSD was examined in a cross-sectional study with various measures of social position (education as measured by vocational training; employment; cohabitation; subjective social status) and delimitations of FSD (irritable bowel syndrome, chronic fatigue syndrome, fibromyalgia, bodily distress syndrome, and symptom profiles). The associations were analyzed using logistic regressions to calculate odds ratios and 95% confidence intervals. Each social measure was analyzed independently and was adjusted for age and sex.

RESULTS

Lower levels of vocational training, being unemployed, and living alone were associated with higher risk of FSD, regardless of the FSD delimitation. There was also a significant negative association between subjective evaluated social status and FSD. The associations remained after multiple adjustments, and seemed to be strongest for the more severe FSD-types.

CONCLUSIONS

Lower social position is associated with higher risk of FSD, especially the more severe FSD delimitations, which might constitute an especially vulnerable group. However, the mechanisms behind the relations remain unknown.

Socioeconomic influence on treatment with liothyronine and desiccated thyroid extract in Denmark

Introduction

High compared with low educational level increases the odds of starting levothyroxine (L-T4) with a normal thyroid-stimulating hormone - the mechanism is most likely patient request. The use of liothyronine (L-T3) and desiccated thyroid extract (DTE) is also speculated to be initiated at patients' request. Therefore, the primary aim of this study was to evaluate if educational level influences treatment with L-T3 and DTE.

Material and methods

In this register-based cross-sectional study, we included all Danish citizens ≥30 years with redeemed prescription of L-T4, L-T3, or DTE during 2017-2020. We defined educational levels as short, medium, and long (<10 years, 10-12 years, and above 12 years, respectively). The association between educational level and treatment with LT3 or DTE vs only LT4 was analyzed in logistic regression models adjusted for age and sex.

Results

We included 154,360 individuals using thyroid medication of whom 3829 were treated with L-T3 (2.48%) and 430 with DTE (0.28%). The usage was highest among women (3.15%) and the age group 40-49 (5.6%). Longer education compared with short increased the odds of being treated with DTE or L-T3 (medium education odds ratio (OR) 1.61 (95% CI 1.50-1.8) and long education OR 1.95 (95% CI 1.79-2.13)). Test for trend: OR: 1.37 (95% CI 1.31-1.42). Adjustment for other covariates did not affect the results substantially.

Conclusion

Persons with a longer compared to a shorter education are more often treated with either DTE or L-T3, and the usage of these drugs is limited to less than 3% of thyroid hormone users.

Socioeconomic differences in animal food consumption: Education rather than income makes a difference

Background/aims

Evidence points toward more sustainable and health-conscious dietary behaviors among individuals with higher socioeconomic status. However, these differences vary considerably depending on which indicator of socioeconomic status is examined. Here, we present a systematic parallel investigation of multiple indicators of socioeconomic status as predictors of animal food consumption frequency and selected food-related behaviors in Germany.

Methods

Data from the German subsample of two large representative European consumer studies (Study 1 n = 1,954; Study 2 n = 2,045) was used. We assessed the associations between the socioeconomic indicators income, current occupation as well as education and consumption frequency of animal foods and selected food-related behaviors in separate ordinal logistic regressions.

Results

Individuals with higher educational attainment engaged in more sustainable and health-conscious dietary behaviors, indicated by significant associations between educational attainment and the consumption frequency of animal foods. Low- and middle-income participants consumed processed meat more frequently (Study 1 only; medium income: OR 1.5, CI 1.09-2.05, p = 0.012; low income: OR 1.43, CI 1.01-2.05, p = 0.047) and fish less frequently (Study 2 only; medium income: OR 0.76, CI 0.59-0.97, p = 0.026; low income: OR 0.061, CI 0.46-0.82, p < 0.001) than participants with high income. Current occupation did not predict the consumption of animal foods or food-related behaviors. Intake frequency of animal-based foods indicates that most participants exceeded national dietary recommendations for meat and processed meat and remained below recommendations for fish and dairy/eggs intake.

