Indicators of socioeconomic position (part 1)

Stress during pregnancy and fetal serum BDNF in cord blood at birth

INTRODUCTION

Adverse environments during pregnancy impact neurodevelopment including cognitive abilities of the developing children. The mediating biological alterations are not fully understood. Maternal stress may impact the neurotrophic regulation of the offspring as early as in utero and at birth. Brain-derived neurotrophic factor (BDNF) is essential for neurodevelopment. Short-term higher levels of BDNF in mice upon stressors associate with lower BDNF later in life, which itself associates with depression in animals and humans. Stress including glucocorticoids may impact BDNF, but there is a lack of data at birth. This study investigated if stress near term associates with fetal BDNF at birth in humans.

METHODS

Pregnant women near term who underwent primary cesarean sections (at 38.80±0.64 weeks), were included in this study (n=41). Stress at the end of pregnancy was assessed before the cesarean section by determining maternal depressive symptoms (EDPS), maternal state and trait anxiety (STAI-S and STAI-T), maternal prenatal distress (PDQ), stress over the past month (PSS), prenatal attachment to the offspring (PAI), maternal social support (F-Sozu), maternal early life stress (CTQ), socioeconomic status, and the glucocorticoids cortisol and cortisone (n=40) in amniotic fluid at birth. The association with fetal BDNF was analyzed. Cord blood serum of n=34 newborns at birth was analyzed for BDNF and newborn anthropometrics (weight, length and head circumference per gestational age at birth) were assessed. The association of fetal BDNF with anthropometrics at birth was analyzed.

RESULTS

After a BDNF-outlier (>3 SD) was removed, higher fetal BDNF associated significantly with maternal depressive symptoms (r=0.398, p=0.022), with lower socioeconomic status as assessed by the average number of people per room in the household (r=0.526, p=0.002) and with borderline significance with net income per person in the household (r=-0.313, p=0.087) in the bivariate analyses. In multivariable analysis, BDNF stayed positively associated with maternal depressive symptoms (β=0.404, 95% CI [7.057, 306.041], p=0.041) and lower net income per person in the household (β=-0.562, 95% CI [-914.511, -60.523], p=0.027) when controlling for maternal age, maternal pre-pregnancy BMI, fetal sex and gestational age. Fetal BDNF did not associate with newborn anthropometrics with the outlier removed in bivariate analyses or in multivariable analyses when controlling for maternal BMI and fetal sex.

CONCLUSION

Maternal depressive symptoms and lower socioeconomic status associated with higher fetal BDNF when controlling for confounders. Fetal BDNF did not associate with newborn anthropometrics with the outlier removed. Further studies should investigate how early altered BDNF associate with the development and possibly psychopathology of the offspring.

Associations between socioeconomic status and rates of blood pressure changes among Chinese older adults: a longitudinal community-based cohort study

OBJECTIVES

The relationships between socioeconomic status (SES) and blood pressure changes among older adults in China remain unclear. This study aimed to examine the associations between SES and rates of blood pressure changes among Chinese older adults.

STUDY DESIGN

Community-based, prospective, longitudinal cohort study.

METHODS

This study included 13,541 participants aged ≥65 years from the Chinese Longitudinal Healthy Longevity Survey between 2002 and 2018. SES was assessed by educational level, occupation, household yearly per capita income, and financial support. The estimated annual changes (EACs) of blood pressure were computed as the difference in blood pressure levels between any two adjacent surveys divided by the time interval. Associations between SES and EACs of blood pressure were evaluated using generalised estimating equations.

RESULTS

Lower SES was significantly associated with greater annual increases of blood pressure among Chinese older adults. The effect of SES on EACs of blood pressure was more pronounced among non-hypertensive participants. Compared to EACs among non-hypertensive participants with high SES, multivariable-adjusted EACs among those with low SES increased by 0.57 mmHg (95% confidence interval [CI]: 0.16, 0.99), 0.32 mmHg (95% CI: 0.07, 0.57), and 0.40 mmHg (95% CI: 0.13, 0.66) for systolic blood pressure, diastolic blood pressure, and mean arterial pressure, respectively.

CONCLUSIONS

This study revealed strong associations between SES and EACs of blood pressure among Chinese older adults, especially in the non-hypertensive population. Findings suggest that prevention strategies for hypertension should pay more attention to the older population with low SES.

Association of socioeconomic status with 30-day survival following out-of-hospital cardiac arrest in Scotland, 2011-2020

BACKGROUND AND AIMS

The aim of this study was to investigate the crude and adjusted association of socioeconomic status with 30-day survival after out-of-hospital cardiac arrest (OHCA) in Scotland and to assess whether the effect of this association differs by sex or age.

METHODS

This is a population-based, retrospective cohort study, including non-traumatic, non-Emergency Medical Services witnessed patients with OHCA where resuscitation was attempted by the Scottish Ambulance Service, between 1 April 2011 and 1 March 2020. Socioeconomic status was defined using the Scottish Index of Multiple Deprivation (SIMD). The primary outcome was 30-day survival after OHCA. Crude and adjusted associations of SIMD quintile with 30-day survival after OHCA were estimated using logistic regression. Effect modification by age and sex was assessed by stratification.

RESULTS

Crude analysis showed lower odds of 30-day survival in the most deprived quintile relative to least deprived [odds ratio (OR) 0.74, 95% confidence interval (CI) 0.63-0.88]. Adjustment for age, sex, and urban/rural residency decreased the relative odds of survival further (OR 0.56, 95% CI 0.47-0.67). The strongest association was observed in males <45 years old. Across quintiles of increasing deprivation, evidence of decreasing trends in the proportion of those presenting with shockable initial cardiac rhythm, those receiving bystander cardiopulmonary resuscitation, and 30-day survival after OHCA were found.

CONCLUSIONS

Socioeconomic status is associated with 30-day survival after OHCA in Scotland, favouring people living in the least deprived areas. This was not explained by confounding due to age, sex, or urban/rural residency. The strongest association was observed in males <45 years old.

Participation in a digital self-management intervention for osteoarthritis and socioeconomic inequalities in patient-related outcomes

OBJECTIVE

To investigate changes in socioeconomic inequalities in patient-related outcomes and pain medication use, following participation in a digital self-management intervention for osteoarthritis (OA) in Sweden.

METHOD

Participants with hip/knee OA enrolled in the digital intervention were included. Self-reported outcomes collected were the numerical rating scale (NRS) pain, activity impairment, general health, Knee/Hip injury and Osteoarthritis Outcome Score (KOOS-12, HOOS-12) Pain, Function, and Quality of Life subscales, 5-level EuroQol 5 Dimensions (EQ-5D-5L), Patient Acceptable Symptom State (PASS) for function, walking difficulties, fear of movement, wish for surgery, pain medication use, physical function measured by the 30s chair-stand test, and level of physical activity. Educational attainment was used as a socioeconomic measure and the concentration index was used to assess the magnitude of inequalities at baseline and 3 month follow-up.

RESULTS

The study included 21,688 participants (mean ± sd age 64.1 ± 9.1 years, 74.4% females). All outcomes except for PASS demonstrated inequalities in favour of highly educated participants at both time-points, with highly educated participants reporting better outcomes. At 3 month follow-up, the magnitude of inequality widened for activity impairment, but narrowed for NRS pain, EQ-5D-5L, KOOS-12/HOOS-12 Pain and Function, physical function, and wish for surgery. There were no statistically conclusive changes in the magnitude of inequalities for the remaining outcomes.

CONCLUSIONS

There were inequalities in patient-related outcomes in favour of those with higher education among participants of a digital self-management intervention for OA, although the magnitude of these pre-existing inequalities generally narrowed after the 3 month intervention.

Diagnoses of common mental disorders among social workers in Sweden: A register-based cohort study

BACKGROUND

Little is known about common mental disorders (CMD) diagnoses among social workers, i.e., depression, anxiety, or stress-related disorders. This study aims to examine the risk of CMD among social workers in comparison to other workers and to further investigate differences between men and women and specific occupational titles.

METHODS

This register-based cohort study consists of 3,034,304 persons, of which 26,610 were social workers (0.9 % of all workers), aged 30-64 years, living in Sweden in 2015. The risk of diagnosed CMDs was followed up until 2020. Cox regression models were used to calculate hazard ratios (HR) and 95 % confidence intervals (CI), adjusting for sex, birth country, education, and birth year.

RESULTS

The participants were followed up by a total of 16,833,742.9 person-years, with an average follow-up of 5.5 years. Social workers, compared to other workers, were at a higher risk of CMD (HR 1.3, 95 % CI 1.2-1.4) after adjustment. The HR was equal, 1.3, for depression (95 % CI 1.2-1.5) and anxiety or stress-related disorder (95 % CI 1.2-1.4). The association between social work and CMD was stronger among men (HR 1.7, 95 % CI 1.6-1.9) compared to women (HR 1.2, 95 % CI 1.1-1.3). Further, men working as assistance analysts had the highest risk among the occupational categories (HR 2.2, 95 % CI 1.2-3.9).

LIMITATIONS

CMD diagnoses only included cases treated in secondary care.

CONCLUSIONS

Social workers, especially male social workers, had a higher risk of CMD. This deserves attention for future research and interventions aimed at improving the mental health of social workers.

Prevalence of self-reported hearing difficulty on the Revised Hearing Handicap Inventory and associated factors

BACKGROUND

Hearing loss is common in aging adults and is an important public health concern. Self-reported measures of hearing difficulty are often used in research and clinical practice, as they capture the functional impacts of hearing loss on individuals. However, little research has evaluated the prevalence or factors associated with self-reported hearing difficulty. Therefore, the purpose of this study was to determine the prevalence of self-reported hearing difficulty, measured by the Revised Hearing Handicap Inventory (RHHI), and associated factors.

METHODS

This study was conducted in a community-based cohort study based in Charleston, SC. We determined the prevalence of RHHI self-reported hearing difficulty (score ≥ 6 points) and evaluated associated factors with logistic regression models. Results are presented as odds ratios (OR) with corresponding 95% confidence intervals (95% CI).

