Neighbourhood unemployment and all cause mortality: a comparison of six countries

Economic inequality in malnutrition: a global systematic review and meta-analysis

OBJECTIVE

To describe the evidence on global and regional economic inequality in malnutrition, and the associations between economic inequality and malnutrition.

METHODS

We conducted a systematic review and meta-analysis. Between 1 November 2020 and 22 January 2021, we searched Medline, Embase, Global Health, Eldis, Web of Science and EBSCO Discovery Service. We contacted 39 experts and tracked citations. We included any study reporting a concentration index (CIX) relating economic status and nutritional status and any multilevel study reporting an association between economic inequality and nutritional status. Nutritional status was measured as stunting, wasting, anaemia, or overweight in children (<5 years), or underweight, overweight or obesity, or anaemia in adults (15-49 years). We had no study date or language restriction. Quality was assessed using the Appraisal Tool for Cross-Sectional Studies (AXIS tool). We mapped estimates and pooled them using multilevel random-effects meta-analyses.

RESULTS

From 6185 results, 91 studies provided 426 CIX (>2.9 million people) and 47 associations (~3.9 million people). Stunting (CIX -0.15 (95% CI -0.19 to -0.11)) and wasting (-0.03 (95% CI -0.05 to -0.02)) are concentrated among poor households. Adult overweight and obesity is concentrated in wealthier households (0.08 (95% CI -0.00 to 0.17)), particularly in South Asia (0.26 (95% CI 0.19 to 0.34)), but not in Europe and Central Asia (-0.02 (95% CI -0.08 to 0.05)) or North America (-0.04 (95% CI -0.10 to 0.03)). We found no association between 0.1 increase in Gini coefficient and adult underweight (OR 1.03 (95% CI 0.94 to 1.12)) or overweight and obesity (0.92 (95% CI 0.80 to 1.05)).

CONCLUSIONS

There is good evidence that the prevalence of malnutrition varies by levels of absolute economic status. Undernutrition is concentrated in poor households, whereas concentration of overweight and obesity by economic status depends on region, and we lack information on economic inequalities in anaemia and child overweight. In contrast, links between malnutrition and relative economic status are less clear and should not be assumed; robust evidence on causal pathways is needed.

PROSPERO REGISTRATION NUMBER

CRD42020201572.

Socioeconomic deprivation and cancer survival in a metropolitan area: An analysis of cancer registry data from Hamburg, Germany

Background

Few studies have investigated socioeconomic inequalities within cities. Yet, such analyses are particularly important given the increasing international trend to urbanization. Here we investigated area-based socioeconomic inequalities in cancer survival in Hamburg, a port city in the North of Germany (population: 1.84 million people).

Methods

Patients with a diagnosis of colorectal, lung, female breast, and prostate cancer in 2004–2018 (follow-up until 31.12.2018) and registered in the Hamburg cancer registry were included. Area-based socioeconomic deprivation on urban district level was assigned to the patients and grouped in five quintiles. Relative survival in 2014–2018 was calculated using the period approach. Trend analyses between 2004 and 2018 were conducted. Relative excess risks adjusted for age and stage were computed with model-based period analyses.

Findings

For the 73,106 included patients, age-standardized 5-year relative survival in 2014–2018 decreased with increasing deprivation with significant differences between the most and least deprived group of 14·7 (prostate), 10·8 (colorectal), 8·0 (breast), and 2·5 (lung) percent units. Standardization by cancer stage decreased the difference for prostate cancer to 8·5 percent units and for breast cancer to 3·6 percent units but had only a minor effect for colorectal and lung cancer. Similar socioeconomic inequalities were already present in 2004–08.

Interpretation

Strong socioeconomic inequalities in cancer survival were observed in Hamburg, which could be partly explained by differences in the stage distribution. Further research including information on screening participation as well as information on cancer care are important to further understand and finally overcome these inequalities.

Funding

10.13039/501100005972German Cancer Aid.

Geographical Variability in Mortality in Urban Areas: A Joint Analysis of 16 Causes of Death

The geographical distribution of mortality has frequently been studied. Nevertheless, those studies often consider isolated causes of death. In this work, we aim to study the geographical distribution of mortality in urban areas, in particular, in 26 Spanish cities. We perform an overall study of 16 causes of death, considering that their geographical patterns could be dependent and estimating the dependence between the causes of death. We study the deaths in these 26 cities during the period 1996-2015 at the census tract level. A multivariate disease mapping model is used in order to solve the potential small area estimation problems that these data could show. We find that most of the geographical patterns found show positive correlations. This suggests the existence of a transversal geographical pattern, common to most causes of deaths, which determines those patterns to a higher/lower extent depending on each disease. The causes of death that exhibit that underlying pattern in a more prominent manner are chronic obstructive pulmonary disease (COPD), lung cancer, and cirrhosis for men and cardiovascular diseases and dementias for women. Such findings are quite consistent for most of the cities in the study. The high positive correlation found between geographical patterns reflects the existence of both high and low-risk areas in urban settings, in general terms for nearly all the causes of death. Moreover, the high-risk areas found often coincide with neighborhoods known for their high deprivation. Our results suggest that dependence among causes of death is a key aspect to be taken into account when mapping mortality, at least in urban contexts.

Promoting health equity through social capital in deprived communities: a natural policy experiment in Trieste, Italy

The Trieste Habitat Micro-area Programme (HMP), an innovative social-health service policy, has offered a natural experiment to empirically evaluate the social mechanisms through which social capital may have an impact on health inequalities. To date, literature clarifying this causal chain is scanty. This empirical study tested the following hypotheses: H1) innovative social-health practices can activate social mechanisms intentionally and systematically so as to generate social capital; H2) such social mechanisms increase specific properties of social capital, in particular those influencing more vulnerable individuals' relationships; H3) investing in these properties can enhance capabilities and, consequently, control over the health of more vulnerable individuals. The study was carried out during 2016-2018 and used both qualitative and quantitative methods. The qualitative part investigated the field experience of the HMP through interviews, focus groups and workshops with HMP professionals. The quantitative part assessed the effect HMP might have on these properties and the capacity to face health risks of more vulnerable individuals. Three samples, each of 200 individuals, residing in the target and in control areas were interviewed using a semi-structured questionnaire. One control sample was matched to the 200 treated subjects using a Propensity Score Matching. The results of the study suggest that the HMP intervention stimulated the development of empowerment, collaboration and interdependence among vulnerable people. This produced an increase in their social capital under several aspects, including enhanced trust, network extension and participation, cooperation and reciprocal help with neighbours, as well as improving their judgement on quality, timing and efficacy of the help received from institutions, relatives or friends. These findings show that socially shared relationships can create innovative local models of a universalistic generative welfare system, which would be both inclusive and able to enhance individual capabilities. These models could be disseminated and carried over to other contexts.

The Contextual Effect of Area-Level Unemployment Rate on Lower Back Pain: A Multilevel Analysis of Three Consecutive Surveys of 962,586 Workers in Japan

This study examined the associations between area-level unemployment rates and lower back pain using large-scale data provided by the Japanese working population. We analyzed data from a nationally representative, repeated, cross-sectional study across three waves from 2010, 2013, and 2016 in 47 Japanese subnational level areas. Workers aged 18-64 years (n = 962,586) were eligible to participate in the study. A multilevel logistic model was used to examine the association between the unemployment rate and lower back pain. The self-report of lower back pain was a dependent variable. The prefecture-level unemployment rate was analyzed as an independent variable, adjusted for individual-level covariates (e.g., gender, age, socioeconomic status). After adjusting for all covariates, the main effect of the prefecture-level unemployment rate was statistically significant: the odds ratio (OR) (95% credible interval (CrI)) was 1.01 (1.002, 1.03). Additionally, the OR (95% CrI) for the interaction between gender and the prefecture-level unemployment rate was 1.02 (1.01, 1.03) indicating that women were more affected by area-level employment status than men. In conclusion, a significant association between the unemployment rate and lower back pain was observed in the Japanese working population. Women were more sensitive to the unemployment rate.