Conclusion

Educational attainment appears to be the strongest and most consistent socioeconomic indicator of sustainable dietary choices in Germany based on current large, representative studies. Future efforts should be directed toward education interventions about nutrition and interpretation of food labels to compensate for differences in dietary behavior among groups with different levels of education.

Racial differences in Financial Hardship and depressive symptoms among older adults

BACKGROUND

The purpose of this study was to examine the association between three specific indicators of financial hardship (difficulty paying bills, food insecurity, reduced medication use due to cost) and depressive symptoms by race.

METHODS

This was a cross sectional study using the Health and Retirement Study to analyze the data by conducting a logistic regression (N = 3014).

RESULTS

When stratified by race, White participants who were food insecure had nearly a 3.0 higher odds of high depressive symptoms (95% CI: 1.59-5.51) and African Americans who took less medication due to cost had a 5.1 higher odds of reporting higher depressive symptoms (95% CI: 2.30-11.2) compared to those who did not report these hardships.

CONCLUSIONS

This research highlights the important role expanded socioeconomic measures such as hardship play in the lives of older adult populations. It further elucidates the differences in the specific measures of hardship that impact older adults by race.

COVID-19 and Unmet Medical Needs for People With Chronic Diseases: A Cross-Sectional Study

Gaps between medical needs and health services accessibility are defined as unmet medical needs (UMN). Previous studies assessing UMNs during the coronavirus disease 2019 (COVID-19) pandemic did not account for factors such as the type of medical insurance or chronic disease. Therefore, this study investigated various factors, including medical insurance and chronic diseases, affecting self-reported UMN during the pandemic in Daejeon Metropolitan City, South Korea. This cross-sectional study was conducted using Daejeon Metropolitan City Health Surveys data from 2020. The weighted prevalence of UMN was estimated among participants (n = 1494) aged ≥18 years, while chi-squared and logistic models were used to assess the association between UMN and participant characteristics. The prevalence of UMN was 6.4% (n = 97). Female sex and low education levels were significantly associated with reporting UMN. Medical aid beneficiaries were less likely to report UMN than adults with National Health Programs coverage. Participants with chronic diseases, such as hypertension and arthritis, and those with depression, were more likely to report UMN than adults without these conditions. The findings highlight the need for targeted efforts to decrease UMN in the COVID-19 pandemic, especially for women and individuals with low education levels. The results also indicate that high-risk disease groups should be targeted with additional enabling services to support the management of chronic conditions.

Increases in symptoms of depression and anxiety in adults during the initial phases of the COVID-19 pandemic are limited to those with less resources: Results from the Lifelines Cohort Study

BACKGROUND

The COVID-19 pandemic may have a differential impact on mental health based on an individual's capital, i.e. resources available to maintain and enhance health. We assessed trajectories of depression and anxiety symptoms, and their association with different elements of capital.

METHODS

Data on 65,854 individuals (mean baseline age = 50·4 (SD = 12·0) years) from the Lifelines COVID-19 cohort were used. Baseline mental health symptoms were on average measured 4.7 (SD = 1·1) years before the first COVID-19 measurement wave, and subsequent waves were (bi)weekly (March 30─August 05, 2020). Mental health symptom trajectories were estimated using a two-part Latent Class Growth Analysis. Class membership was predicted by economic (education, income, and occupation) and person capital (neuroticism, poor health condition, and obesity) FINDINGS: Most individuals were unlikely to report symptoms of depression (80·6%) or anxiety (75·9%), but stable-high classes were identified for both conditions (1·6% and 6·7%, respectively). The stable-high depression class saw the greatest increase in symptoms after COVID, and the stable-high anxiety class reported an increase in the probability of reporting symptoms after COVID. At the first COVID-measurement, the mean number of symptoms increased compared to baseline (depression:4·7 vs 4·1; anxiety:4·3 vs 4·2); the probability of reporting symptoms also increased (depression:0·96 vs 0·65; anxiety:0·92 vs 0·70). Membership in these classes was generally predicted by less capital, especially person capital; odds ratios for person capital ranged from 1·10-2·22 for depression and 1·08-1·51 for anxiety.