RESULTS

There were 1558 participants included in this study (mean age 63.7 [SD 14.4], 56.9% female, 20.0% Minority race). The prevalence of RHHI self-reported hearing difficulty was 48.8%. In a multivariable model, older age (per + 1 year; OR 0.97 [95% CI 0.96, 0.98]), Minority (vs. White) race (OR 0.68 [95% CI 0.49, 0.94]), and speech-in-noise scores that are better than predicted (OR 0.99 [95% CI 0.98, 1.00]) were associated with lower odds of RHHI self-reported hearing difficulty. Furthermore, female (vs. male) sex (OR 1.39 [95% CI 1.03, 1.86]), higher PTA in the worse ear (per + 1 dB; OR 1.10 [95% CI 1.09, 1.12]), more comorbid conditions (vs. 0; 1 condition: OR 1.50 [95% CI 1.07, 2.11]; 2 conditions: OR 1.96 [95% CI 1.32, 2.93]; 3 + conditions: OR 3.00 [95% CI 1.60, 5.62]), noise exposure (OR 1.54 [95% CI 1.16, 2.03]), bothersome tinnitus (OR 2.16 [95% CI 1.59, 2.93]), and more depressive symptoms (OR 1.04 [95% CI 1.01, 1.07]) were associated with higher odds of RHHI self-reported hearing difficulty.

CONCLUSIONS

The prevalence of RHHI self-reported hearing difficulty is high, and associated factors included demographics, audiometric hearing and other hearing-related factors, and physical and mental health. The RHHI likely captures functional impacts of hearing loss that are not captured by audiometry alone. Study findings can support the correct interpretation of the RHHI in research and clinical settings.

Impact of socioeconomic status on healthy immune responses in humans

Individuals with low socioeconomic status (SES) are at greater risk of contracting and developing severe disease compared with people with higher SES. Age, sex, host genetics, smoking and cytomegalovirus (CMV) serostatus are known to have a major impact on human immune responses and thus susceptibility to infection. However, the impact of SES on immune variability is not well understood or explored. Here, we used data from the Milieu Intérieur project, a study of 1000 healthy volunteers with extensive demographic and biological data, to examine the effect of SES on immune variability. We developed an Elo-rating system using socioeconomic features such as education, income and home ownership status to objectively rank SES in the 1000 donors. We observed sex-specific SES associations, such as females with a low SES having a significantly higher frequency of CMV seropositivity compared with females with high SES, and males with a low SES having a significantly higher frequency of active smoking compared with males with a high SES. Using random forest models, we identified specific immune genes which were significantly associated with SES in both baseline and immune challenge conditions. Interestingly, many of the SES associations were sex stimuli specific, highlighting the complexity of these interactions. Our study provides a new way of computing SES in human populations that can help identify novel SES associations and reinforces biological evidence for SES-dependent susceptibility to infection. This should serve as a basis for further understanding the molecular mechanisms behind SES effects on immune responses and ultimately disease.

Employment situation among long-term Hodgkin lymphoma survivors in Europe: an analysis of patients from nine consecutive EORTC-LYSA trials

PURPOSE

Little is known about the employment situation of long-term Hodgkin lymphoma (HL) survivors despite their young age at diagnosis and the favorable prognosis of the disease. In this cross-sectional study, we aim to describe the employment situation in a cohort of long-term HL survivors compared to the general population and investigate the associations with disease characteristics and treatment exposure.

METHODS

HL survivors > 25 years (n = 1961) were matched 1:25 to controls (n = 49,025) from the European Union Labour Force Survey. Individual treatment information was obtained from trial records. Employment and socio-demographic characteristics were collected using the Life Situation Questionnaire. Logistic regression models were used to estimate associations between disease and treatment characteristics with employment status and work-related attitudes.

RESULTS

At employment assessment, 69.7% of survivors (95% CI: 67.6-71.7%) were working; of these, 68.9% (95% CI: 66.3-71.3%) worked full-time, a figure comparable to that of controls (p value 0.17). The risk of not working was associated with increasing age at diagnosis, increasing age at survey, female sex, lower educational level, and relapse history. Of those who were at work during treatment, 16.8% (95% CI: 14.5-19.3%) stated their income had subsequently decreased, which was attributed to their HL by 65.4% (95% CI: 57.5-72.8). Among those not at work, 25.1% (95% CI: 20.7-29.8) survivors were disabled compared to only 14.5% (95% CI: 13.8-15.3%) of controls.

CONCLUSIONS

In this cohort of HL survivors, employment status was comparable to that of the general population. However, increasing age at follow-up, female sex, lower educational level, and relapse history are risk factors for unemployment, a perceived decrease in income, and disability.

IMPLICATIONS FOR CANCER SURVIVORS

To further improve follow-up care, special attention should be paid to these vulnerable subgroups.

Selective Reduction of Socioeconomic Disparities in the Experimental Tobacco Marketplace: Effects of Cigarette and E-cigarette Flavor Restrictions

INTRODUCTION

Cigarette smoking accounts for >30% of the socioeconomic gap in life expectancy. Flavored restrictions claim to promote equity; however, no previous studies have compared the effect of cigarette and e-cigarette flavor restrictions among individuals who smoke with lower and higher socioeconomic status (SES).

AIMS AND METHODS

In a between-group within-subject design, individuals with lower (n = 155) and higher (n = 125) SES completed hypothetical purchasing trials in the experimental tobacco marketplace (ETM). Conditions were presented in a 2 × 2 factorial design (cigarette flavors restricted or unrestricted and e-cigarette flavors restricted or unrestricted) with increasing cigarette prices across trials.

RESULTS

Results show (1) SES differences in cigarette, e-cigarette, and NRT purchases under unrestricted policies, with lower SES showing higher cigarette demand and lower e-cigarette and NRT substitution than higher SES, (2) cigarette restrictions decreased cigarette and increased NRT purchases among lower SES, but no significant changes among higher SES, (3) decreased SES differences in cigarette demand under cigarette restrictions, but persistence under e-cigarette restrictions or their combination, (4) persistence of SES differences in e-cigarette purchases when all restrictions were enforced, and (5) waning of SES differences in NRT purchasing under all restrictions.

CONCLUSIONS

Flavor restrictions differentially affected individuals based on SES. Within-group comparisons demonstrated restrictions significantly impacted lower SES, but not higher SES. Between-group comparisons showed SES differences in cigarette purchasing decreased under cigarette restrictions, but persisted under e-cigarette-restrictions or their combination. Additionally, SES differences in NRT substitution decreased under flavor restrictions. These findings highlight the utility of the ETM to investigate SES disparities.

IMPLICATIONS

With increasing trends of socioeconomic differences in smoking prevalence and cessation rates, smoking-related health disparities are expected to continue to widen. Restricting menthol flavor in cigarettes while enhancing the availability and affordability of NRT have the potential to alleviate SES disparities in tobacco use, therefore, positively impacting health equity. However, this effect may depend on flavor availability in other tobacco products.

Associations between Parental Engagement in the Neonatal Intensive Care Unit and Neighborhood-Level Socioeconomic Status

OBJECTIVE

 This study aimed to (1) determine the effect of neighborhood-level socioeconomic status (SES), which considers the social and physical environment where a person lives, on parental engagement in the Neonatal Intensive Care Unit (NICU) and (2) compare the relationships between parental engagement and individual versus neighborhood-level measures of SES.

STUDY DESIGN

 In this cohort study, parents (n = 45) of premature neonates ≤34 weeks' gestation were assessed at 2 and 6 weeks after birth from December 2017 to October 2019. Neighborhood-level SES was determined using census data per the Association of Maternal and Child Health Programs' methodology, and parents self-reported their education level as an individual-level measure of SES. Data on frequency of engagement in NICU activities, including telephone updates, visitation, providing expressed breastmilk, and participating in kangaroo care, were collected from the electronic medical record. Parent psychosocial factors were assessed using validated surveys. Statistical analysis was performed using Fisher's exact test, t-test, and logistic regression.

RESULTS

 In multivariate regression analysis, disadvantaged neighborhood-level SES was associated with decreased odds of kangaroo care (OR = 0.16, 95% CI: [0.03-0.89]) and visitation (OR = 0.14, 95% CI: [0.02-0.87]), while lower individual-level SES was not significantly associated with kangaroo care, visiting, calling, or pumping (p > 0.05).

CONCLUSION

 Parental engagement was more consistently and significantly associated with neighborhood-level SES than with individual-level SES. Therefore, neighborhood-level SES measures may be more explanatory than individual-level SES measures. Further studies and targeted interventions are needed to address disparities in the frequency of kangaroo care and visitation according to SES.

KEY POINTS

· Parents from disadvantaged neighborhoods are less likely to do kangaroo care and visit the NICU.. · Parent engagement was more significantly associated with neighborhood than with parent education.. · Neighborhood-level SES measures may be more explanatory than individual-level SES measures.. · Interventions are needed to address SES-related disparities in NICU kangaroo care and visitation..

Integrating genetic and socioeconomic data to predict the progression of nonalcoholic fatty liver disease

OBJECTIVES

Nonalcoholic fatty liver disease (NAFLD) is the leading cause of chronic liver disease globally, with an estimated prevalence exceeding 25%. Variants in the PNPLA3 and HSD17B13 genes have been a focus of investigations surrounding the etiology and progression of NAFLD and are believed to contribute to a greater burden of disease experienced by Hispanic Americans. However, little is known about socioeconomic factors influencing NAFLD progression or its increased prevalence among Hispanics.

MATERIALS AND METHODS

We cross-sectionally analyzed 264 patients to assess the role of genetic and socioeconomic variables in the development of advanced liver fibrosis in individuals at risk for NAFLD.

RESULTS

Adjusting for age, sex, body mass index, and PNPLA3 genotype, lacking a college degree was associated with 3.3 times higher odds of advanced fibrosis (95% confidence interval [CI]: 1.21-8.76, p = 0.019), an effect comparable to that of possessing the major PNPLA3 risk variant. Notably, the effect of PNPLA3 genotype on advanced fibrosis was attenuated to nonsignificance following adjustment for education and other socioeconomic markers. The effect of the protective HSD17B13 variant, moreover, diminished after adjustment for education (odds ratio [OR]: 0.39 [95% CI: 0.13-1.16, p = 0.092]), while lower education continued to predict advanced fibrosis following multivariable adjustment with an OR of 8.0 (95% CI: 1.91-33.86, p = 0.005).

DISCUSSION

Adjusting for education attenuated the effects of genotype and Hispanic ethnicity on liver fibrosis, suggesting that social factors-rather than genes or ethnicity-may be driving disease severity within some populations. Findings reveal the importance of including socioenvironmental controls when considering the role of genetics or ethnicity in complex disease.