Deprivation-specific life tables using multivariable flexible modelling - trends from 2000-2002 to 2010-2012, Portugal

BACKGROUND

Completing mortality data by information on possible socioeconomic inequalities in mortality is crucial for policy planning. The aim of this study was to build deprivation-specific life tables using the Portuguese version of the European Deprivation Index (EDI) as a measure of area-level socioeconomic deprivation, and to evaluate mortality trends between the periods 2000-2002 and 2010-2012.

METHODS

Statistics Portugal provided the counts of deaths and population by sex, age group, calendar year and area of residence (parish). A socioeconomic deprivation level was assigned to each parish according to the quintile of their national EDI distribution. Death counts were modelled within the generalised linear model framework as a function of age, deprivation level and calendar period. Mortality Rate Ratios (MRR) were estimated to evaluate variations in mortality between deprivation groups and periods.

RESULTS

Life expectancy at birth increased from 74.0 and 80.9 years in 2000-2002, for men and women, respectively, and to 77.6 and 83.8 years in 2010-2012. Yet, life expectancy at birth differed by deprivation, with, compared to least deprived population, a deficit of about 2 (men) and 1 (women) years among most deprived in the whole study period. The higher mortality experienced by most deprived groups at birth (in 2010-2012, mortality rate ratios of 1.74 and 1.29 in men and women, respectively) progressively disappeared with increasing age.

CONCLUSIONS

Persistent differences in mortality and life expectancy were observed according to ecological socioeconomic deprivation. These differences were larger among men and mostly marked at birth for both sexes.

Study protocol: a pragmatic, stepped-wedge trial of tailored support for implementing social determinants of health documentation/action in community health centers, with realist evaluation

BACKGROUND

National leaders recommend documenting social determinants of health and actions taken to address social determinants of health in electronic health records, and a growing body of evidence suggests the health benefits of doing so. However, little evidence exists to guide implementation of social determinants of health documentation/action.

METHODS

This paper describes a 5-year, mixed-methods, stepped-wedge trial with realist evaluation, designed to test the impact of providing 30 community health centers with step-by-step guidance on implementing electronic health record-based social determinants of health documentation. This guidance will entail 6 months of tailored support from an interdisciplinary team, including training and technical assistance. We will report on tailored support provided at each of five implementation steps; impact of tailored implementation support; a method for tracking such tailoring; and context-specific pathways through which these tailored strategies effect change. We will track the competencies and resources needed to support the study clinics' implementation efforts.

DISCUSSION

Results will inform how to tailor implementation strategies to meet local needs in real-world practice settings. Secondary analyses will assess impacts of social determinants of health documentation and referral-making on diabetes outcomes. By learning whether and how scalable, tailored implementation strategies help community health centers adopt social determinants of health documentation and action, this study will yield timely guidance to primary care providers. We are not aware of previous studies exploring implementation strategies that support adoption of social determinants of action using electronic health and interventions, despite the pressing need for such guidance.

TRIAL REGISTRATION

clinicaltrials.gov, NCT03607617 , registration date: 7/31/2018-retrospectively registered.

Non-specific effects of childhood vaccines on acute childhood morbidity among HIV-exposed children in sub-Saharan Africa: a multilevel analysis

We examined the roles of determining factors responsible for acute respiratory infections and diarrhoea among immunised human immunodeficiency virus (HIV)-exposed children in sub-Saharan Africa. This study used demographic and health surveys obtained from 27 sub-Saharan African countries. The outcome variable is defined as symptoms of acute respiratory infections or episode of diarrhoea in the child of an HIV-infected mother who is vaccinated with the third dose of diphtheria-tetanus-pertussis containing vaccines. Multivariable logistic regression models were used to analyse the association between individual and contextual factors. The odds of developing symptoms of acute respiratory infections increased among those living in communities with high unemployment rate (Odds ratio = 1.15, 95% credible interval 1.05 to 1.26). The odds of developing diarrhoea increased among young mothers such that children of women aged 15-24 years were two times likely to develop diarrhoea compared to children of women aged 35-49 years (Odds ratio = 2.22, 95% credible interval 1.66 to 2.93). Public healthcare programmes should target adolescent and young women, and their family members on how to prevent diarrhoea. Efforts should be made to identify the hotspots for development of acute respiratory diseases especially in communities with high rate of unemployment and to develop strategies to combat the diseases in such communities. Initiatives such as the integrated Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea which recommends an interrelated approach for the elimination of preventable diarrhoea and pneumonia deaths should be adopted.

Assessing Statewide All-Cause Future One-Year Mortality: Prospective Study With Implications for Quality of Life, Resource Utilization, and Medical Futility

Background

For many elderly patients, a disproportionate amount of health care resources and expenditures is spent during the last year of life, despite the discomfort and reduced quality of life associated with many aggressive medical approaches. However, few prognostic tools have focused on predicting all-cause 1-year mortality among elderly patients at a statewide level, an issue that has implications for improving quality of life while distributing scarce resources fairly.

Objective

Using data from a statewide elderly population (aged ≥65 years), we sought to prospectively validate an algorithm to identify patients at risk for dying in the next year for the purpose of minimizing decision uncertainty, improving quality of life, and reducing futile treatment.

Methods

Analysis was performed using electronic medical records from the Health Information Exchange in the state of Maine, which covered records of nearly 95% of the statewide population. The model was developed from 125,896 patients aged at least 65 years who were discharged from any care facility in the Health Information Exchange network from September 5, 2013, to September 4, 2015. Validation was conducted using 153,199 patients with same inclusion and exclusion criteria from September 5, 2014, to September 4, 2016. Patients were stratified into risk groups. The association between all-cause 1-year mortality and risk factors was screened by chi-squared test and manually reviewed by 2 clinicians. We calculated risk scores for individual patients using a gradient tree-based boost algorithm, which measured the probability of mortality within the next year based on the preceding 1-year clinical profile.

Results

The development sample included 125,896 patients (72,572 women, 57.64%; mean 74.2 [SD 7.7] years). The final validation cohort included 153,199 patients (88,177 women, 57.56%; mean 74.3 [SD 7.8] years). The c-statistic for discrimination was 0.96 (95% CI 0.93-0.98) in the development group and 0.91 (95% CI 0.90-0.94) in the validation cohort. The mortality was 0.99% in the low-risk group, 16.75% in the intermediate-risk group, and 72.12% in the high-risk group. A total of 99 independent risk factors (n=99) for mortality were identified (reported as odds ratios; 95% CI). Age was on the top of list (1.41; 1.06-1.48); congestive heart failure (20.90; 15.41-28.08) and different tumor sites were also recognized as driving risk factors, such as cancer of the ovaries (14.42; 2.24-53.04), colon (14.07; 10.08-19.08), and stomach (13.64; 3.26-86.57). Disparities were also found in patients’ social determinants like respiratory hazard index (1.24; 0.92-1.40) and unemployment rate (1.18; 0.98-1.24). Among high-risk patients who expired in our dataset, cerebrovascular accident, amputation, and type 1 diabetes were the top 3 diseases in terms of average cost in the last year of life.