INTERPRETATION

A minority of individuals, possessing less capital, reported an increase in symptoms of depression or anxiety after COVID.

FUNDING

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Family Structure and Family Climate in Relation to Health and Socioeconomic Status for Older Adults: A Longitudinal Moderated Mediation Analysis

Family characteristics are associated with individuals' health and wellbeing. However, the link between family structure (e.g., operationalized via marital status) and health outcomes is ambiguous, and whether family climate mediates the relationship is unclear. This study uses the Biobehavioral Family Model (BBFM) to investigate the association of older adults' family structure with later health, the mediating role of family climate and mental health and how these links vary by socioeconomic status (SES). Using data from n = 29,457 respondents aged over 50 in Waves 4, 5 and 6 (2011, 2013 and 2015) of the Survey of Health, Retirement and Ageing in Europe (SHARE), the BBFM was applied in a longitudinal mediation analysis of family structure and health, including both indicators of mental and physical health. Structural equation modeling was applied, and a multigroup analysis was performed to test the role of SES in a moderated mediation. Family climate and mental health mediated the relationship between family structure and subsequent physical health. Good levels of family climate were found to be consistently associated with improved mental and physical health. These relationships were significantly moderated by SES, showing that the association of family climate and health was weaker for those in low SES positions. Family climate and mental health should be considered as potential mechanisms linking family structure to later physical health outcomes across time; however, these associations are diminished for those with low SES.

Social Deprivation, Healthcare Access and Diabetic Foot Ulcer: A Narrative Review

The diabetic foot ulcer (DFU) is a common and serious complication of diabetes. There is also a strong relationship between the environment of the person living with a DFU and the prognosis of the wound. Financial insecurity seems to have a major impact, but this effect can be moderated by social protection systems. Socioeconomic and socio-educational deprivations seem to have a more complex relationship with DFU risk and prognosis. The area of residence is a common scale of analysis for DFU as it highlights the effect of access to care. Yet it is important to understand other levels of analysis because some may lead to over-interpretation of the dynamics between social deprivation and DFU. Social deprivation and DFU are both complex and multifactorial notions. Thus, the strength and characteristics of the correlation between the risk and prognosis of DFU and social deprivation greatly depend not only on the way social deprivation is calculated, but also on the way questions about the social deprivation−DFU relationship are framed. This review examines this complex relationship between DFU and social deprivation at the individual level by considering the social context in which the person lives and his or her access to healthcare.

Associations of childhood and adult socioeconomic circumstances with recommended food habits among young and midlife Finnish employees

Background

Disadvantaged socioeconomic circumstances are associated with certain unhealthy food habits such as inadequate consumption of fruit and vegetables. This study examined whether multiple socioeconomic measures are consistently associated with a variety of food habits.

Methods

We examined associations of 2 childhood and 6 adult socioeconomic measures with 8 recommended food habits among 19–39-year-old employees of the City of Helsinki, Finland. The data were collected in 2017 via online and mailed surveys. Our sample consisted of 4621 employees (80% women). The analyses included adjusted binary logistic regression models.

Results

More advantaged socioeconomic circumstances were positively associated with the recommended consumption of vegetables, fruit or berries, dark bread, skimmed milk products, fish, and cooking oil, but not consistently with red or processed meat and fat spread. All socioeconomic measures were positively associated with having several (6–8) recommended food habits after gender and age adjustments. The strongest associations were found for participant’s education, occupational class, and current financial difficulties. These associations remained after adjustments of childhood and adult socioeconomic measures, although especially participant’s education attenuated the associations for occupational class.

Conclusions

The consistent associations between multiple childhood and adult socioeconomic measures and food habits found among employees highlight the need for improving food habits among people with disadvantaged socioeconomic circumstances in particular. Financial barriers together with social aspects of adhering to healthy diets should be considered in future dietary interventions and policy actions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40795-022-00557-0.