Agreement between audiometric hearing loss and self-reported hearing difficulty on the Revised Hearing Handicap Inventory differs by demographic factors

BACKGROUND

New standardised measures of self-reported hearing difficulty can be validated against audiometric hearing loss. This study reports the influence of demographic factors (age, sex, race and socioeconomic position (SEP)) on the agreement between audiometric hearing loss and self-reported hearing difficulty.

METHODS

Participants were 1558 adults (56.9% female; 20.0% racial minority; mean age 63.7 (SD 14.1) years) from the Medical University of South Carolina Longitudinal Cohort Study of Age-Related Hearing Loss (1988-current). Audiometric hearing loss was defined as the average of pure-tone thresholds at frequencies 0.5, 1.0, 2.0 and 4.0 kHz >25 dB HL in the worse ear. Self-reported hearing difficulty was defined as ≥6 points on the Revised Hearing Handicap Inventory (RHHI) or RHHI screening version (RHHI-S). We report agreement between audiometric hearing loss and the RHHI(-S), defined by sensitivity, specificity, accuracy, positive predictive value, negative predictive value and observed minus predicted prevalence. Estimates were stratified to age group, sex, race and SEP proxy.

RESULTS

The prevalence of audiometric hearing loss and self-reported hearing difficulty were 49.0% and 48.8%, respectively. Accuracy was highest among participants aged <60 (77.6%) versus 60-70 (71.4%) and 70+ (71.9%) years, for white (74.6%) versus minority (68.0%) participants and was similar by sex and SEP proxy. Generally, agreement of audiometric hearing loss and RHHI(-S) self-reported hearing difficulty differed by age, sex and race.

CONCLUSIONS

Relationships of audiometric hearing loss and self-reported hearing difficulty vary by demographic factors. These relationships were similar for the full (RHHI) and screening (RHHI-S) versions of this tool.

Multimorbid life expectancy across race, socio-economic status, and sex in South Africa

Multimorbidity is increasing globally as populations age. However, it is unclear how long individuals live with multimorbidity and how it varies by social and economic factors. We investigate this in South Africa, whose apartheid history further complicates race, socio-economic, and sex inequalities. We introduce the term 'multimorbid life expectancy' (MMLE) to describe the years lived with multimorbidity. Using data from the South African National Income Dynamics Study (2008-17) and incidence-based multistate Markov modelling, we find that females experience higher MMLE than males (17.3 vs 9.8 years), and this disparity is consistent across all race and education groups. MMLE is highest among Asian/Indian people and the post-secondary educated relative to other groups and lowest among African people. These findings suggest there are associations between structural inequalities and MMLE, highlighting the need for health-system and educational policies to be implemented in a way proportional to each group's level of need.

Socioeconomic gradients in 24-hour movement patterns across weekends and weekdays in a working-age sample: evidence from the 1970 British Cohort Study

BACKGROUND

Socioeconomic differences in movement behaviours may contribute to health inequalities. The aim of this descriptive study was to investigate socioeconomic patterns in device-measured 24-hour movement and assess whether patterns differ between weekdays and weekends.

METHODS

4894 individuals aged 46 years from the 1970 British Cohort Study were included. Participants wore thigh-worn accelerometers for 7 days. Movement behaviours were classified in two 24-hour compositions based on intensity and posture, respectively: (1) sleep, sedentary behaviour, light-intensity activity and moderate-vigorous activity; and (2) sleep, lying, sitting, standing, light movement, walking and combined exercise-like activity. Four socioeconomic measures were explored: education, occupation, income and deprivation index. Movement behaviours were considered compositional means on a 24-hour scale; isometric log ratios expressed per cent differences in daily time in each activity compared with the sample mean.

RESULTS

Associations were consistent across all socioeconomic measures. For example, those with a degree spent more time in exercise-like activities across weekdays (10.8%, 95% CI 7.3 to 14.7; ref: sample mean) and weekends (21.9%, 95% CI 17.2 to 26.9). Other patterns differed markedly by the day of the week. Those with no formal qualifications spent more time standing (5.1%, 95% CI 2.3 to 7.1), moving (10.8%, 95% CI 8.6 to 13.1) and walking(4.0%, 95% CI 2.2 to 6.1) during weekdays, with no differences on weekends. Conversely, those with no formal qualifications spent less time sitting during weekdays (-6.6%, 95% CI -7.8 to -4.8), yet more time lying on both weekends (8.8%, 95% CI 4.9 to 12.2) and weekdays (7.5%, 95% CI 4.0 to 11.5).

CONCLUSIONS

There were strong socioeconomic gradients in 24-hour movement behaviours, with notable differences between weekdays/weekends and behaviour type/posture. These findings emphasise the need to consider socioeconomic position, behaviour type/posture and the day of the week when researching or designing interventions targeting working-age adults.

Social Representativeness and Intervention Adherence-A Systematic Review of Clinical Physical Activity Trials in Breast Cancer Patients

Objectives

Representativeness in physical activity randomised controlled trials (RCT) in breast cancer patients is essential to analyses of feasibility and validity considering privileged- social groups. A step-by-step exclusion of less privileged groups through the trial process could reinforce health inequality. This study aimed at examining representativeness in breast cancer (BC) physical activity trials, investigate associations between socio-economic status (SES) and intervention adherence, and explore associations between representativeness and the relationship between SES and intervention adherence.

Methods

Systematic, computerised searches were performed in PubMed, CINAHL, AMED, EMBASE and PsycINFO. Additional citation-based searches retrieved 37 articles. Distributions of education level, ethnicity, and marital status in study samples were compared to national populations data to estimate representativeness in less privileged groups.

Results

A preponderance of studies favoured educated, married and white patients. Only six studies reported SES-adherence associations, hampering conclusions on this relationship and possible associations between representativeness and an SES-adherence relationship.

Conclusion

Less educated, unmarried and non-white individuals may be underrepresented in BC physical activity RCTs, while SES-adherence associations in such trials are inconclusive. Unintentional social misrepresentations may indicate that disguised inequity warrants revived attention.

Obesity and hypertension mediate the effect of education on deep intracerebral hemorrhage: A Mendelian randomization study

BACKGROUND

Educational attainment (EA) as a stable indicator of socioeconomic status has been confirmed to affect intracerebral hemorrhage (ICH), but the mechanism relating EA and ICH is still unknown.

AIM

To explore the causal relationship between EA and ICH through a bidirectional and two-step Mendelian randomization (MR) study.

METHODS

Using summary-level Genome-wide Association Study using GWAS data FROM CASES AND CONTROLS of European ancestry, we performed bidirectional and two-step MR analyses to explore the causal relationship between educational attainment and ICH to understand the mediating influence of risk factors in this process. We also carried out subgroup analysis according to the different sites (deep and lobar) of ICH. A set of sensitivity analyses were performed to test valid MR assumptions.

RESULTS

Bidirectional MR analysis consistently demonstrated a unidirectional causal effect, revealing that higher EA had a protective influence on ICH. Each additional 1-standard deviation (SD) increase in genetically predicted years of schooling was associated with a reduced risk of all ICH (inverse variance weighted (IVW) OR: 0.381 [95 %CI: 0.264-0.549]), deep ICH (OR: 0.334 [95 %CI: 0.216-0.517]), and lobar ICH (OR: 0.422 [95 %CI: 0.261-0.682]). The mediating effect of EA on all ICH was mediated via systolic blood pressure (SBP) (6.93 % [1.20-13.45 %]) and body mass index (BMI) (17.87 % [3.92-34.64 %]), and the mediating effect of EA on deep ICH was also mediated via SBP (7.85 % [1.55-15.07 %]) and BMI (18.63 % [4.02-36.26 %]).

CONCLUSION

This study provides robust genetic evidence for supporting the protective effect of EA on ICH risk, with further evidence that the effect of EA on deep ICH is partially mediated through hypertension and obesity. Further validation is needed to ascertain whether these findings are applicable to other racial or general population groups.

Socio-economic inequities in emergency department visits for wholly alcohol-attributable acute and chronic harms in Canada, 2003-2017

INTRODUCTION

Individuals with low socio-economic position (SEP) experience disproportionate alcohol-attributable harm. Limited research has investigated whether these inequities are driven by alcohol-attributable conditions that are acute or chronic. The study aimed to estimate the sex-specific associations between SEP and incident wholly alcohol-attributable emergency department (ED) visits for acute and chronic harms, respectively.

METHODS

A cohort study was conducted using the Canadian Community Health Survey (2003-2008) linked to the National Ambulatory Care Reporting System (2002-2017) in Alberta and Ontario. SEP was measured using educational attainment. Acute and chronic ED visits were captured in the National Ambulatory Care Reporting System follow-up data. Hazard models were fit to estimate the association between SEP and acute and chronic wholly alcohol-attributable ED visits.

RESULTS

The analytical sample included 88,865 respondents. In men and women, individuals with lower SEP had increased hazard of acute ED visits (women hazard ratio [HR] 1.75, 95% confidence interval [CI] 1.07-2.87; men HR 3.47, 95% CI 2.29-5.25) and chronic ED visits (women HR 2.24, 95% CI 1.04-4.80; men HR 5.02, 95% CI 2.88-8.75). Acute and chronic wholly alcohol-attributable ED visit rates were higher in men than women.

DISCUSSION AND CONCLUSIONS

The findings indicated lower SEP was associated with greater harms for both acute and chronic wholly alcohol-attributable ED visits when compared to their higher SEP counterparts. We conclude that gradients in SEP are associated with acute and chronic harms. These results highlight a need for equitable interventions that reduce the absolute burden of inequities in both acute and chronic wholly alcohol-attributable ED visits.

Influence of multimorbidity and socioeconomic position on long-term healthcare utilization and prognosis in patients after cardiac resynchronization therapy implantation

Aims

We aimed to investigate the influence of socioeconomic position (SEP) and multimorbidity on cross-sectional healthcare utilization and prognosis in patients after cardiac resynchronization therapy (CRT) implantation.