Conclusions

Our study prospectively validated an accurate 1-year risk prediction model and stratification for the elderly population (≥65 years) at risk of mortality with statewide electronic medical record datasets. It should be a valuable adjunct for helping patients to make better quality-of-life choices and alerting care givers to target high-risk elderly for appropriate care and discussions, thus cutting back on futile treatment.

Community Socioeconomic Disadvantage in Midlife Relates to Cortical Morphology via Neuroendocrine and Cardiometabolic Pathways

Residing in communities of socioeconomic disadvantage confers risk for chronic diseases and cognitive aging, as well as risk for biological factors that negatively affect brain morphology. The present study tested whether community disadvantage negatively associates with brain morphology via 2 biological factors encompassing cardiometabolic disease risk and neuroendocrine function. Participants were 448 midlife adults aged 30-54 years (236 women) who underwent structural neuroimaging to assess cortical and subcortical brain tissue morphology. Community disadvantage was indexed by US Census data geocoded to participants' residential addresses. Cardiometabolic risk was indexed by measurements of adiposity, blood pressure, glucose, insulin, and lipids. Neuroendocrine function was indexed from salivary cortisol measurements taken over 3 days, from which we computed the cortisol awakening response, area-under-the-curve, and diurnal cortisol decline. Community disadvantage was associated with reduced cortical tissue volume, cortical surface area, and cortical thickness, but not subcortical morphology. Moreover, increased cardiometabolic risk and a flatter (dysregulated) diurnal cortisol decline mediated the associations of community disadvantage and cortical gray matter volume. These effects were independent of age, sex, and individual-level socioeconomic position. The adverse risks of residing in a disadvantaged community may extend to the cerebral cortex via cardiometabolic and neuroendocrine pathways.

The Role of Contextual Socioeconomic Circumstances and Neighborhood Poverty Segregation on Mortality in 4 European Cities

Several studies have recognized the health disadvantage of residents in socioeconomically deprived neighborhoods, independent of the influence of individual socioeconomic conditions. The effect of neighborhood socioeconomic deprivation on general mortality has appeared heterogeneous among the cities analyzed: the underlying mechanisms have been less empirically explored, and explanations for this heterogeneous health effect remain unclear. The present study aimed to: (1) analyze the distribution of socioeconomically disadvantaged persons in neighborhoods of 4 European cities—Turin, Barcelona, Stockholm and Helsinki—trying to measure segregation of residents according to their socioeconomic conditions. Two measuring approaches were used, respectively, through dissimilarity index and clustering estimated from Bayesian models. (2) Analyze the distribution of mortality in the above mentioned cities, trying to disentangle the independent effects of both neighborhood socioeconomic deprivation and neighborhood segregation of residents according to their socioeconomic conditions, using multilevel models. A significantly higher risk of death was observed among residents in more deprived neighborhoods in all 4 cities considered, slightly heterogeneous across them. Poverty segregation appeared to be slightly associated with increasing mortality in Turin and, among females and only according to dissimilarity, in Barcelona. Few studies have explored the health effects of social clustering, and results could inform urban policy design with regard to social mix.

Developing Electronic Health Record (EHR) Strategies Related to Health Center Patients' Social Determinants of Health

BACKGROUND

"Social determinants of heath" (SDHs) are nonclinical factors that profoundly affect health. Helping community health centers (CHCs) document patients' SDH data in electronic health records (EHRs) could yield substantial health benefits, but little has been reported about CHCs' development of EHR-based tools for SDH data collection and presentation.

METHODS

We worked with 27 diverse CHC stakeholders to develop strategies for optimizing SDH data collection and presentation in their EHR, and approaches for integrating SDH data collection and the use of those data (eg, through referrals to community resources) into CHC workflows.

RESULTS

We iteratively developed a set of EHR-based SDH data collection, summary, and referral tools for CHCs. We describe considerations that arose while developing the tools and present some preliminary lessons learned.

CONCLUSION

Standardizing SDH data collection and presentation in EHRs could lead to improved patient and population health outcomes in CHCs and other care settings. We know of no previous reports of processes used to develop similar tools. This article provides an example of 1 such process. Lessons from our process may be useful to health care organizations interested in using EHRs to collect and act on SDH data. Research is needed to empirically test the generalizability of these lessons.

Socioeconomic position and outdoor nitrogen dioxide (NO2) exposure in Western Europe: A multi-city analysis

BACKGROUND

Inconsistent associations between socioeconomic position (SEP) and outdoor air pollution have been reported in Europe, but methodological differences prevent any direct between-study comparison.

OBJECTIVES

Assess and compare the association between SEP and outdoor nitrogen dioxide (NO₂) exposure as a marker of traffic exhaust, in 16 cities from eight Western European countries.

METHODS

Three SEP indicators, two defined at individual-level (education and occupation) and one at neighborhood-level (unemployment rate) were assessed in three European multicenter cohorts. NO₂ annual concentration exposure was estimated at participants' addresses with land use regression models developed within the European Study of Cohorts for Air Pollution Effects (ESCAPE; http://www.escapeproject.eu/). Pooled and city-specific linear regressions were used to analyze associations between each SEP indicator and NO₂. Heterogeneity across cities was assessed using the Higgins' I-squared test (I²).

RESULTS

The study population included 5692 participants. Pooled analysis showed that participants with lower individual-SEP were less exposed to NO₂. Conversely, participants living in neighborhoods with higher unemployment rate were more exposed. City-specific results exhibited strong heterogeneity (I²>76% for the three SEP indicators) resulting in variation of the individual- and neighborhood-SEP patterns of NO₂ exposure across cities. The coefficients from a model that included both individual- and neighborhood-SEP indicators were similar to the unadjusted coefficients, suggesting independent associations.

CONCLUSIONS

Our study showed for the first time using homogenized measures of outcome and exposure across 16 cities the important heterogeneity regarding the association between SEP and NO₂ in Western Europe. Importantly, our results showed that individual- and neighborhood-SEP indicators capture different aspects of the association between SEP and exposure to air pollution, stressing the importance of considering both in air pollution health effects studies.

Does contextual unemployment matter for health status across the life course? A longitudinal multilevel study exploring the link between neighbourhood unemployment and functional somatic symptoms

This study examines whether neighbourhood unemployment is related to functional somatic symptoms, independently of the individual employment, across the life course and at four specific life course periods (age 16, 21, 30 and 42). Self-reported questioner data was used from a 26-year prospective Swedish cohort (n=1010) with complementary neighbourhood register data. A longitudinal and a set of age-specific cross-sectional hierarchal linear regressions was carried out. The results suggest that living in a neighbourhood with high unemployment has implications for residents' level of functional somatic symptoms, regardless of their own unemployment across time, particularly at age 30.

Trends in socioeconomic inequalities in mortality in small areas of 33 Spanish cities

BACKGROUND

In Spain, several ecological studies have analyzed trends in socioeconomic inequalities in mortality from all causes in urban areas over time. However, the results of these studies are quite heterogeneous finding, in general, that inequalities decreased, or remained stable. Therefore, the objectives of this study are: (1) to identify trends in geographical inequalities in all-cause mortality in the census tracts of 33 Spanish cities between the two periods 1996-1998 and 2005-2007; (2) to analyse trends in the relationship between these geographical inequalities and socioeconomic deprivation; and (3) to obtain an overall measure which summarises the relationship found in each one of the cities and to analyse its variation over time.