What drives variations in public health and social services expenditures? the association between political fragmentation and local expenditure patterns

The US spends two times more than the OECD average in health expenditure but has a much smaller portion of public health spending to total health expenditure than other OECD countries. While it has been suggested that public health and social services spending is crucial to promoting health outcomes, less is known about what drives variations in public health expenditure across regions. This study aims to examine whether political fragmentation in local governance is associated with variations in public health and social services expenditures. Using the US Census of Governments, we constructed a panel dataset of political fragmentation and local government spending patterns (1997-2012) for 792 US counties (population > 60,882, top 25%) and employed Least Squares Dummy Variable (LSDV) and Generalized Estimating Equations (GEE) models. We found that per capita public health spending tended to be smaller in areas where the degree of political fragmentation was higher (Coef:  - 0.034; p < 0.01), particularly when general-purpose governments were more fragmented (Coef:  - 0.087; p < 0.001). The proportion of public health spending also decreased when local governments were more fragmented (Coef:  - 0.012; p < 0.001). Social services expenditures and their proportions to total government expenditure fell with an increase in the degree of political fragmentation. Our findings suggest that fragmented governance settings, in which localities are more likely to face competition with others, may lead to a reduction in public spending essential for population health and that political fragmentation can also have a deterrent effect on broader categories of health-related social services spending.

Collaboration between general practitioners and social workers: a scoping review

OBJECTIVES

Aim of the study is to present an overview of collaboration structures and processes between general practitioners and social workers, the target groups addressed as well the quality of available scientific literature.

DESIGN

A scoping review following the guidelines of the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews).

INCLUDED SOURCES AND ARTICLES

According to a pre-published protocol, three databases (PubMed, Web of Science, DZI SoLit) were searched using the participant-concept-context framework. The searches were performed on 21 January 2021 and on 10 August 2021. Literature written in English and German since the year 2000 was included. Two independent researchers screened all abstracts for collaboration between general practitioners and social workers. Articles selected were analysed regarding structures, processes, outcomes, effectiveness and patient target groups.

RESULTS

A total of 72 articles from 17 countries were identified. Collaborative structures and their routine differ markedly between healthcare systems: 36 publications present collaboration structures and 33 articles allow an insight into the processual routines. For all quantitative studies, a level of evidence was assigned. Various measurements are used to determine the effectiveness of collaborations, for example, hospital admissions and professionals' job satisfaction. Case management as person-centred care for defined patient groups is a central aspect of all identified collaborations between general practitioners and social workers.

CONCLUSION

This scoping review showed evidence for benefits on behalf of patients, professionals and healthcare systems by collaborations between general practitioners and social workers, yet more rigorous research is needed to better understand the impact of these collaborations.

TRIAL REGISTRATION NUMBER

www.osf.io/w673q.

Diabetes, antidiabetic medications and risk of depression - A population-based cohort and nested case-control study

OBJECTIVE

Diabetes type 2 is associated with depression, but the impact of antidiabetic drugs is not clear. The objective was to analyze the association between diabetes type 2, antidiabetic drugs, and depression.

METHODS

This register-based study included 116.699 patients with diabetes type 2 diagnosed from 2000 to 2012 and an age, gender, and municipality matched reference group of 116.008 individuals without diabetes. All participants were followed for a diagnosis of depression or prescription of antidepressant medication. Based on this, a case-control study was nested within the cohort, using risk set sampling. Antidiabetic medication was categorized into insulin, metformin, sulfonylureas and glinides combined, glitazones, dipeptidyl peptidase 4 (DPP4) inhibitors, glucagon-like peptide 1 (GLP1) analogs, sodium-glucose transport protein 2 (SGLT2) inhibitors and acarbose. The association between diabetes and depression was analyzed using Cox proportional hazards regression, whereas conditional logistic regression was used to analyze the association between use of antidiabetic drugs and depression.