Methods and results

We included first-time CRT recipients with left ventricular ejection fraction ≤35% implanted between 2000 and 2017. Data on chronic conditions, use of healthcare services, and demographics were obtained from Danish national administrative and health registries. Healthcare utilization (in- and outpatient hospitalizations, activities in general practice) was compared by multimorbidity categories and SEP by using a negative binomial regression model. The association between SEP, multimorbidity, and prognostic outcomes was analysed using Cox proportional hazards regression. We followed 2007 patients (median age of 70 years), 79% were male, 75% were on early retirement or state pension, 37% were living alone, and 41% had low education level for a median of 5.2 [inter-quartile range: 2.2-7.3) years. In adjusted regression models, a higher number of chronic conditions were associated with increased healthcare utilization. Both cardiovascular and non-cardiovascular hospital contacts were increased. Patients with low SEP had a higher number of chronic conditions, but SEP had limited influence on healthcare utilization. Patients living alone and those with low educational level had a trend towards a higher risk of all-cause mortality [adjusted hazard ratio (aHR): 1.17, 95% confidence interval (CI) 1.03-1.33, and aHR 1.09, 95% CI 0.96-1.24).

Conclusion

Multimorbidity increased the use of cross-sectional healthcare services, whereas low SEP had minor influence on the utilizations. Living alone and low educational level showed a trend towards a higher risk of mortality after CRT implantation.

Health and social home services among community-dwelling older people during COVID-19: Results from the cross-sectional LOST in Lombardia project

BACKGROUND

Few studies have focused on changes in health and social services access due to the COVID-19 pandemic. We aimed to describe changes in the use of selected health and social home services due to the pandemic and to investigate potential associated factors, including socio-demographic characteristics, number of chronic diseases and mental health indicators, among older Italian individuals.

METHODS

We analysed data from the LOST in Lombardia cross-sectional study conducted in November 2020 on a large representative sample of 4400 individuals aged ⩾65 years. To identify potential factors associated with the increased use of three selected health and social home services, we estimated odds ratios (OR) and confidence intervals (CI) using multivariable logistic regression models.

RESULTS

Compared to the year before, 5.0% of older adults increased help from domestic workers (vs. 6.9% reducing) during the pandemic, 4.4% increased help from non-familiar caregivers (vs. 1.3% decreasing) and 4.7% increased medical home visits (vs. 1.0% decreasing). An increase in the use of these services was more frequent among participants with co-morbidities (p for trend <0.001), especially with diabetes (for caregivers: OR=12.2, 95% CI 6.0-24.8), and worse mental health (for caregivers and for those with a GAD-2 score ⩾3 vs. <3: OR=10.6, 95% CI 5.8-19.4). Conversely, people living in more crowded households less frequently increased health and social services use during the pandemic.

CONCLUSIONS

Our results should inform targeted interventions for the identified vulnerable groups to close the gap in health and social inequities.

Developing content for a virtual reality scenario that motivates quit attempts in adult smokers: A focus group study with art-based methods

Virtual reality (VR) could be used to deliver messages to smokers that encourages them to attempt quitting. For a VR smoking cessation intervention to be effective, the target population must find the content engaging, relevant, inoffensive, and compelling. Informed by health behaviour theory and narrative transportation theory, this study used focus groups combined with art-based methods (participant sketches) to inform the development of VR content that will appropriately address smokers' beliefs about quitting smoking. Data were analysed using reflexive thematic analysis. Four in-person focus groups (N = 21) were held between July and August 2023. Just under half the sample were from an ethnic minority (42.8%) and women (42.9%), and the mean age was 33.6 years (standard deviation = 15.9). More than half the sample had a low motivation to quit (61.0%). We developed six themes concerning: the VR content suggested by participants, the rationale behind it, its technological execution and potential widescale implementation. Many participants downplayed the health consequences of smoking, prioritising the immediate rewards of smoking over quitting's long-term benefits. Therefore, participants suggested content set in the future, showing the benefits of cessation or the negative consequences of continued smoking. Family members were recommended as supporting VR characters to increase the contents' emotional salience. Participants also suggested graphic content that would trigger anxiety about smoking, suggesting that fear appeals were welcome. Participants wanted a truly novel intervention- not a leaflet about smoking statistics presented through VR. Participants suggested healthcare locations (e.g., doctors' offices) for implementation, as home ownership of VR headsets is low. Also, this would make the VR appear more legitimate as a health intervention (rather than casual entertainment) and could complement in-person advice. Future research will refine the participant-generated ideas with experts in VR design and smoking cessation.

Socioeconomic Position and Health Among Children and Adolescents With CKD Across the Life-Course

Children and adolescents in families of lower socioeconomic position (SEP) experience an inequitable burden of reduced access to healthcare and poorer health. For children living with chronic kidney disease (CKD), disadvantaged SEP may exacerbate their considerable disease burden. Across the life-course, CKD may also compromise the SEP of families and young people, leading to accumulating health and socioeconomic disadvantage. This narrative review summarizes the current evidence on relationships of SEP with kidney care and health among children and adolescents with CKD from a life-course approach, including impacts of family SEP on kidney care and health, and bidirectional impacts of CKD on SEP. It highlights relevant conceptual models from social epidemiology, current evidence, clinical and policy implications, and provides directions for future research. Reflecting the balance of available evidence, we focus primarily on high-income countries (HICs), with an overview of key issues in low- and middle-income countries (LMICs). Overall, a growing body of evidence indicates sobering socioeconomic inequities in health and kidney care among children and adolescents with CKD, and adverse socioeconomic impacts of CKD. Dedicated efforts to tackle inequities are critical to ensuring that all young people with CKD have the opportunity to live long and flourishing lives. To prevent accumulating disadvantage, the global nephrology community must advocate for local government action on upstream social determinants of health; and adopt a life-course approach to kidney care that proactively identifies and addresses unmet social needs, targets intervening factors between SEP and health, and minimizes adverse socioeconomic outcomes across financial, educational and vocational domains.

Social inequality in prevalence of NCD risk factors: a cross-sectional analysis from the population-based Tromsø Study 2015-2016

OBJECTIVE

We aimed to examine associations between educational level, serving as an indicator of socioeconomic position, and prevalence of WHO-established leading behavioural and biological risk factors for non-communicable diseases (NCDs), in middle-aged to older women and men.

DESIGN

Population-based cross-sectional study.

SETTING

All inhabitants of the municipality of Tromsø, Norway, aged ≥40 years, were invited to the seventh survey (2015-2016) of the Tromsø Study; an ongoing population-based cohort study.

PARTICIPANTS

Of the 32 591 invited; 65% attended, and a total of 21 069 women (53%) and men aged 40-99 years were included in our study.

OUTCOME MEASURES

We assessed associations between educational level and NCD behavioural and biological risk factors: daily smoking, physical inactivity (sedentary in leisure time), insufficient fruit/vegetable intake (<5 units/day), harmful alcohol use (>10 g/day in women, >20 g/day in men), hypertension, obesity, intermediate hyperglycaemia and hypercholesterolaemia. These were expressed as odds ratios (OR) per unit decrease in educational level, with 95% CIs, in women and men.

RESULTS

In women (results were not significantly different in men), we observed statistically significant associations between lower educational levels and higher odds of daily smoking (OR 1.69; 95% CI 1.60 to 1.78), physical inactivity (OR 1.38; 95% CI 1.31 to 1.46), insufficient fruit/vegetable intake (OR 1.54, 95% CI 1.43 to 1.66), hypertension (OR 1.25; 95% CI 1.20 to 1.30), obesity (OR 1.23; 95% CI 1.18 to 1.29), intermediate hyperglycaemia (OR 1.12; 95% CI 1.06 to 1.19), and hypercholesterolaemia (OR 1.07; 95% CI 1.03 to 1.12), and lower odds of harmful alcohol use (OR 0.75; 95% CI 0.72 to 0.78).

CONCLUSION

We found statistically significant educational gradients in women and men for all WHO-established leading NCD risk factors within a Nordic middle-aged to older general population. The prevalence of all risk factors increased at lower educational levels, except for harmful alcohol use, which increased at higher educational levels.

Social inequalities in pregnancy metabolic profile: findings from the multi-ethnic Born in Bradford cohort study

BACKGROUND

Lower socioeconomic position (SEP) associates with adverse pregnancy and perinatal outcomes and with less favourable metabolic profile in nonpregnant adults. Socioeconomic differences in pregnancy metabolic profile are unknown. We investigated association between a composite measure of SEP and pregnancy metabolic profile in White European (WE) and South Asian (SA) women.

METHODS

We included 3,905 WE and 4,404 SA pregnant women from a population-based UK cohort. Latent class analysis was applied to nineteen individual, household, and area-based SEP indicators (collected by questionnaires or linkage to residential address) to derive a composite SEP latent variable. Targeted nuclear magnetic resonance spectroscopy was used to determine 148 metabolic traits from mid-pregnancy serum samples. Associations between SEP and metabolic traits were examined using linear regressions adjusted for gestational age and weighted by latent class probabilities.

RESULTS

Five SEP sub-groups were identified and labelled 'Highest SEP' (48% WE and 52% SA), 'High-Medium SEP' (77% and 23%), 'Medium SEP' (56% and 44%) 'Low-Medium SEP' (21% and 79%), and 'Lowest SEP' (52% and 48%). Lower SEP was associated with more adverse levels of 113 metabolic traits, including lower high-density lipoprotein (HDL) and higher triglycerides and very low-density lipoprotein (VLDL) traits. For example, mean standardized difference (95%CI) in concentration of small VLDL particles (vs. Highest SEP) was 0.12 standard deviation (SD) units (0.05 to 0.20) for 'Medium SEP' and 0.25SD (0.18 to 0.32) for 'Lowest SEP'. There was statistical evidence of ethnic differences in associations of SEP with 31 traits, primarily characterised by stronger associations in WE women e.g., mean difference in HDL cholesterol in WE and SA women respectively (vs. Highest-SEP) was -0.30SD (-0.41 to -0.20) and -0.16SD (-0.27 to -0.05) for 'Medium SEP', and -0.62SD (-0.72 to -0.52) and -0.29SD (-0.40 to -0.20) for 'Lowest SEP'.

CONCLUSIONS

We found widespread socioeconomic differences in metabolic traits in pregnant WE and SA women residing in the UK. Further research is needed to understand whether the socioeconomic differences we observe here reflect pre-conception differences or differences in the metabolic pregnancy response. If replicated, it would be important to explore if these differences contribute to socioeconomic differences in pregnancy outcomes.