METHODS

Ecological study of trends with 2 cross-sectional cuts, corresponding to two periods of analysis: 1996-1998 and 2005-2007. Units of analysis were census tracts of the 33 Spanish cities. A deprivation index calculated for each census tracts in all cities was included as a covariate. A Bayesian hierarchical model was used to estimate smoothed Standardized Mortality Ratios (sSMR) by each census tract and period. The geographical distribution of these sSMR was represented using maps of septiles. In addition, two different Bayesian hierarchical models were used to measure the association between all-cause mortality and the deprivation index in each city and period, and by sex: (1) including the association as a fixed effect for each city; (2) including the association as random effects. In both models the data spatial structure can be controlled within each city. The association in each city was measured using relative risks (RR) and their 95 % credible intervals (95 % CI).

RESULTS

For most cities and in both sexes, mortality rates decline over time. For women, the mortality and deprivation patterns are similar in the first period, while in the second they are different for most cities. For men, RRs remain stable over time in 29 cities, in 3 diminish and in 1 increase. For women, in 30 cities, a non-significant change over time in RR is observed. However, in 4 cities RR diminishes. In overall terms, inequalities decrease (with a probability of 0.9) in both men (RR = 1.13, 95 % CI = 1.12-1.15 in the 1st period; RR = 1.11, 95 % CI = 1.09-1.13 in the 2nd period) and women (RR = 1.07, 95 % CI = 1.05-1.08 in the 1st period; RR = 1.04, 95 % CI = 1.02-1.06 in the 2nd period).

CONCLUSIONS

In the future, it is important to conduct further trend studies, allowing to monitoring trends in socioeconomic inequalities in mortality and to identify (among other things) temporal factors that may influence these inequalities.

Experiences with Recruitment of Marginalized Groups in a Danish Health Promotion Program: A Document Evaluation Study

Background

Studies have found that marginalized groups living in deprived neighborhoods are less likely to participate in health programs compared to the majority of society. This study evaluates recruitment approaches conducted during a national government-funded project in 12 deprived neighborhoods across Denmark between 2010 and 2014. The aim of this study was to understand how recruitment approaches could promote participation in health programs within deprived neighborhoods to reach marginalized groups.

Method

Documents from all 12 of the included municipalities were collected to conduct a document evaluation. The collected documents consisted of 1,500 pages of written material with 12 project descriptions, three midterm and 10 final evaluations. The collected data were analyzed through a qualitative content analysis.

Results

The results are based on the fact that only 10 municipalities have developed evaluations related to recruitment, and only three evaluations provided a description of which marginalized groups were recruited. Challenges related to recruitment consist of difficulties involving the target group, including general distrust, language barriers and a lack of ability to cope with new situations and strangers. Additional geographical challenges emerged, especially in rural areas. Positive experiences with recruitment approaches were mainly related to relationship building and trust building, especially through face-to-face contact and the project employees’ presence in the neighborhood. Additionally, adjusting some of the interventions and the recruitment strategy increased participation.

Conclusion

This study found that relation and trust between the residents and the project employees is an important factor in the recruitment of marginalized groups in deprived neighborhoods as well as adjusting the health interventions or recruitment strategy to the target groups. In future research, it is necessary to examine which recruitment approaches are effective under which circumstances to increase participation among marginalized groups.

Twenty years of socioeconomic inequalities in premature mortality in Barcelona: The influence of population and neighbourhood changes

The objective of this study was to analyse trends in socioeconomic inequalities in premature mortality in Barcelona from 1992 to 2011, accounting for population changes. We conducted a repeated cross-sectional study of the Barcelona population (25-64 years) using generalized linear mixed models for trend analysis, and found that socioeconomic inequalities in premature mortality persisted between neighbourhoods, but tended to diminish. However, the reduction in inequality was related to an increase in the number of foreign-born individuals mainly in socioeconomic disadvantaged neighbourhoods, in which the decrease in premature mortality was more marked. To study trends in geographical inequalities in mortality, it is essential to understand demographic changes occurred in different places related to local levels of deprivation.

Inequalities in mortality by socioeconomic factors and Roma ethnicity in the two biggest cities in Slovakia: a multilevel analysis

Background

The socioeconomic and ethnic composition of urban neighbourhoods may affect mortality, but evidence on Central European cities is lacking. The aim of this study was to assess the associations between socioeconomic and ethnic neighbourhood indicators and the mortality of individuals aged 20–64 years old in the two biggest cities of the Slovak Republic.

Methods

We obtained data on the characteristics of neighbourhoods and districts (educational level, unemployment, income and share of Roma) and on individual mortality of residents aged 20–64 years old, for the two largest cities in the Slovak Republic (Bratislava and Kosice) in the period 2003–2005. We performed multilevel Poisson regression analyses adjusted for age and gender on the individual (mortality), neighbourhood (education level and share of Roma in population) and district levels (unemployment and income).

Results

The proportions of Roma and of low-educated residents were associated with mortality at the neighbourhood level in both cities. Mutually adjusted, only the association with the proportion of Roma remained in the model (risk ratio 1.02; 95 % confidence interval 1.01–1.04). The area indicators – high education, income and unemployment – were not associated with mortality.

Conclusion

The proportion of Roma is associated with early mortality in the two biggest cities in the Slovak Republic.

"Community vital signs": incorporating geocoded social determinants into electronic records to promote patient and population health

Social determinants of health significantly impact morbidity and mortality; however, physicians lack ready access to this information in patient care and population management. Just as traditional vital signs give providers a biometric assessment of any patient, "community vital signs" (Community VS) can provide an aggregated overview of the social and environmental factors impacting patient health. Knowing Community VS could inform clinical recommendations for individual patients, facilitate referrals to community services, and expand understanding of factors impacting treatment adherence and health outcomes. This information could also help care teams target disease prevention initiatives and other health improvement efforts for clinic panels and populations. Given the proliferation of big data, geospatial technologies, and democratization of data, the time has come to integrate Community VS into the electronic health record (EHR). Here, the authors describe (i) historical precedent for this concept, (ii) opportunities to expand upon these historical foundations, and (iii) a novel approach to EHR integration.

Effect of unemployment on cardiovascular risk factors and mental health

BACKGROUND

Following the economic changes in Poland, increasing health discrepancies were observed during a period of 20 years, which may be partly attributable to the consequences of unemployment.

AIMS

To assess the association between unemployment, major cardiovascular risk factors and mental health.

METHODS

A cross-sectional study in which data were collected between 2009 and 2010 during preventive health examinations by an occupational medicine service in Gdansk, Poland. Data on blood pressure, resting heart rate, information about smoking habits, body mass index and history of use of mental health services were collected during these assessments. Multiple logistic regression was used during data analysis to adjust for age, gender, education and length of employment.

RESULTS

Study participants comprised 3052 unemployed and 2059 employed individuals. After adjustment for age, gender, education and number of previous employments, the odds ratio (OR) for hypertension in relation to unemployment was 1.02 [95% confidence interval (95% CI) 0.84-1.23]. There was a statistically significant negative association between being overweight and unemployment (OR = 0.81, 95% CI: 0.66-0.99). Smoking was positively associated with unemployment after adjustment for age and sex (OR = 1.45, 95% CI: 1.25-1.67). There was a positive relationship between mental ill-health and unemployment among study participants (OR = 2.05, 95% CI: 0.91-4.65), but this was not statistically significant.

CONCLUSIONS

The patterns of major cardiovascular risk factors differed between unemployed and employed individuals in Poland. Our observations suggest employment status is a predictor of specific disease risk profiles; consequently, specific preventive measures are needed in unemployed individuals.