RESULTS

Patients with diabetes had higher risk of depression compared to individuals without diabetes (hazard ratio 1.14 (95% confidence interval 1.14-1.15)). Low doses of metformin, DPP4 inhibitors, GLP1 analogs, and SGLT2 inhibitors were associated with lower risk of depression in patients with diabetes compared to non-users, with the lowest risk for sodium-glucose transport protein 2 inhibitor users (odds ratio 0.55 (0.44-0.70)). Use of insulin, sulfonylurea and high doses of metformin were associated with higher risk of depression.

CONCLUSION

Patients with diabetes had increased risk of depression. However, users of specific antidiabetic drugs had lower risk of depression compared to non-users.

Changes in socioeconomic differentials in old age life expectancy in four Nordic countries: the impact of educational expansion and education-specific mortality

Overall progress in life expectancy (LE) depends increasingly on survival in older ages. The birth cohorts now reaching old age have experienced considerable educational expansion, which is a driving force for the social change and social inequality. Thus, this study examines changes in old age LE by educational attainment in the Nordic countries and aims to find out to what extent the change in national LEs is attributable to education-specific mortality and the shifting educational composition. We used national register data comprising total 65 + populations in Denmark, Finland, Norway and Sweden to create period life tables stratified by five-year age groups (65-90 +), sex and educational attainment. Difference in LE between 2001 and 2015 was decomposed into the contributions of mortality changes within each educational group and changes in educational composition. Increasing LE at all ages and in all educational groups coincided with persistent and growing educational inequalities in all countries. Most of the gains in LE at age 65 could be attributed to decreased mortality (63-90%), especially among those with low education, the largest educational group in most countries. The proportion of the increase in LE attributable to improved education was 10-37%, with the highest contributions recorded for women in Norway and Sweden. The rising educational levels in the Nordic countries still carry potential for further gains in national LEs. However, the educational expansion has contributed to uneven gains in LE between education groups, which poses a risk for the future increase of inequalities in LE.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10433-022-00698-y.

Measuring Health Equity in Emergency Care Using Routinely Collected Data: A Systematic Review

Introduction: Achieving equity in health care remains a challenge for health care systems worldwide and marked inequities in access and quality of care persist. Identifying health care equity indicators is an important first step in integrating the concept of equity into assessments of health care system performance, particularly in emergency care.

Methods: We conducted a systematic review of administrative data-derived health care equity indicators and their association with socioeconomic determinants of health (SEDH) in emergency care settings. Following PRISMA-Equity reporting guidelines, Ovid MEDLINE, EMBASE, PubMed, and Web of Science were searched for relevant studies. The outcomes of interest were indicators of health care equity and the associated SEDH they examine.

Results: Among 29 studies identified, 14 equity indicators were identified and grouped into four categories that reflect the patient emergency care pathway. Total emergency department (ED) visits and ambulatory care-sensitive condition-related ED visits were the two most frequently used equity indicators. The studies analyzed equity based on seven SEDH: social deprivation, income, education level, social class, insurance coverage, health literacy, and financial and nonfinancial barriers. Despite some conflicting results, all identified SEDH are associated with inequalities in access to and use of emergency care.

Conclusion: The use of administrative data-derived indicators in combination with identified SEDH could improve the measurement of health care equity in emergency care settings across health care systems worldwide. Using a combination of indicators is likely to lead to a more comprehensive, well-rounded measurement of health care equity than using any one indicator in isolation. Although studies analyzed focused on emergency care settings, it seems possible to extrapolate these indicators to measure equity in other areas of the health care system. Further studies elucidating root causes of health inequities in and outside the health care system are needed.

Influence of socioeconomic status on oral disease burden: a population-based study

Background

Dental caries is associated with Biological, behavioral, socioeconomic, and environmental factors; however, socioeconomic status is a distal determinant of dental caries development that modulates exposure to risk and protective factors. This study aimed to analyze the socioeconomic factors associated with the concentration of oral diseases in a population-based study in Brazil.