Sex Disparity in the Association of Metabolic Syndrome with Cognitive Impairment

Background/Objectives: Metabolic syndrome (MS) is a constellation of several cardiometabolic risk factors. We investigated sex disparity in the associations between MS and cognitive impairment using cross-sectional data from Taiwan Biobank. Methods: We determined the associations of MS and its five components with cognitive impairment (mini-mental state examination, MMSE < 24) and the five domains of MMSE using logistic regression analyses. Results: A total of 7399 men and 11,546 women were included, and MS was significantly associated with cognitive impairment only in women (adjusted OR 1.48, 95% CI 1.29-1.71, p = 0.001) (p for interaction 0.005). In women, the association with MS was significant in orientation (adjusted OR 1.21, 95% CI 1.07-1.37, p = 0.003), memory (adjusted OR 1.12, 95% CI 1.01-1.25, p = 0.034) and design copying (adjusted OR 1.41, 95% CI 1.23-1.62, p = 0.001) (p value for interaction 0.039, 0.023, and 0.093, respectively). Among the components of MS, a large waist circumference (adjusted OR 1.25, 95% CI 1.08-1.46, p = 0.003), high fasting glucose (adjusted OR 1.16, 95% CI 1.00-1.34, p = 0.046), and low HDL cholesterol (adjusted OR 1.16, 95% CI 1.00-1.34, p = 0.049) were significantly associated with cognitive impairment in women. Conclusions: Our findings suggest that sex has a significant influence on the association between MS and cognitive dysfunction, especially in orientation and memory.

Health and health behaviours in adolescence as predictors of education and socioeconomic status in adulthood - a longitudinal study

BACKGROUND

The positive association of health with education level and socioeconomic status (SES) is well-established. Two theoretical frameworks have been delineated to understand main mechanisms leading to socioeconomic health inequalities: social causation and health selection but how these work in adolescence is poorly known. We studied if adolescent health and health behaviours predict higher education and higher SES in adulthood and if family background and school performance in adolescence explain these associations.

METHODS

Surveys on health and health behaviours were sent to representative samples of 12-18-year-old Finns in 1981-1997 every second year (response rate 77.8%, N = 55,682). The survey data were linked with the respondents' and their parents' socioeconomic data from the Finnish national registries. Both latent variables, namely, health (perceived health, health complaints, chronic disease), health-compromising behaviours (smoking status, drunkenness frequency), and family background (parents' occupation-based SES, education, family type) and variables directly measuring health-enhancing behaviours (toothbrushing, physical activity) and school performance were used to predict higher education and higher occupation-based SES at age 34. Logistic regression analysis and structural equation models (SEM) were used.

RESULTS

In logistic regression analyses, good health, health-enhancing behaviours, and lack of health-compromising behaviours were related to higher education and SES, also after controlling for family background and school performance. In the SEM analyses, good health, health-enhancing behaviours, and lack of health-compromising behaviours directly predicted higher SES and higher education, although the standardised coefficients were low (from 0.034 to 0.12). In all models, health, lack of health-compromising behaviours, and health-enhancing behaviours predicted school performance, which in turn, predicted the outcomes, suggesting indirect routes to these. Good socioeconomic prospects in terms of family background predicted good health, healthy behaviours, and good school performance in adolescence and higher SES and higher education in adulthood.

CONCLUSION

Health and health behaviours in adolescence predicted education and SES in adulthood. Even though the relationships were modest, they support the health selection hypotheses and emphasise the importance of adolescence for health inequalities during the life-course. Health and health behaviours were strongly associated with school performance and family background which together modified the paths from health and health behaviours to the outcomes.

A causal relationship between educational attainment and risk of infectious diseases: A Mendelian randomisation study

Background

Previous observational studies have investigated the association between educational attainment and sepsis, pneumonia, and urinary tract infections (UTIs). However, their findings have been susceptible to reverse causality and confounding factors. Furthermore, no study has examined the effect of educational level on the risk of infections of the skin and subcutaneous tissue (SSTIs). Thus, we aimed to evaluate the causal relationships between educational level and the risk of four infectious diseases using Mendelian randomisation (MR) techniques.

Methods

We used univariable MR analysis to investigate the causal associations between educational attainment (years of schooling (n = 766 345) and holding college or university degree (n = 334 070)) and four infectious diseases (sepsis (n = 486 484), pneumonia (n = 486 484), UTIs (n = 463 010), and SSTIs (n = 218 792)). We included genetic instrumental variables with a genome-wide significance (P < 5 × 10-8) in the study. We used inverse variance-weighted estimation in the primary analysis and explored the stability of the results using multivariable MR analysis after adjusting for smoking, alcohol consumption, and body mass index.

Results

Genetically predicted years of schooling were associated with a reduced risk of sepsis (odds ratio (OR) = 0.763; 95% confidence interval (CI) = 0.668-0.870, P = 5.525 × 10-5), pneumonia (OR = 0.637; 95% CI = 0.577-0.702, P = 1.875 × 10-19), UTIs (OR = 0.995; 95% CI = 0.993-0.997, P = 1.229 × 10-5), and SSTIs (OR = 0.696; 95% CI = 0.605-0.801, P = 4.034 × 10-7). We observed consistent results for the correlation between qualifications and infectious diseases. These findings remained stable in the multivariable MR analyses.

Conclusions

Our findings suggest that increased educational attainment may be causally associated with a decreased risk of sepsis, pneumonia, UTIs, and SSTIs.

The role of lifestyle factors in the association between education and self-reported fibromyalgia: a mediation analysis

BACKGROUND

Socioeconomic status as measured by education, income, or occupation, has been associated with fibromyalgia but the underlying mechanism and the role of lifestyle factors are unclear. Thus, we examine the role of modifiable lifestyle factors (body mass index, physical activity, alcohol consumption and smoking) in the association between education and self-reported fibromyalgia.

METHODS

We used data from 74,157 participants in the population-based prospective Norwegian Women and Cancer (NOWAC) study. Socioeconomic position, operationalized as years of educational attainment, and lifestyle factors were assessed via self-reported questionnaires. Multiple mediation analysis was used to decompose total effects into direct and indirect effects. Estimates were reported as hazard ratios (HRs) with 95% confidence intervals (CIs).

RESULTS

The cumulative incidence of fibromyalgia was 3.2% after a median follow up time of 13 years. Fibromyalgia was inversely associated with years of educational attainment for ≤ 9 years (HR = 2.56; 95% CI 2.32-2.91) and for 10-12 years (HR = 1.84; 95% CI 1.72-2.02), compared with ≥ 13 years of education. Overall, all lifestyle factors together jointly mediated 17.3% (95% CI 14.3-21.6) and 14.1% (95% CI 11.3-18.9) of the total effect for ≤ 9 years and 10-12 years of education, respectively. Smoking and alcohol consumption contributed the most to the proportion mediated, for ≤ 9 years (5.0% and 7.0%) and 10-12 years (5.6% and 4.5%) of education.

CONCLUSION

The association between education and self-reported fibromyalgia was partly explained through lifestyle factors, mainly smoking and alcohol consumption.

A prospective longitudinal approach to examine the association between social position in childhood, adolescence, and adulthood with the control of hypertension during adulthood

Introduction

Hypertension is one of the main concerns in public health, since it is related with increased morbidity, and potential years of life lost in addition to loss of quality of life. This study aimed to assess: (1) the distribution of indicators of life course SEP in a cohort of Colombian patients with hypertension and (2) to assess the association of life course SEP and control of hypertension among this cohort of patients.

Methods

Data were obtained using the baseline survey of 258 patients from the Social Determinants and Inequities in the Control of Blood Hypertension Program (ProDSICHA). Mother occupation and housing conditions were measured with the Event History Calendar. Mother educational level was measured with the questionnaire developed by the Project on Ethnicity and Race in Latin America (PERLA). Socioeconomic position during adulthood was measured using education, occupation, and income level based in the MacArthur Network.

Results

The group with a higher lifelong social position and the group of lower lifelong social position showed better control of hypertension (OR = 1.21; p <0.05; OR = 1.33; p < .05, respectively) compared to those whose social position throughout life varied the most. No statistical differences were found in the relations between single lifetime social position variables, and hypertension control in the three time points analyzed.

Discussion

These findings warrant further research to deeper our understanding on the role of a multidimensional and cumulative approach of social position in hypertension control.

Drivers of perceived discrimination among older adults in India: an intersectional analysis

Discrimination is harmful action taken against individuals or groups to protect customary relations of power and privilege. Older adults are particularly vulnerable to experiences of discrimination that adversely affect their quality of life. We use data from the Longitudinal Ageing Study of India (LASI; Wave 1; 2017-2018) to examine different contextual forces that shape the experiences of discrimination in older adults in India, specifically gender, caste, and economic condition. We used the theory of intersectionality to hypothesize that economic condition, caste, and gender combine uniquely to engender perceived discrimination in older adults. We first used a concentration index to determine the sample's pre-existing inequality levels. The concentration curve evidenced a disproportionate concentration of discrimination among people with low income. Next, we used a three-way ANCOVA to examine the effects of caste, gender, and economic condition on individuals' experiences of discrimination. A significant interaction effect of caste, gender, and economic condition [F(1, 30,394) = 8.91 p = 0.003] evidenced the compounding effects of inequalities on experiences of discrimination. Finally, we ran a moderation model to test the ameliorating effects of education on experiences of discrimination experienced by marginalized castes. The model was significant (β= -0.192; p < 0.001), thereby supporting the proposition that increased education level can lead to an increased sense of belonging and perceptions of equal treatment, which relate negatively to perceived discrimination. Results are discussed considering intersectionality in peoples' struggles and resilience in India.

Associations between life course longitudinal growth and hip shapes at ages 60-64 years: evidence from the MRC National Survey of Health and Development

OBJECTIVE

We sought to examine associations between height gain across childhood and adolescence with hip shape in individuals aged 60-64 years from the Medical Research Council National Survey of Health and Development, a nationally representative British birth cohort.

METHODS

Height was measured at ages 2, 4, 6, 7, 11 and 15 years, and self-reported at age 20 years. 10 modes of variation in hip shape (HM1-10), described by statistical shape models, were previously ascertained from DXA images taken at ages 60-64 years. Associations between (1) height at each age; (2) Super-Imposition by Translation And Rotation (SITAR) growth curve variables of height size, tempo and velocity; and (3) height gain during specific periods of childhood and adolescence, and HM1-10 were tested.

RESULTS

Faster growth velocity was associated with a wider, flatter femoral head and neck, as described by positive scores for HM6 (regression coefficient 0.014; 95% CI 0.08 to 0.019; p<0.001) and HM7 (regression coefficient 0.07; 95% CI 0.002 to 0.013; p=0.009), and negative scores for HM10 (regression coefficient -0.006; 95% CI -0.011 to 0.00, p=0.04) and HM2 (males only, regression coefficient -0.017; 95% CI -0.026 to -0.09; p<0.001). Similar associations were observed with greater height size and later height tempo. Examination of height gains during specific periods of childhood and adolescence identified those during the adolescence period as being most consistently associated.