Social differences in avoidable mortality between small areas of 15 European cities: an ecological study

Background

Health and inequalities in health among inhabitants of European cities are of major importance for European public health and there is great interest in how different health care systems in Europe perform in the reduction of health inequalities. However, evidence on the spatial distribution of cause-specific mortality across neighbourhoods of European cities is scarce. This study presents maps of avoidable mortality in European cities and analyses differences in avoidable mortality between neighbourhoods with different levels of deprivation.

Methods

We determined the level of mortality from 14 avoidable causes of death for each neighbourhood of 15 large cities in different European regions. To address the problems associated with Standardised Mortality Ratios for small areas we smooth them using the Bayesian model proposed by Besag, York and Mollié. Ecological regression analysis was used to assess the association between social deprivation and mortality.

Results

Mortality from avoidable causes of death is higher in deprived neighbourhoods and mortality rate ratios between areas with different levels of deprivation differ between gender and cities. In most cases rate ratios are lower among women. While Eastern and Southern European cities show higher levels of avoidable mortality, the association of mortality with social deprivation tends to be higher in Northern and lower in Southern Europe.

Conclusions

There are marked differences in the level of avoidable mortality between neighbourhoods of European cities and the level of avoidable mortality is associated with social deprivation. There is no systematic difference in the magnitude of this association between European cities or regions. Spatial patterns of avoidable mortality across small city areas can point to possible local problems and specific strategies to reduce health inequality which is important for the development of urban areas and the well-being of their inhabitants.

Books average previous decade of economic misery

For the 20^th century since the Depression, we find a strong correlation between a ‘literary misery index’ derived from English language books and a moving average of the previous decade of the annual U.S. economic misery index, which is the sum of inflation and unemployment rates. We find a peak in the goodness of fit at 11 years for the moving average. The fit between the two misery indices holds when using different techniques to measure the literary misery index, and this fit is significantly better than other possible correlations with different emotion indices. To check the robustness of the results, we also analysed books written in German language and obtained very similar correlations with the German economic misery index. The results suggest that millions of books published every year average the authors' shared economic experiences over the past decade.

Gender differences in the association of individual social class and neighbourhood unemployment rate with prevalent type 2 diabetes mellitus: a cross-sectional study from the DIAB-CORE consortium

OBJECTIVE

To analyse gender differences in the relationship of individual social class, employment status and neighbourhood unemployment rate with present type 2 diabetes mellitus (T2DM).

DESIGN

Five cross-sectional studies.

SETTING

Studies were conducted in five regions of Germany from 1997 to 2006.

PARTICIPANTS

The sample consisted of 8871 individuals residing in 226 neighbourhoods from five urban regions.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalent T2DM.

RESULTS

We found significant multiplicative interactions between gender and the individual variables--social class and employment status. Social class was statistically significantly associated with T2DM in men and women, whereby this association was stronger in women (lower vs higher social class: OR 2.68 (95% CIs 1.66 to 4.34)) than men (lower vs higher social class: OR 1.78 (95% CI 1.22 to 2.58)). Significant associations of employment status and T2DM were only found in women (unemployed vs employed: OR 1.73 (95% CI 1.02 to 2.92); retired vs employed: OR 1.77 (95% CI 1.10 to 2.84); others vs employed: OR 1.64 (95% CI 1.01 to 2.67)). Neighbourhood unemployment rate was associated with T2DM in men (high vs low tertile: OR 1.52 (95% CI 1.18 to 1.96)). Between-study and between-neighbourhood variations in T2DM prevalence were more pronounced in women. The considered covariates helped to explain statistically the variation in T2DM prevalence among men, but not among women.

CONCLUSIONS

Social class was inversely associated with T2DM in both men and women, whereby the association was more pronounced in women. Employment status only affected T2DM in women. Neighbourhood unemployment rate is an important predictor of T2DM in men, but not in women.

Socioeconomic characteristics of residential areas and risk of death: is variation in spatial units for analysis a source of heterogeneity in observed associations?

OBJECTIVES

Evidence on the association between the adverse socioeconomic characteristics of residential area and mortality is mixed. We examined whether the choice of spatial unit is critical in detecting this association.

DESIGN

Register-linkage study.

SETTING

Data were from the Finnish Public Sector study's register cohort.

PARTICIPANTS

The place of residence of 146 600 cohort participants was linked to map grids and administrative areas, and they were followed up for mortality from 2000 to 2011. Residential area socioeconomic deprivation and household crowding were aggregated into five alternative areas based on map grids (250×250 m, 1×1 km and 10×10 km squares), and administrative borders (zip-code area and town).

PRIMARY AND SECONDARY OUTCOME MEASURES

All-cause mortality.

RESULTS

For the 250×250 m area, mortality risk increased with increasing socioeconomic deprivation (HR for top vs bottom quintile 1.36, 95% CI 1.21 to 1.52). This association was either weaker or missing when broader spatial units were used. For household crowding, excess mortality was observed across all spatial units, the HRs ranging from 1.14 (95% CI 1.03 to 1.25) for zip code, and 1.21 (95% CI 1.11 to 1.31) for 250×250 m areas to 1.28 (95% CI 1.10 to 1.50) for 10×10 km areas.

CONCLUSIONS

Variation in spatial units for analysis is a source of heterogeneity in observed associations between residential area characteristics and risk of death.

Urban neighbourhood unemployment history and depressive symptoms over time among late middle age and older adults

BACKGROUND

Little is known about how a neighbourhood's unemployment history may set the stage for depressive symptomatology. This study examines the effects of urban neighbourhood unemployment history on current depressive symptoms and subsequent symptom trajectories among residentially stable late middle age and older adults. Contingent effects between neighbourhood unemployment and individual-level employment status (ie, cross-level interactions) are also assessed.

METHODS

Individual-level survey data are from four waves (2000, 2002, 2004 and 2006) of the original cohort of the nationally representative US Health and Retirement Study. Neighbourhoods are operationalised with US Census tracts for which historical average proportion unemployed between 1990 and 2000 and change in proportion unemployed between 1990 and 2000 are used to characterise the neighbourhood's unemployment history. Hierarchical linear regressions estimate three-level (time, individual and neighbourhood) growth models.

RESULTS

Symptoms in 2000 are highest among those residing in neighbourhoods characterised by high historical average unemployment beginning in 1990 and increasing unemployment between 1990 and 2000, net of a wide range of socio-demographic controls including individual-level employment status. These neighbourhood unemployment effects are not contingent upon individual-level employment status in 2000. 6-year trajectories of depressive symptoms decrease over time on average but are not significantly influenced by the neighbourhood's unemployment history.

CONCLUSIONS

Given the current US recession, future studies that do not consider historical employment conditions may underestimate the mental health impact of urban neighbourhood context. The findings suggest that exposure to neighbourhood unemployment earlier in life may be consequential to mental health later in life.

Neighborhood deprivation and clinical outcomes among head and neck cancer patients

The unique effects of neighborhood-level economic deprivation on survival, recurrence, and second primary malignancy development were examined using adjusted Cox proportional hazards regression models among 1151 incident squamous cell carcinomas of the head and neck patients. Cancer site was examined as a potential moderator. Main analyses yielded null results; however, interaction analyses indicated poorer overall survival [HR=1.59 (1.00-2.53)] and greater second primary malignancy development [HR=2.99 (1.46-6.11)] among oropharyngeal cancer patients from highly deprived neighborhoods relative to less deprived neighborhoods. Results suggest a dual focus on individual and neighborhood risk factors could help improve clinical outcomes among oropharyngeal cancer patients.