Methods

This is a quantitative, analytical, cross-sectional study based on secondary data from the SB São Paulo 2015 epidemiological survey. A total of 17,560 subjects were included. The concentration of oral disease in the population was estimated by the oral disease burden (ODB) variable. The ODB consists of four components: dental caries; tooth loss; need for dental prosthesis and periodontal condition. Thus, the total score on the ODB could vary between 0 and 4, with the highest score indicating the worst possible situation. ODB was analyzed in multivariate negative binomial regression, and multivariate binary logistic regression analysis. The following factors were included as independent variables: age group, skin color, socioeconomic factors, family income and Oral Impact on Daily Performance (OIDP).

Results

In the sample, 86.9% had no minimum ODP component. Negative multivariate binomial regression showed a statistically significant relationship (p < 0.005) between ODB and all variables analyzed (skin color, family income, education, OIDP results and age range). The adjusted multivariate binary logistic regression showed that the individuals most likely to have at least one component of ODB were nonwhite (25.5%), had a family income of up to R$ 1500.00/month (19.6%), had only completed primary education (19.1%), and reported that their oral health had an impact on their daily activities (57.6%). Older adults individuals were two times more likely than adolescents to have an ODB component.

Conclusions

ODB is associated with factors related to social inequality. Adults and older adults individuals had the highest cumulative number of ODB components.

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.

Greater inequalities in dental caries treatment than in caries experience: a concentration index decomposition approach

Background

The aim of the current study was to (a) measure the socioeconomic inequalities in oral health and examine whether the inequalities are greater in disease experience or in its treatment and to (b) decompose the factors that influence oral health inequalities among the adults of Guangdong Province.

Methods

A cross-sectional study was conducted among 35- to 44-year-old and 65- to 74-year-old adults in Guangdong Province. All participants underwent oral health examinations and answered questionnaires about their oral health. We measured the concentration indices of the DMFT and its separate components, namely, decayed teeth (DT), missing teeth (MT), and filled teeth (FT), to explore the inequalities in oral health status; then, we analysed its decomposition to interpret the factors that influence the inequalities.

Results

The results showed that significant inequality was concentrated on FT (CI =  0.24, 95% CI = 0.14/0.33, SE = 0.05). The concentration indices for the DMFT (CI =  0.02, 95% CI =  0.02/0.06, SE = 0.02) and MT (CI =  0.02, 95% CI 0.03/0.08, SE = 0.03) were small and close to zero, while the concentration for DT (CI =  − 0.04, 95% CI =  − 0.01/0.02, SE = 0.03) was not statistically significant. The results from the decomposition analysis suggested that a substantial proportion of the inequality was explained by household income, high education level, regular oral examination and type of insurance (5.1%, 12.4%, 43.2%, − 39.6% (Urban Employee Basic Medical Insurance System) and 34.5% (New-Type Rural Medical Collaboration System), respectively).

Conclusions

The results indicated greater inequalities in dental caries than in caries experience. Among the included factors, household income, high education level, and regular oral health examinations had the greatest impact on the inequalities in the number of FT. In addition, the current medical insurance systems, including the Urban Employee Basic Medical Insurance System, Urban Resident Basic Medical Insurance System, and the New-Type Rural Medical Collaboration System, have not been effectively used in oral treatment. Policy-making and the implementation of interventions for tackling socioeconomic oral health inequalities should focus on reducing the burden of treatment and providing greater access to dental care for low-income groups. Welfare policies are skewed towards rural areas and low-income people.

Impact of the COVID-19 pandemic on unmet healthcare needs in Seoul, South Korea: a cross-sectional study

OBJECTIVES

This study investigated the factors influencing unmet healthcare needs of people during the early stage of the COVID-19 pandemic in Seoul, South Korea. The findings help to identify people who have difficulty accessing healthcare services during a pandemic situation.

DESIGN

We conducted a cross-sectional study using a proportionate quota sampling method according to five major districts, sex and age, using an online survey. We analysed the key characteristics of influencing factors of unmet healthcare needs based on the Andersen behavioural model of healthcare utilisation: predisposing factors (eg, sex, age), need factors (eg, health status, illness) and enabling factors (eg, income, efficacy belief).