CONCLUSION

Our analyses suggest that individual growth patterns, particularly in the adolescent period, are associated with modest variations in hip shape at 60-64 years, which are consistent with features seen in osteoarthritis.

Impairments and related social inequalities among adults: a population-based study in São Paulo city, Brazil

The study of the association of social variables with the prevalence of impairments can provide subsidies for more adequate care and health policies for the most needy people by incorporating social aspects. This article aims to estimate the prevalence of diverse types of impairments, the degree of difficulty, limitations, and the need for help they cause and attest whether this prevalence differ by educational attainment in individuals aged 20 years or older. This is a populational cross-sectional study (2015 Health Survey of São Paulo-ISA Capital). Data from 3184 individuals were analyzed via educational attainment as exposure variable and outcome variables related to visual, hearing, intellectual, and mobility impairments. 19.9% of participants had visual, 7.8%, hearing, 2.7%, intellectual, and 7.4%, mobility impairments. Mobility and intellectual impairments limited participants' daily activities the most, 70.3% and 63.3%, respectively; who, thus, needed the most help: 48.9% and 48.5%, respectively. Lower schooling was associated with a higher prevalence of impairments, greater need for help due to visual and intellectual impairments, and greater limitations due to hearing and visual impairments.

Socioeconomic inequalities in cardiovascular disease: a causal perspective

Socioeconomic inequalities in cardiovascular disease (CVD) persist in high-income countries despite marked overall declines in CVD-related morbidity and mortality. After decades of research, the field has struggled to unequivocally answer a crucial question: is the association between low socioeconomic position (SEP) and the development of CVD causal? We review relevant evidence from various study designs and disciplinary perspectives. Traditional observational, family-based and Mendelian randomization studies support the widely accepted view that low SEP causally influences CVD. However, results from quasi-experimental and experimental studies are both limited and equivocal. While more experimental and quasi-experimental studies are needed to aid causal understanding and inform policy, high-quality descriptive studies are also required to document inequalities, investigate their contextual dependence and consider SEP throughout the lifespan; no simple hierarchy of evidence exists for an exposure as complex as SEP. The COVID-19 pandemic illustrates the context-dependent nature of CVD inequalities, with the generation of potentially new causal pathways linking SEP and CVD. The linked goals of understanding the causal nature of SEP and CVD associations, their contextual dependence, and their remediation by policy interventions necessitate a detailed understanding of society, its change over time and the phenotypes of CVD. Interdisciplinary research is therefore key to advancing both causal understanding and policy translation.

Relationship between educational level and survival of patients with cancer: A multicentre cohort study

BACKGROUND

Although socioeconomic factors are important determinants of population mortality, the effect of educational level on the survival of patients with cancer in China is unclear. This study aimed to assess whether educational level is associated with the prognosis of patients with cancer and to explore the mediators of this association.

METHODS

This multicentre cohort study included 18,251 patients diagnosed with cancer between May 2013 and December 2018. The main parameters measured were overall survival (OS) and all-cause mortality. The relationship between educational level and all-cause mortality was assessed using multifactor-corrected Cox survival analysis. Logistic regression was used to analyze the association between educational level and patient-generated subjective global assessment (PG-SGA).

RESULTS

The mean age of the 18,251 participants (men, 9939 [54.4%]) was 57.37 ± 11.66 years. Multifactorial survival analysis showed that patients survived longer with increasing education (university and above vs. elementary school and below; p = p = <0.001, HR = 0.84, 95% CI: 0.77-0.92), and the differences were statistically significant in different subgroups. The potential impact factors included sex, age, TNM stage, and PG-SGA score. Logistic regression showed a significant negative association between educational level and the modifiable factor PG-SGA (secondary vs. primary and below; p = 0.004, HR = 0.90, 95% CI: 0.83-0.97; university and above vs. primary and below; p < 0.001, HR = 0.79, 95% CI: 0.71-0.88).

CONCLUSIONS

Educational level was a significant prognostic factor for patients with cancer, independent of other known prognostic factors. This association was further improved by modifying the nutritional status.

Comparison of birth outcomes of mothers covered by Medicaid versus those privately insured when accounting for social determinants of health

OBJECTIVES

To determine the association between maternal health insurance type and birth outcomes [prematurity, small for gestational age (SGA), Term/Appropriate for gestational age NICU admission (Term/AGA-NICU) & composite birth outcomes (CBO)] accounting for social determinants of health.

DESIGN/METHODS

A cross-sectional study of maternal surveys and birth certificate data of singleton live births in NY born to mothers with Medicaid (M) or Private Insurance (PI).

RESULTS

1015 mothers [M = 631, PI = 384) included. Individual birth outcomes did not differ between groups. Adjusting for social, demographic and clinical covariates, M mothers had similar odds of preterm birth, SGA, Term/AGA-NICU admission and CBO compared to PI.

CONCLUSIONS

M mothers were as likely as PI mothers to deliver a preterm, SGA or a Term/AGA-NICU infant after controlling for social determinants of health. Despite more social adversity among enrollees, our study suggests NY Medicaid recipients have similar birth outcomes to privately insured, socially advantaged women.

Socioeconomic inequalities in deaths of despair: Age heterogeneity in Canada's working age population

PURPOSE

Although prior literature documented socioeconomic inequalities in deaths of despair among working age population, it is unclear whether and how (a) the link between socioeconomic status and deaths of despair differs by age (b) each measure of socioeconomic status has independent effects on deaths of despair. This study aims to reduce these knowledge gaps.

METHODS

Using data from a large scale nationally representative linked dataset (2011 Canadian Census Health and Environment Cohorts), this study employed Fine-Gray subdistribution hazard models to estimate the link between socioeconomic status and deaths of despair due to suicide, drug overdose, and alcoholic liver disease among working age population (N = 4,076,530). Age stratified analysis was conducted to examine age heterogeneity.

RESULTS

Socioeconomic status, such as housing tenure, employment status, household income, and education level, was associated with deaths of despair among working age population. Age differences in the association between socioeconomic status and deaths of despair were found. While education level was pronounced for deaths of despair for younger adults, a combination of socioeconomic status was significantly associated with deaths of despair for those in late adulthood.

CONCLUSIONS

Socioeconomic inequalities in deaths of despair are manifest among Canadian working age population. This study lends support the social and health policies aimed at reducing gaps in mortalities.

Sedentary time at school and work in Canada

OBJECTIVES

High levels of sedentary time (ST) are associated with poor physical and mental health. Given that Canadians spend a large portion of their days at school and work, they may be important targets for reducing ST. Our objectives are to estimate the daily amount of school and work ST among Canadians, examine differences by subgroups, and determine associations with health.

METHODS

Using the 2020 Canadian Community Health Survey Healthy Living Rapid Response module (N = 5242), the amount of time spent sitting while at school and work was estimated among youth (12-17 years) and adults (18-34 and 35-64 years). Differences by sociodemographics and 24-Hour Movement Guideline adherence were assessed with independent t-tests. Associations between school and work ST and health indicators were assessed using adjusted logistic regression.

RESULTS

Canadian youth aged 12-17 years and adults aged 18-34 years reported an average of 4.5 and 5.2 h/day of school ST, respectively. Adults 18-34 years and 35-64 years reported an average of 3.9 and 4.0 h/day of work ST, respectively. School and work ST differed within several subgroups. Among adults 18-34 years, higher school ST was associated with a reduced odds of 'excellent/very good' mental health, whereas higher work ST was associated with a greater likelihood of reporting 'excellent/very good' general health.

CONCLUSION

Canadian youth and working-age adults report an average of 4-5 h/day sedentary at school or work. This is the first study estimating school and work ST in a representative sample of Canadians and will aid in increasing awareness of setting-specific behaviours to better inform targeted interventions including addressing inequalities in ST.

Adult offspring's education and parental mortality: A nationwide cohort study of the mediating role of lifestyle-related diseases

Aim: The mechanisms behind the association between adult offspring's socioeconomic position and their parents' mortality are not well understood. This study investigates lifestyle-related diseases as a potential mediating pathway between adult offspring's education and parental mortality. Methods: This nationwide register-based cohort study consists of 963,742 older adults aged 65 years between 2000 and 2018. Lifestyle-related diseases were measured between 60 and 65 years and those with prior lifestyle-related diseases were excluded. Natural Effect Models were performed to assess potential mediation through lifestyle-related diseases of the association between offspring's education and parental mortality measured by additive hazard estimates with 95% confidence intervals (CIs). Results: Between 60 and 65 years, 150,501 (15.6%) older adults were diagnosed with lifestyle-related diseases and 149,647 (15.5%) died during follow-up. Compared with having offspring with long education, short education was associated with 631 (95% CI: 555; 707) and 581 (95% CI: 525; 638) additional deaths per 100,000 person-years for women and men, respectively, of which 15.4% (95% CI: 9.0; 21.6) and 16.8% (95% CI: 14.6; 18.9) were mediated by lifestyle-related diseases. The corresponding numbers for medium education were 276 (95% CI: 205; 347) and 299 (95% CI: 255; 343) with 26.2% (95% CI: 12.0; 40.6) and 27.6% (95% CI: 25.1; 31.8) mediated by lifestyle-related diseases. Conclusions: Lifestyle-related diseases accounted for 15-28% of the association between offspring's education and parental mortality for both men and women.

From test to rest: evaluating socioeconomic differences along the COVID-19 care pathway in the Netherlands

INTRODUCTION

The COVID-19 pandemic exacerbated healthcare needs and caused excess mortality, especially among lower socioeconomic groups. This study describes the emergence of socioeconomic differences along the COVID-19 pathway of testing, healthcare use and mortality in the Netherlands.

METHODOLOGY

This retrospective observational Dutch population-based study combined individual-level registry data from June 2020 to December 2020 on personal socioeconomic characteristics, COVID-19 administered tests, test results, general practitioner (GP) consultations, hospital admissions, Intensive Care Unit (ICU) admissions and mortality. For each outcome measure, relative differences between income groups were estimated using log-link binomial regression models. Furthermore, regression models explained socioeconomic differences in COVID-19 mortality by differences in ICU/hospital admissions, test administration and test results.