The association between residential area characteristics and mental health outcomes among men and women in Belgium

AIM

Recently, interest has grown in the association between contextual factors and health outcomes. This study questions whether mental health complaints vary according to the socio-economic characteristics of the residential area where people live. The gender-specific patterns are studied.

METHODS

Complaints of depression and generalized anxiety were measured by means of the relevant subscales of the Symptoms Checklist 90-Revised. Multilevel models were estimated with PASW statistics 18, based on a unique dataset, constructed by merging data from the Belgian Health Interview Surveys from 2001 and 2004 with data from 264 municipalities derived from Statistics Belgium and the General Socio-Economic Survey.

MAIN FINDINGS

The results of this exploratory study indicate that the local unemployment rate is associated with complaints of depression among women.

CONCLUSION

This study suggests that policy should approach the male and female population differently when implementing mental health prevention campaigns.

Using matched areas to explore international differences in population health

In this paper, we develop and test a method for examining the influence of national level contextual influences on population health. Acknowledging calls for the use of experimental study designs to explore contextual influences on health, we develop a study design in which sets of local areas from Britain and Belgium became akin to two 'treatment' groups; one exposed to British society and culture and the other exposed to Belgian society and culture. The areas are matched on the basis of showing very strong similarities in economic, demographic and historical characteristics. Data describing these characteristics are obtained from national census data. A principal component analysis of these variables permits areas in Britain and Belgium with similar scores on the resulting components to be matched into pairs. A sequence of logistic regression models identifies between-country difference in the risk of reporting poor health. Our final model compares the risk of reporting poor health among Belgians and people from Britain living in similar local contexts, adjusting for any residual differences in individual level characteristics. We compare results from this new method with those from more conventional approaches. All approaches show that residence in Britain is associated with a substantial and significantly higher risk of reporting poor health for both men and women, after adjustment for both individual and local contextual influences. We then critically reflect on our method and on the context-composition framework for research into area variation in health. We conclude that whilst our approach succeeded in applying the idea of comparable groups with different exposures to an observational, international comparison, it also brought associated questions about external validity and the extent to which a sample of matched areas captures a 'national' context.

Does context matter for the relationship between deprivation and all-cause mortality? The West vs. the rest of Scotland

Background

A growing body of research emphasizes the importance of contextual factors on health outcomes. Using postcode sector data for Scotland (UK), this study tests the hypothesis of spatial heterogeneity in the relationship between area-level deprivation and mortality to determine if contextual differences in the West vs. the rest of Scotland influence this relationship. Research into health inequalities frequently fails to recognise spatial heterogeneity in the deprivation-health relationship, assuming that global relationships apply uniformly across geographical areas. In this study, exploratory spatial data analysis methods are used to assess local patterns in deprivation and mortality. Spatial regression models are then implemented to examine the relationship between deprivation and mortality more formally.

Results

The initial exploratory spatial data analysis reveals concentrations of high standardized mortality ratios (SMR) and deprivation (hotspots) in the West of Scotland and concentrations of low values (coldspots) for both variables in the rest of the country. The main spatial regression result is that deprivation is the only variable that is highly significantly correlated with all-cause mortality in all models. However, in contrast to the expected spatial heterogeneity in the deprivation-mortality relationship, this relation does not vary between regions in any of the models. This result is robust to a number of specifications, including weighting for population size, controlling for spatial autocorrelation and heteroskedasticity, assuming a non-linear relationship between mortality and socio-economic deprivation, separating the dependent variable into male and female SMRs, and distinguishing between West, North and Southeast regions. The rejection of the hypothesis of spatial heterogeneity in the relationship between socio-economic deprivation and mortality complements prior research on the stability of the deprivation-mortality relationship over time.

Conclusions

The homogeneity we found in the deprivation-mortality relationship across the regions of Scotland and the absence of a contextualized effect of region highlights the importance of taking a broader strategic policy that can combat the toxic impacts of socio-economic deprivation on health. Focusing on a few specific places (e.g. 15% of the poorest areas) to concentrate resources might be a good start but the impact of socio-economic deprivation on mortality is not restricted to a few places. A comprehensive strategy that can be sustained over time might be needed to interrupt the linkages between poverty and mortality.

Parental education and lung function of children in the PATY study

Studies of the relationships between low socio-economic status and impaired lung function were conducted mainly in Western European countries and North America. East-West differences remain unexplored. Associations between parental education and lung function were explored using data on 24,010 school-children from eight cross-sectional studies conducted in North America, Western and Eastern Europe. Parental education was defined as low and high using country-specific classifications. Country-specific estimates of effects of low parental education on volume and flow parameters were obtained using linear and logistic regression, controlling for early life and other individual risk factors. Meta-regressions were used for assessment of heterogeneity between country-specific estimates. The association between low parental education and lung function was not consistent across the countries, but showed a more pronounced inverse gradient in the Western countries. The most consistent decrease associated with low parental education was found for peak expiratory flow (PEF), ranging from -2.80 to -1.14%, with statistically significant associations in five out of eight countries. The mean odds ratio for low PEF (<75% of predicted) was 1.34 (95% CI 1.06-1.70) after all adjustments. Although social gradients were attenuated after adjusting for known risk factors, these risk factors could not completely explain the social gradient in lung function.

Does it matter what you measure? Neighbourhood effects in a canadian setting

Data from 8,032 Manitoba respondents to the 1996/97 Canadian National Population Health Survey were linked to the 1996 census to study whether measures of morbidity, both self-reported and objectively determined, were affected by neighbourhood context. Once age, gender, smoking status, diabetes, body mass index and individual income were added to individual and multi-level regression models, effects of various neighbourhood characteristics were attenuated and significant in relatively few cases. Caution is definitely called for in generalizing from studies based on one or two dependent variables. Weak relationships are likely to lead to contradictory findings with respect to the importance of neighbourhood effects.

Inequalities in mortality in small areas of eleven Spanish cities (the multicenter MEDEA project)

The objectives of this study are to identify inequalities in mortality among census tracts of 11 Spanish cities in the period 1996-2003 and to analyse the relationship between these geographical inequalities and socioeconomic deprivation. It is a cross-sectional ecological study where the units of analysis are census tracts. We obtained an index of socioeconomic deprivation and estimated SMR by each census tract using hierarchical Bayesian models which take into account the spatial structure. In the majority of the cities geographical patterns in total mortality were found in both sexes, which were similar to those for the index of socioeconomic deprivation. Among men, four specific causes of death (lung cancer, ischemic heart diseases, respiratory diseases and cirrhosis) were positively associated with deprivation in the majority of cities. Among women the specific causes diabetes and cirrhosis were positively associated, while lung cancer was negatively associated with deprivation. The excess of mortality related with deprivation was 59,445 deaths among men and 23,292 among women. These results highlight the importance of intra-urban inequalities in health.

Urban neighborhood context and mortality in late life

OBJECTIVE

To examine the contextual effects of urban neighborhood characteristics on mortality among older adults.

METHOD

Data are from the Study of Assets and Health Dynamics Among the Oldest Old (AHEAD). Death is assessed between the baseline assessment (1993) and the first follow-up interview (1995). Neighborhood data are from the 1990 Census.

RESULTS

The log odds of dying between the two time points are higher in high proportion Hispanic neighborhoods, net of individual-level sociodemographic variables, but this effect is partly mediated by individual-level health. The log odds of dying are significantly (p < .05) lower in affluent neighborhoods, controlling for all individual-level variables and neighborhood proportion Hispanic.

DISCUSSION

There are survival-related benefits of living in an affluent urban neighborhood, which we posit may be manifested through the diffusion of innovations in health care and health-promotion activities.