SETTING

The questionnaire was sent via email and mobile text messages from the end of April to the beginning of May 2020 during the first wave of the COVID-19 pandemic.

PARTICIPANTS

A sample of 813 respondents was used, and the respondent information was anonymised in the analysis process.

RESULTS

For the predisposing factors, sex, age, education level and occupational cluster were associated with unmet needs for healthcare. Chronic diseases and mental health were the influencing factors as an enabling factor that exerted an influence on the unmet need for healthcare in South Korea. Women, younger persons, those with lower education and persons with white-collar jobs were more likely to experience unmet healthcare needs. In addition, the more chronic diseases people had, the more COVID-19 negatively affected them mentally; and the more people felt fear of COVID-19, the higher chances they experienced unmet healthcare needs.

CONCLUSION

Government and policymakers are guided to draw out measures such as health communication and telemedicine to reduce the unmet healthcare needs during the pandemic and to recognise the different influencing factors.

Association of Parental Socioeconomic Status and Physical Activity with Development of Arterial Stiffness in Prepubertal Children

The present study examined the prospective association of parental household income, education level, migration background, and physical activity (PA) behavior with the development of pulse wave velocity (PWV) in prepubertal children. A total of 223 children (initial age 6–8 years) were included in this prospective school-based cohort study from 2014 to 2018. Parental socioeconomic status, migration background, and PA behavior were assessed by the use of questionnaires at both times points. PWV was measured by an oscillometric device at follow-up (2018). No significant association of household income, education level, and parental migration background with PWV in children after four years was found. However, a high level of maternal PA was related to a lower childhood PWV at follow-up (mean (95% CI) 4.6 (4.54–4.66) m/s) compared to children of mothers with a low PA behavior (mean (95% CI) 4.7 (4.64–4.77) m/s) (p = 0.049). Children of mothers with a high PA level revealed a beneficial arterial stiffness after four years. Little evidence for an association of socioeconomic status and migration background with childhood arterial stiffness was found. Increased parental PA seems to support the development of childhood vascular health and should be considered in the generation of future primary prevention strategies of childhood cardiovascular health.

Socioeconomic factors in disability retirement due to mental disorders in Finland

Background

Previous research has identified low socioeconomic status (SES) as an epidemiological risk factor for early retirement and disability pension (DP) due to mental disorders. This study aims to examine these associations in greater detail, with separate consideration of the risk factors for mood disorders (F30–39) and non-affective psychotic disorder (F20–29) DP.

Methods

In this case–control setting the subjects (N = 36 879) were all those granted DP due to a mental disorder for the first time between 2010 and 2015 in Finland. All the subjects were matched with three controls for their gender, age and hospital district (N = 94 388). Three measures of dimensions of SES were used: education, income and occupational status, as well as family type as a control factor. Differences between DP recipients and controls, and between diagnostic groups, were studied using calculated characteristics and conditional logistic regression models.

Results

DP recipients often lived alone and had low educational and income levels. These characteristics were more prominent in non-affective psychotic disorder than in mood disorder DP. In white-collar occupational groups, the risk of DP was greater compared with blue-collar workers. Students were associated with the highest level of risk for all mental and mood disorder DPs.

Conclusions

We found evidence of SES factors associating with mental disorder-related severe loss of working and studying ability in a disorder-specific way. Notably, white-collar workers had an increased risk of mental disorder DP. This could be related to the psychosocially demanding contemporary working life in non-manual work.