RESULTS

Among the Dutch population, the lowest income group had a lower test probability (RR = 0.61) and lower risk of testing positive (RR = 0.77) compared to the highest income group. However, among individuals with at least one administered COVID-19 test, the lowest income group had a higher risk of testing positive (RR = 1.40). The likelihood of hospital admissions and ICU admissions were higher for low income groups (RR = 2.11 and RR = 2.46, respectively). The lowest income group had an almost four times higher risk of dying from COVID-19 (RR = 3.85), which could partly be explained by a higher risk of hospitalization and ICU admission, rather than differences in test administration or result.

DISCUSSION

Our findings indicated that socioeconomic differences became more pronounced at each step of the care pathway, culminating to a large gap in mortality. This underlines the need for enhancing social security and well-being policies and incorporation of health equity in pandemic preparedness plans.

Equity in the recovery of elective and oncological surgery volumes after the COVID-19 lockdown: a multicentre cohort study in Italy

BACKGROUND

The COVID-19 pandemic has had, and still has, a profound impact on national health systems, altering trajectories of care and exacerbating existing inequalities in health. Postponement of surgeries and cancellation of elective surgical procedures have been reported worldwide. In Italy, the lock-down measures following the COVID-19 pandemic caused cancellations of surgical procedures and important backlogs; little is known about potential social inequalities in the recovery process that occurred during the post-lockdown period. This study aims at evaluating whether all population social strata benefited equally from the surgical volumes' recovery in four large Italian regions.

METHODS

This multicentre cohort study covers a population of approximately 11 million people. To assess if social inequalities exist in the recovery of eight indicators of elective and oncological surgery, we estimated Risk Ratios (RR) through Poisson models, comparing the incidence proportions of events recorded during COVID-19 (2020-21) with those in pre-pandemic years (2018-19) for each pandemic period and educational level.

RESULTS

Compared to 2018-19, volumes of elective surgery showed a U-shape with the most significant drops during the second wave or the vaccination phase. The recovery was socially unequal. At the end of 2021, incidence proportions among highly educated people generally exceeded the expected ones; RRs were 1.31 (95%CI 1.21-1.42), 1.24 (95%CI 1.17-1.23), 1.17 (95%CI 1.08-1.26) for knee and hip replacement and prostatic surgery, respectively. Among low educated patients, RR remained always < 1. Oncological surgery indicators showed a similar social gradient. Whereas volumes were preserved among the highly educated, the low educated were still lagging behind at the end of 2021.

CONCLUSIONS

Surgical procedures generally returned to pre-pandemic levels but the low educated experienced the slowest recovery. An equity-oriented appraisal of trends in healthcare provision should be included in pandemic preparedness plans, to ensure that social inequalities are promptly recognised and tackled.

Disruption of hospital care during the first year of the COVID-19 pandemic impacted socioeconomic groups differently: population based study using routine registration data

BACKGROUND

During the COVID-19 pandemic, provision of non-COVID healthcare was recurrently severely disrupted. The objective was to determine whether disruption of non-COVID hospital use, either due to cancelled, postponed, or forgone care, during the first pandemic year of COVID-19 impacted socioeconomic groups differently compared with pre-pandemic use.

METHODS

National population registry data, individually linked with data of non-COVID hospital use in the Netherlands (2017-2020). in non-institutionalised population of 25-79 years, in standardised household income deciles (1 = low, 10 = high) as proxy for socioeconomic status. Generic outcome measures included patients who received hospital care (dichotomous): outpatient contact, day treatment, inpatient clinic, and surgery. Specific procedures were included as examples of frequently performed elective and acute procedures, e.g.: elective knee/hip replacement and cataract surgery, and acute percutaneous coronary interventions (PCI). Relative risks (RR) for hospital use were reported as outcomes from generalised linear regression models (binomial) with log-link. An interaction term was included to assess whether income differences in hospital use during the pandemic deviated from pre-pandemic use.

RESULTS

Hospital use rates declined in 2020 across all income groups. With baseline (2019) higher hospital use rates among lower than higher income groups, relatively stronger declines were found for lower income groups. The lowest income groups experienced a 10% larger decline in surgery received than the highest income group (RR 0.90, 95% CI 0.87 - 0.93). Patterns were similar for inpatient clinic, elective knee/hip replacement and cataract surgery. We found small or no significant income differences for outpatient clinic, day treatment, and acute PCI.

CONCLUSIONS

Disruption of non-COVID hospital use in 2020 was substantial across all income groups during the acute phases of the pandemic, but relatively stronger for lower income groups than could be expected compared with pre-pandemic hospital use. Although the pandemic's impact on the health system was unprecedented, healthcare service shortages are here to stay. It is therefore pivotal to realise that lower income groups may be at risk for underuse in times of scarcity.

Toxoplasma gondii infection associated with inflammasome activation and neuronal injury

Toxoplasma gondii (TOXO) infection typically results in chronic latency due to its ability to form cysts in the brain and other organs. Latent toxoplasmosis could promote innate immune responses and impact brain function. A large body of evidence has linked TOXO infection to severe mental illness (SMI). We hypothesized that TOXO immunoglobulin G (IgG) seropositivity, reflecting previous infection and current latency, is associated with increased circulating neuron-specific enolase (NSE), a marker of brain damage, and interleukin-18 (IL-18), an innate immune marker, mainly in SMI. We included 735 patients with SMI (schizophrenia or bipolar spectrum) (mean age 32 years, 47% women), and 518 healthy controls (HC) (mean age 33 years, 43% women). TOXO IgG, expressed as seropositivity/seronegativity, NSE and IL-18 were measured with immunoassays. We searched for main and interaction effects of TOXO, patient/control status and sex on NSE and IL-18. In the whole sample as well as among patients and HC separately, IL-18 and NSE concentrations were positively correlated (p < 0.001). TOXO seropositive participants had significantly higher NSE (3713 vs. 2200 pg/ml, p < 0.001) and IL-18 levels (1068 vs. 674 pg/ml, p < 0.001) than seronegative participants, and evaluation within patients and HC separately showed similar results. Post-hoc analysis on cytomegalovirus and herpes simplex virus 1 IgG status showed no associations with NSE or IL-18 which may suggest TOXO specificity. These results may indicate ongoing inflammasome activation and neuronal injury in people with TOXO infections unrelated to diagnosis.

Contribution of non-socioeconomic factors to healthy quality of life in socioeconomically deprived patients with advanced gastrointestinal cancer: Measuring attributable fraction

BACKGROUND

The quality of life of patients with advanced gastrointestinal cancer is seriously impaired, and socioeconomic deprivation often has a serious impact on their quality of life. However, little is known about the relative contribution of non-socioeconomic factors to the quality of life of patients with advanced gastrointestinal cancer with socioeconomic deprivation.

AIM

This study aims to investigate the situation and predictors of quality of life of patients with socioeconomic deprivation and evaluate the independent effects of some non-socioeconomic factors.

DESIGN

A retrospective study based on cross-sectional design.

METHODS

Data were obtained from 1075 patients with advanced gastrointestinal cancer who received family palliative treatment in the hospice ward of Zhongnan Hospital of Wuhan University from March 2010 to October 2020, including demographic and clinical questionnaires, Karnofsky Performance Status scale and Cancer Pain and Quality of Life Questionnaire of Chinese Cancer Patients.

RESULTS

The quality of life of patients with advanced gastrointestinal cancer with socioeconomic deprivation is impaired and is affected by gait, self-care ability, abdominal distension, nutritional status, weight loss, constipation and posture. Improvement in six of these factors-gait, self-care ability, abdominal distension, nutritional status, weight loss and posture-has an independent positive impact on the development of a healthy quality of life for patients.

CONCLUSIONS

Gait, self-care ability, abdominal distension, nutritional status, weight loss and posture are important determinants of healthy quality of life in patients with advanced gastrointestinal cancer with socioeconomic deprivation, and early identification and strength management of these non-socioeconomic factors may neutralize the negative impact of socioeconomic factors on the quality of life.

IMPLICATIONS FOR PRACTICE

This study provides new ideas and intervention entry points for global nurses in practice innovations to improve the quality of life of socioeconomically deprived patients with advanced gastrointestinal cancer. It enables them to focus on the effectiveness of non-socioeconomic factors in the development and implementation of targeted care plans for patients with advanced gastrointestinal cancer experiencing socioeconomic deprivation globally.

REPORTING METHOD

This study was reported in strict compliance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Diverging death risks: Mortality as a corollary of economic, social, cultural and person capital

Introduction

Diverging death risks are associated with a wide range of social factors, including not only education and income but also other economic and non-economic resources. The aim of this study was to assess the association of mortality risks with four types of resources: economic, social, cultural and person capital.

Methods

We used data of 2,952 participants from the Disparities in the Netherlands survey and annual mortality data from Statistics Netherlands for the period 2014 to 2021. Economic capital was measured through education, income, occupation, home equity, and liquid assets. Social capital was measured by the strength of social ties, the size of the core discussion network, and access to people in resourceful positions; cultural capital by lifestyle, digital skills, and mastery of English, and person capital by self-rated health, impediments to climbing stairs, self-confidence, self-image, people's appearance, and body mass index. To accommodate the fact that each capital was derived from several indicators, we used Partial Least Squares (PLS) Cox Regression.

Results

In multiple regression, higher economic, cultural, and person capital were associated with lower mortality (hazard ratio, 0.77; 95% confidence interval [CI, 0.65 to 0.90], 0.77 [0.64-0.93] and 0.80; [0.70-0.92]), adjusted for all capital measures and sex.

Conclusion

The finding that more economic, cultural and person capital is associated with lower mortality provides empirical support for an approach that uses a broad spectrum of capital measures - hitherto rarely included simultaneously in epidemiological research - in order to understand diverging death risks. By integrating sociological concepts, cohort data, and epidemiological research methods, our study highlights the need for further research on the interplay between different forms of resources in shaping health inequalities. In designing public health interventions, we advocate the adoption of a multidimensional capital-based framework for tackling social disparities in mortality.