Mortality effects of average education: a multilevel study of small neighbourhoods in rural and urban areas in Norway

Background

The intention was to find out whether there was an association between the socio-economic resources in a small neighbourhood ("basic statistical unit"; BSU) and individual mortality, net of individual resources, and whether this association differed between municipalities including a quite large city and others. The possibility of a rural-urban difference in the health effect of community resources has not been checked earlier.

Methods

Discrete-time hazard models for mortality at age 60-89 were estimated for 1990-1992 and 2000-2002, using register data that cover the entire Norwegian population. For each person, the educational level and the municipality and BSU of residence in 1990 and 2000 were known. Average education was computed by aggregating over the individual data. In total, there were about 200000 deaths in more than 13000 BSUs during 5 million person-years of observation.

Results

There was a significant relationship between average education in the BSU and individual mortality, but only in the medium-sized and largest municipalities. The sharpest relationship was seen in the latter, where for example OR per year of education was 0.908 (95% CI 0.887-0.929) in the 1990-92 period. The findings were robust to various alternative specifications.

Conclusion

These results from a large data set are consistent with the idea that neighbourhood socio-economic resources may affect individual mortality, but suggest that distinctions according to population size or density be made in future research and that one should be careful, if focusing on cities, to generalize beyond that setting. With these data, one can only speculate about the reasons for the rural-urban difference. A stronger higher-level spatial segregation in urban areas may be one explanation.

Health status and health behaviours in neighbourhoods: a comparison of Glasgow, Scotland and Hamilton, Canada

Health status has been demonstrated to vary by neighbourhood socioeconomic status (SES). However, neighbourhood effects may vary between countries. In this study, neighbourhood variations in health outcomes are compared across four socially contrasting neighbourhoods in Glasgow, Scotland and Hamilton, Ontario Canada. Data came from the 2001 wave of the West of Scotland Twenty-07 Longitudinal Study and a 2000/2001 cross-sectional survey conducted in Hamilton. The results of the comparison point to important variations in the relationship between neighbourhood SES and health. While both cities display a socioeconomic gradient with respect to various measures of health and health behaviours, for some outcome measures the high SES neighbourhoods in Glasgow display distributions similar to those found in the low SES neighbourhoods in Hamilton. Our results suggest that a low SES neighbourhood in one country may not mean the same for health as a low SES neighbourhood in another country. As such, country context may explain the distribution of health status and health behaviours among socially contrasting neighbourhoods, and neighbourhood variations in health may be context specific.

Spatial variability in mortality inequalities, socioeconomic deprivation, and air pollution in small areas of the Barcelona Metropolitan Region, Spain

BACKGROUND

There is evidence that geographic variability of social health inequalities continues to exist even after individual risk factors have been taken into account. However, relatively few studies have examined the contribution of exposure to air pollutants to those inequalities.

OBJECTIVES

To study the geographic variability of inequalities in mortality and their associations with socioeconomic and environmental inequalities in small areas of the metropolitan of Barcelona during the period 1994 to 2003.

METHODS

As in the MEDEA Project, the small area unit was the census tract. Study population consisted of the residents of the metropolitan area of Barcelona. Response variables were all-cause and specific-cause standardized mortality ratio (SMR). Explanatory variables were deprivation index, summarizing socioeconomic variables of the census tracts, and estimates of air pollutant exposures. Bayesian hierarchical models were used in order to reduce the extra variability when using SMR and to assess associations between mortality and deprivation and air pollution.

RESULTS

Statistically significant associations with deprivation were found for the causes of death related to consumption of tobacco and alcohol for men and, besides lung cancer, diet-related causes for women. Statistically significant pollution coefficients were only found in the metropolitan area of Barcelona and in men. A positive interaction between pollutants and the deprivation index was statistically significant for respiratory mortality and PM(10), and ischemic disease mortality and NO(2), both for men.

CONCLUSIONS

We found deprivation to be associated in a statistically significant way with the geographical variation in mortality in the census tracts of the metropolitan area of Barcelona, in the period 1994 to 2003. Those air pollutants more directly related with traffic modify some of these associations.

Mental health in a gendered context: Gendered community effect on depression and problem drinking

Socio-economic features of a community influence people's health. However, not all inhabitants are affected similarly. The present study explores gendered contextual effects on problem drinking and depression with the differential exposure, vulnerability and expression hypotheses of the social stress model in mind. Analyses are based on the pooled data of the Belgian Health Interview Survey 2001 and 2004 (N=21.367 respondents, N=589 municipalities). Results reveal that living in an area with high unemployment is more detrimental for women in terms of depression, but has the same impact on men and women when problem drinking is the outcome.

Smoking, drinking and body weight after re-employment: does unemployment experience and compensation make a difference?

BACKGROUND

The impact of unemployment on behaviours such as smoking, drinking and body weight has been extensively researched. However, little is known about the possible protective effects of social assistance programs on these behavioural changes. This study examines the impact of unemployment periods on smoking, drinking and body weight changes among re-employed individuals and investigates whether the receipt of unemployment benefits influences these behaviours.

METHODS

This study used panel data provided by the Panel Study of Income Dynamics. Logistic regression models were used to analyze whether a period of unemployment in 2000 resulted in an increase in smoking and drinking or fluctuations in body weight among 2001 re-employed individuals in comparison with 1999 baseline levels. A total of 3,451 respondents who had been initially healthy and who had been continuously employed between 1998 and 1999 were included in the analysis.

RESULTS

Compared to stably employed respondents, those who had experienced periods of unemployment in 2000 and did not receive unemployment benefits were more likely than continuously employed individuals to report an increase in alcohol consumption (OR 1.8, 95% CI 1.0-3.1) and a decrease in body weight (OR 1.7, 95% CI 1.1-2.8) when they were already re-employed in 2001.

CONCLUSION

Our findings suggest that the receipt of unemployment benefits confers a protective effect on health behavioural changes following periods of unemployment. These findings underscore the need to monitor the impact of unemployment assistance programs on health, particularly in light of the rapidly changing structure of employment and unemployment benefits.

Evaluating options for measurement of neighborhood socioeconomic context: evidence from a myocardial infarction case-control study

We hypothesized that neighborhood socioeconomic context would be most strongly associated with risk of myocardial infarction (MI) for smaller "neighborhood" definitions. We used data on 487 non-fatal, incident MI cases and 1873 controls from a case-control study in Washington State. Census data on income, home ownership, and education were used to estimate socioeconomic context across four neighborhood definitions: 1 km buffer, block group, census tract, and ZIP code. No neighborhood definition led to consistently stronger associations with MI. Although we confirmed the association between neighborhood socioeconomic measures and risk of MI, we did not find these associations sensitive to neighborhood definition.

Do socioeconomic characteristics of neighbourhood of residence independently influence incidence of coronary heart disease and all-cause mortality in older British men?

BACKGROUND

The relationship between coronary heart disease (CHD) incidence and death, and individual sociodemographic status is well established. Our aim was to examine whether neighbourhood deprivation scores predict CHD and death in older men, independently of individual sociodemographic status.

METHODS

Prospective study of 5049 men, born between 1918 and 1939, recruited from 24 British towns encompassing 969 electoral wards, without documented evidence of previous major CHD when responding to a questionnaire in 1992, and followed up for incidence of major CHD and death.