Parental socioeconomic status and adolescent health in Japan

There is no consensus on which parental socioeconomic indicators should be used to define adolescents’ socioeconomic status (SES). Utilising the data for 3154 parent-adolescent pairs obtained from the sample of the Survey of Lifestyle Value of Parents and Children 2011 conducted by the Cabinet Office in Japan, the associations between adolescent’s subjective economic status, parental SES (i.e. education, occupation, and household income), and child health-related outcomes (i.e. self-rated health, dietary and oral health behaviours) were analysed using multilevel mixed-effects ordered logistic regression to investigate heterogeneity in these relationships across SES indicators and health outcome measures. Results demonstrated that income was the strongest predictor of adolescent health outcomes, suggesting that adolescents in the middle- or high-income groups tended to report better health status compared to the low-income group, have a higher frequency of having breakfast, and more likely to regularly brush their teeth by 24% (OR 1.24, 95% CI [1.06–1.46]) to 66% (OR 1.66, 95% CI [1.30–2.12]). Parental education was also related to child health-related behaviours, with higher levels of habitual healthy behaviours being observed in the middle- and high-education groups than in the low-education group by 15% (OR 1.15, 95% CI [1.01–1.32]) to 63% (OR 1.63, 95% CI [1.31–2.03]). Future studies regarding health disparities among children/adolescents should carefully choose an SES indicator, taking multiple pathways between each SES indicator and health/health behaviours into consideration.

Influence of educational level on test and treatment for incident hypothyroidism

OBJECTIVE

The incidence of hypothyroidism is not expected to differ by socioeconomic factors. However, the decision to test and initiate treatment may differ. We aimed to examine whether educational level influences the probability of thyroid stimulation hormone (TSH)-measurement and initiation of levothyroxine treatment.

DESIGN

Citizens in the greater Copenhagen Area during 2001-2015 were included. Individual-level data on educational level, diagnoses, GP-contact, TSH-measurement and medication were derived from administrative and healthcare registers. The relative risks (RR) between educational levels of annual TSH-measurement and treatment initiation following a TSH-measurement were analysed in Poisson regression models with generalized estimation equations.

RESULTS

A TSH-measurement was performed in 19% of 9,390,052 person years. The probability of TSH-measurement was higher with short (RR 1.16 [95% CI 1.15-1.16]) and medium (RR 1.11 [95% CI 1.06-1.12]) compared with long education. Treatment was initiated after 0.8% of 2,049,888 TSH-measurements. For TSH < 5 mIU/L, RR for treatment initiation ranged between 0.47 (95%CI 0.39-0.57) and 0.78 (95%CI 0.67-0.91) for short and medium compared with long education. For TSH 5-10 mIU/L, there was no statistically significant difference. For TSH > 10 mIU/L, RR was 1.07 (95% CI 1.02-1.12) for short and 1.08 (95% CI 1.03-1.13) for medium compared with long education.

CONCLUSION

The probability of TSH-measurement was higher with shorter education, and the probability of treatment initiation with TSH > 10 mIU/L was marginally higher with short-medium education compared with long education. However, the probability of treatment initiation with TSH < 5 mIU/L, that is treatment incongruous with guidelines, was substantially higher in persons with long education.

Interdependent pathways between socioeconomic position and health: A Swedish longitudinal register-based study

Health inequalities are generated by the conditions in which people are born, grow, live, work and age. From a life-course perspective, these conditions are formed by complex causal relationships with mutual and intertwined paths between socioeconomic position and health. This study attempts to disentangle some of these processes by examining pathways between socioeconomic position and health across the life-course. We used yearly Swedish national register data with information from over 31 years for two cohorts born 1941-1945 and 1961-1965. We analyzed associations between several indicators of childhood and adult socioeconomic position and health, measured by number of in-patient hospitalizations. We estimated within- and between-person associations using random intercept cross-lagged panel models. The results showed bi-directional associations between socioeconomic position and health that varied in strength across the life-course. Age variations in the associations were primarily observed when individuals aged into or out of age-stratified institutions. In ages where transitions from education to the labor market are common, the associations from health to income and education were strong. Around and after retirement age, the between-person association from health to income was weak, while the association from income to health strengthened. Within-person estimates showed no association between income and subsequent hospitalization among older persons, indicating no direct causal effect of income change on health in this age group. For persons of middle age, the associations were of similar strength in both directions and present at both the between- and within-person level. Our findings highlight the importance of theoretical frameworks and methods that can incorporate the interplay between social, economic, and biological processes over the life-course in order to understand how health inequalities are generated.