Acceptability, Preferred Medium, and Components of Nurse-Led Cardiac Telerehabilitation: A Cross-Sectional Study

Cardiac rehabilitation (CR) is a comprehensive and multidisciplinary secondary prevention care in coronary heart disease (CHD). There are barriers at the patient and health system levels that prevent CR from being utilized. Cardiac telerehabilitation led by nurses (Ne-CTR) can alleviate the obstacles to participation in CR. A patient perspective can improve CR access. This study was the first pre-program investigation to clarify the status of knowledge and participation in CTR. We sought to clarify the acceptability, the reasons for rejection, the desired form, components, and associated factors with the components needed for (Ne-CTR) in patients with CHD. The study aimed to help develop a protocol for Ne-CTR for Chinese patients with CHD. A cross-sectional study was conducted between 2020 and 2021. Hospitals in four provinces in China were included. The participants were 671 patients with CHD in hospitals located in three regions of China. A self-administered questionnaire collected information about demographics, knowledge, and participation in CTR, acceptability, preferred medium, and components of Ne-CTR. Student's t-test, analysis of variance, and multiple linear regression analyzed the factors associated with component needs. All the analyses were conducted using IBM SPSS version 25.0. Most participants (n = 434, 66.77%) had a poor understanding and participation in CTR. In addition, 65.38% (n = 439) of participants were willing to accept the Ne-CTR program, and 43.56% (n = 98) identified safety as reasons for not accepting such a program. In the group accepting Ne-CTR, 35% chose hospital-designed professional applications as a medium for Ne-CTR when offered. Education (4.44 ± 1.056) and drug information (4.44 ± 1.040) had the highest average need score. Education, monthly income, marital status, previous CTR participation, and health insurance were associated with the demand level scores of Ne-CTR. This study demonstrated high levels of need for Ne-CTR among patients with CHD and identified the desired medium, components, and associated factors of Ne-CTR. These findings provide reference information for the construction of a Ne-CTR program.

Investigating social inequalities in children's independent mobility, active transportation and outdoor free play in two Canadian cities

Background

Active transportation (AT) and free play (FP) are the primary ways in which children engage in unstructured physical activity in cities, with independent mobility (IM) gaining increased attention as a potential precursor of AT and FP. However, current trends show that children are engaging in less FP and AT, and have less IM, than previous generations and it is not well understood how these practices, and their interrelatedness, differ by neighbourhood-level socio-economic stats (SES) and municipal contexts.

Objectives

This study aims to address the gaps in knowledge by quantifying, comparing, and correlating IM, AT, and FP practices in high and low-SES neighbourhoods within and across the cities of Montreal and Kingston, Canada.

Methods

584 questionnaires were distributed among children in grades 1 to 5, living in low- and high-SES neighbourhoods of these two citiesResultsEngagement in the three practices was low in every study neighbourhood, though all three practices were higher in high-SES compared to low-SES neighbourhoods in both cities. Levels of FP were higher in Kingston compared to Montreal, while AT was higher in Montreal than in Kingston.

Conclusion

This study revealed social inequalities in all three of these practices based on socioeconomic status and city. Since IM is likely a precursor to both independent FP and AT, more research is warranted into how our cities can become more conducive to IM in children, particularly in low SES neighbourhoods where children have less freedom of movement independently and otherwise.

Income-Related Inequality Changes in Osteoarthritis First-Line Interventions: A Cohort Study

OBJECTIVE

To examine income-related inequality changes in the outcomes of an osteoarthritis (OA) first-line intervention.

DESIGN

Retrospective cohort study.

SETTING

Swedish health care system.

PARTICIPANTS

We included 115,403 people (age: 66.2±9.7 years; females 67.8%; N=115,403) with knee (67.8%) or hip OA (32.4%) recorded in the "Swedish Osteoarthritis Registry" (SOAR).

INTERVENTIONS

Exercise and education.

MAIN OUTCOME MEASURES

Erreygers' concentration index (E) measured income-related inequalities in "Pain intensity," "Self-efficacy," "Use of NSAIDs," and "Desire for surgery" at baseline, 3-month, and 12-month follow-ups and their differences over time. E-values range from -1 to +1 if the health variables are more concentrated among people with lower or higher income. Zero represents perfect equality. We used entropy balancing to address demographic and outcome imbalances and bootstrap replications to estimate confidence intervals for E differences over time.

RESULTS

Comparing baseline to 3 months, "pain" concentrated more among individuals with lower income initially (E=-0.027), intensifying at 3 months (difference with baseline: E=-0.011 [95% CI: -0.014; -0.008]). Similarly, the "Desire for surgery" concentrated more among individuals with lower income initially (E=-0.009), intensifying at 3 months (difference with baseline: E=-0.012 [-0.018; -0.005]). Conversely, "Self-efficacy" concentrated more among individuals with higher income initially (E=0.058), intensifying at 3 months (difference with baseline: E=0.008 [0.004; 0.012]). Lastly, the "Use of NSAIDs" concentrated more among individuals with higher income initially (E=0.068) but narrowed at 3 months (difference with baseline: E=-0.029 [-0.038; -0.021]). Comparing baseline with 12 months, "pain" concentrated more among individuals with lower income initially (E=-0.024), intensifying at 12 months (difference with baseline: E=-0.017 [-0.022; -0.012]). Similarly, the "Desire for surgery" concentrated more among individuals with lower income initially (E=-0.016), intensifying at 12 months (difference with baseline: E=-0.012 [-0.022; -0.002]). Conversely, "Self-efficacy" concentrated more among individuals with higher income initially (E=0.059), intensifying at 12 months (difference with baseline: E=0.016 [0.011; 0.021]). The variable 'Use of NSAIDs' was not recorded in the SOAR at 12-month follow-up.

CONCLUSION

Our results highlight the increase of income-related inequalities in the SOAR over time.

A longitudinal analysis of health inequalities from adolescence to young adulthood and their underlying causes

Research suggests that children of low-educated parents face greater health burdens during the passage from adolescence to young adulthood, as they are more likely to become low-educated themselves, establish behavioural and psychosocial disadvantages, or being exposed to unhealthy working conditions. However, studies examining the development and drivers of health inequalities during this particular life stage are limited in number and have produced varied results. This study investigates trajectories of self-rated health and overweight from 14 to 25 years of age, stratified by parental education, and explores the role of potential mediators (educational achievement, health behaviours, psychosocial factors, working conditions). We rely on prospective cohort data from the National Educational Panel Study (NEPS), a representative sample of 14,981 German ninth graders interviewed yearly from 2011 to 2021 (n = 90,096 person-years). First, we estimated random-effects growth curves for self-rated health and overweight over participants' age and calculated the average marginal effect of high versus low parental education. Second, a series of simulation-based mediation analyses were performed to test how much of health inequalities were explained by children's educational attainment (years of school education, years in university), health behaviours (smoking, alcohol, physical inactivity), psychosocial factors (number of grade repetitions, years in unemployment, chronic stress, self-esteem) and working conditions (physical and psychosocial job demands). We accounted for potential confounding by controlling for age, sex, migration background, residential area, household composition, and interview mode. Results show that higher parental education was related to higher self-rated health and lower probabilities of being overweight. Interaction between parental education and age indicated that, after some equalisation in late adolescence, health inequalities increased in young adulthood. Furthermore, educational attainment, health behaviours, psychosocial factors, and early-career working conditions played a significant role in mediating health inequalities. Of the variables examined, the level of school education and years spent in university were particular strong mediating factors. School education accounted for around one-third of the inequalities in self-rated health and one-fifth of the differences in overweight among individuals. Results support the idea that the transition to adulthood is a sensitive period in life and that early socio-economic adversity increases the likelihood to accumulate health disadvantages in multiple dimensions. In Germany, a country with comparatively low educational mobility, intergenerational continuities in class location seem to play a key role in the explanation of health inequalities in youth.

Impact of household income on the risk of overweight and obesity over time among preschool-aged children: a population-based cohort study

BACKGROUND

The temporality of household income level with overweight/obesity in children has not been extensively studied. Little research has been conducted to determine the impact of household income on the risk of childhood overweight/obesity over time. This population-based cohort study aimed to investigate the impact of household income on the risk of overweight/obesity over time among preschool-aged children in Taiwan.

METHODS

From 2009 to 2018, we recruited 1,482 preschool-aged children ( ≦ 7 y of age) from low-income households and selected age- and sex-matched controls from non-low-income households for comparison; All participants were selected from those who consistently participated in the Taipei Child Development Screening Program and were monitored for overweight/obesity using body mass index (BMI) until December 31, 2018. Low-income households were defined as those with an average monthly disposable income < 60% of the minimum standard of living expense in Taiwan. The primary outcome was childhood overweight or obesity in study participants, defined as BMI (kg/m2) ≥ 85th percentile or ≥ 95th percentile, respectively. The generalized estimating equations (GEE) model was used to determine the impact of low-income households on the risk of overweight/obesity in study participants.

RESULTS

Over 21,450 person-years of follow-up, 1,782 participants developed overweight /obesity, including 452 (30.5%) and 1,330 (22.4%) children from low- and non-low-income households, respectively. The GEE model showed that the first group had a significantly higher risk of becoming overweight/obese than the other during the follow-up period (adjusted odds ratio [aOR] = 1.44, 95% CI: 1.29-1.60). Moreover, children of foreign mothers had a higher risk of becoming overweight/obese than those of Taiwanese mothers during the follow-up period (aOR = 1.51, 95% CI: 1.24-1.8). The subgroup analysis revealed a significant association between low-income households and an increased risk of overweight/obesity in children aged 2-7 years (P =.01). However, this association was not observed in children aged 0-1 years (P >.999).

CONCLUSIONS

During the follow-up period, there was a notable correlation between low-income households and an increased risk of preschool-aged children developing overweight or obesity. Implementing health promotion initiatives aimed at reducing overweight and obesity in this demographic is crucial.

The impact of reproductive factors on the metabolic profile of females from menarche to menopause

We explore the relation between age at menarche, parity and age at natural menopause with 249 metabolic traits in over 65,000 UK Biobank women using multivariable regression, Mendelian randomization and negative control (parity only). Older age of menarche is related to a less atherogenic metabolic profile in multivariable regression and Mendelian randomization, which is largely attenuated when accounting for adult body mass index. In multivariable regression, higher parity relates to more particles and lipids in VLDL, which are not observed in male negative controls. In multivariable regression and Mendelian randomization, older age at natural menopause is related to lower concentrations of inflammation markers, but we observe inconsistent results for LDL-related traits due to chronological age-specific effects. For example, older age at menopause is related to lower LDL-cholesterol in younger women but slightly higher in older women. Our findings support a role of reproductive traits on later life metabolic profile and provide insights into identifying novel markers for the prevention of adverse cardiometabolic outcomes in women.