RESULTS

Four hundred and seventy-two new major CHD events (1.08% pa), and 1021 deaths (2.28% pa) occurred over an average of 9.75 years. When men were divided into fifths according to increasing neighbourhood deprivation score, CHD incidences (% pa) were 0.92, 0.89, 0.99, 1.33 and 1.29. When modelling continuous trends, the rate ratio for men in the top fifth compared with the bottom fifth was 1.55 (95% confidence interval 1.19-2.00) for CHD. This rate ratio was, however, no longer statistically significant [1.22 (95% confidence interval 0.92-1.61)] when effects of individual sociodemographic status measures (car ownership, housing, longest held occupation, marital status and social networks) were accounted for.

CONCLUSION

Little evidence of an independent relationship of neighbourhood deprivation with CHD incidence was found once individual measures of sociodemographic status had been adjusted for.

A tool for developing gender research in medicine: examples from the medical literature on work life

BACKGROUND

Interest is growing both in implementing a gender perspective in medical research and in developing gender research. However, few models exist that can help researchers who want to develop gender research.

OBJECTIVES

The objectives of this article were to analyze gender research compared with sex/gender blind research as well as with research on sex/gender differences in work-life research, and to propose a tool that can be used by researchers who want to develop gender research.

METHODS

Using the PubMed database, the search period for the main analyses covered January 1, 2000, to November 1, 2006. In the first of 2 searches, the search criteria were English language and the term unemployment. In the second search, the criteria used were English language and 3 combinations of search terms: (1) underemploy or employ and (fixed-term or types or temporary or atypical or precarious or casual); (2) labor market and (attachment or core periphery or trajectory); and (3) job and (flexibility or casual).

RESULTS

The number of articles about women and gender in unemployment research that are available in PubMed steadily increased during the 1990s. The proposed model could be regarded as a tool that by necessity is simplified. The tool should not be interpreted as if all research fulfills all the characteristics in the model; rather, the tool illustrates the potentials with gender research. Whereas gender research questions the dominating epistemology of medicine (eg, through challenging biological determinism), the other 2 research traditions are often performed within the dominating medical paradigm. Gender is an analytic category, and structural analyses of gender relations are central in medical gender research, whereas sex/gender is often analyzed as a variable on the individual level in other research. Masculinity research constitutes a dynamic part of gender research. However, in other research, men as well as women are often analyzed as one of several variables. Through questioning the existing field of knowledge, gender research, with its base in power analyses and theoretical development, can provide new and different knowledge about men and women. In gender research, there has been an increasing awareness of the need for vigilance to avoid exaggerating differences (both biological and sociocultural) between men and women. Thus, the risk of essentialism (ie, the tendency to regard differences between men and women as constant, pervasive, and unchangeable) is lower than in other research.

CONCLUSION

A model has been suggested that may be used to implement gender research. This tool needs continuous development through active dialogue between gender researchers.

Doenças respiratórias agudas: um estudo das desigualdades em saúde

Apresentam-se as desigualdades em saúde valendo-se das doenças respiratórias agudas na infância na área de abrangência de um centro de saúde na cidade de São Paulo, Brasil, para subsidiar o planejamento local de ações de promoção da saúde. O trabalho se fundamentou em estudos ecológicos que utilizam a área geográfica como unidade de análise, permitindo a comparação de indicadores de saúde e sócio-econômicos mediante dados censitários. Foram construídos indicadores de "inserção social" e de "qualidade do domicílio", gerando o "índice potencial de exposição" que reflete as condições de risco para o adoecimento por agravos respiratórios. O tratamento estatístico incluiu o agrupamento pela técnica de cluster. Foram identificados quatro grupos sociais homogêneos nas condições de risco para as doenças respiratórias agudas. Os grupos III e IV - com as piores condições sócio-econômicas - mostraram diferenciais importantes em relação aos grupos I e II. Os diferenciais de mortes por pneumonia encontrados, sugerem iniqüidades em saúde. Os resultados permitiram a localização geográfica de maior e menor concentração das carências relativas às condições de vida e a comparação entre os setores censitários para o reconhecimento de necessidades distintas, que subsidiem propostas para a articulação intersetorial.

Pathways to obesity: Identifying local, modifiable determinants of physical activity and diet

Many studies document small area inequalities in morbidity and mortality and show associations between area deprivation and health. However, few studies unpack the "black box" of area deprivation to show which specific local social and physical environmental characteristics impact upon health, and might be amenable to modification. We theorised a model of the potential causal pathways to obesity and employed path analysis using a rich data set from national studies in England and Scotland to test the model empirically. Significant associations between obesity and neighbourhood disorder and access to local high street facilities (local shops, financial services and health-related stores found in a typical small UK town) were found. There was a tendency for lower levels of obesity in areas with more swimming pools and supermarkets. In turn, policing levels, physical dereliction and recorded violent crime were associated with neighbourhood disorder. The analysis identifies several factors that are associated with (and are probably determinants of) obesity and which are outside the standard remit of the healthcare sector. They highlight the role that public and private sector organisations have in promoting the nation's health. Public health professionals should seek to work alongside or within these organisations to capitalise on opportunities to improve health.

Neighbourhood socioeconomic status and cardiovascular risk factors: a multilevel analysis of nine cities in the Czech Republic and Germany

Background

Previous studies have shown that deprived neighbourhoods have higher cardiovascular mortality and morbidity rates. Inequalities in the distribution of behaviour related risk factors are one possible explanation for this trend. In our study, we examined the association between cardiovascular risk factors and neighbourhood characteristics. To assess the consistency of associations the design is cross-national with data from nine industrial towns from the Czech Republic and Germany.

Methods

We combined datasets from two population based studies, one in Germany ('Heinz Nixdorf Recall (HNR) Study'), and one in the Czech Republic ('Health, Alcohol and Psychosocial Factors in Eastern Europe (HAPIEE) Study'). Participation rates were 56% in the HNR and 55% in the HAPIEE study. The subsample for this particular analysis consists of 11,554 men and women from nine German and Czech towns. Census based information on social characteristics of 326 neighbourhoods were collected from local administrative authorities. We used unemployment rate and overcrowding as area-level markers of socioeconomic status (SES). The cardiovascular risk factors obesity, hypertension, smoking and physical inactivity were used as response variables. Regression models were complemented by individual-level social status (education) and relevant covariates.

Results

Smoking, obesity and low physical activity were more common in deprived neighbourhoods in Germany, even when personal characteristics including individual education were controlled for. For hypertension associations were weak. In the Czech Republic associations were observed for smoking and physical inactivity, but not for obesity and hypertension when individual-level covariates were adjusted for. The strongest association was found for smoking in both countries: in the fully adjusted model the odds ratio for 'high unemployment rate' was 1.30 [95% CI 1.02–1.66] in the Czech Republic and 1.60 [95% CI 1.29–1.98] in Germany.

Conclusion

In this comparative study, the effects of neighbourhood deprivation varied by country and risk factor; the strongest and most consistent effects were found for smoking. Results indicate that area level SES is associated with health related lifestyles, which might be a possible pathway linking social status and cardiovascular disease. Individual-level education had a considerable influence on the association between neighbourhood characteristics and risk factors.

Neighbourhood inequalities in health and health-related behaviour: Results of selective migration?

We hypothesised that neighbourhood inequalities in health and health-related behaviour are due to selective migration between neighbourhoods. Ten-year follow-up data of 25-74-year-old participants in a Dutch city (Eindhoven) showed an increased probability of both upward and downward migration in 25-34-year-old participants, and in single and divorced participants. Women and those highly educated showed an increased probability of upward migration from the most deprived neighbourhoods; lower educated showed an increased probability of moving downwards. Adjusted for these factors, health and health-related behaviour were weakly associated with migration. Over 10 years of follow-up, selective migration will hardly contribute to neighbourhood inequalities in health and health-related behaviour.