Magnitude and causes of socioeconomic differentials in mortality: further evidence from the Whitehall Study

Is society caught up in a Death Spiral? Modeling societal demise and its reversal

Just like an army of ants caught in an ant mill, individuals, groups and even whole societies are sometimes caught up in a Death Spiral, a vicious cycle of self-reinforcing dysfunctional behavior characterized by continuous flawed decision making, myopic single-minded focus on one (set of) solution(s), denial, distrust, micromanagement, dogmatic thinking and learned helplessness. We propose the term Death Spiral Effect to describe this difficult-to-break downward spiral of societal decline. Specifically, in the current theory-building review we aim to: (a) more clearly define and describe the Death Spiral Effect; (b) model the downward spiral of societal decline as well as an upward spiral; (c) describe how and why individuals, groups and even society at large might be caught up in a Death Spiral; and (d) offer a positive way forward in terms of evidence-based solutions to escape the Death Spiral Effect. Management theory hints on the occurrence of this phenomenon and offers turn-around leadership as solution. On a societal level strengthening of democracy may be important. Prior research indicates that historically, two key factors trigger this type of societal decline: rising inequalities creating an upper layer of elites and a lower layer of masses; and dwindling (access to) resources. Historical key markers of societal decline are a steep increase in inequalities, government overreach, over-integration (interdependencies in networks) and a rapidly decreasing trust in institutions and resulting collapse of legitimacy. Important issues that we aim to shed light on are the behavioral underpinnings of decline, as well as the question if and how societal decline can be reversed. We explore the extension of these theories from the company/organization level to the society level, and make use of insights from both micro-, meso-, and macro-level theories (e.g., Complex Adaptive Systems and collapsology, the study of the risks of collapse of industrial civilization) to explain this process of societal demise. Our review furthermore draws on theories such as Social Safety Theory, Conservation of Resources Theory, and management theories that describe the decline and fall of groups, companies and societies, as well as offer ways to reverse this trend.

Rural Health Disparities in Allergy, Asthma, and Immunologic Diseases: The Current State and Future Direction for Clinical Care and Research

Rural health disparities are well documented and continue to jeopardize the long-term health and wellness for the millions of individuals who live in rural America. The disparities observed between urban and rural residents encompass numerous morbidity and mortality measures for several chronic diseases and have been referred to as the "rural mortality penalty." Although the unmet health needs of rural communities are widely acknowledged, little is known about rural health disparities in allergies, asthma, and immunologic diseases. Furthermore, the intersection between rural health disparities and social determinants of health has not been fully explored. To achieve a more complete understanding of the factors that perpetuate rural health disparities, greater research efforts followed by improved practice and policy are needed that account for the complex social context within rural communities rather than a general comparison between urban and rural environments or focusing on biomedical factors. Moreover, research efforts must prioritize community inclusion throughout rural areas through meaningful engagement of stakeholders in both clinical care and research. In this review, we examine the scope of health disparities in the rural United States and the impact of social determinants of health. We then detail the current state of rural health disparities in the field of allergy, asthma, and immunology. To close, we offer future considerations to address knowledge gaps and unmet needs for both clinical care and research in addressing rural health disparities.

Rethinking dehumanization, empathy, and burnout in healthcare context

Dehumanization has been characterized as common in medical settings, despite limited work directly examining this. In this context, everyday dehumanization is believed to be largely unconscious and unintentional, resulting from a variety of factors often related to structural and organizational aspects of healthcare. This article adopts the patients' and the healthcare providers' perspective to explore how dehumanization can have helpful and hurtful effects on patient outcomes and provider well-being. Future directions include more direct assessment of dehumanization in healthcare settings, centering the needs and experiences of people with mental illness and comorbid conditions, and improving our understanding of dehumanization relative to emotion regulation processes.

DNA methylation signatures as biomarkers of socioeconomic position

This review article provides a framework for the use of deoxyribonucleic acid (DNA) methylation (DNAm) biomarkers to study the biological embedding of socioeconomic position (SEP) and summarizes the latest developments in the area. It presents the emerging literature showing associations between individual- and neighborhood-level SEP exposures and DNAm across the life course. In contrast to questionnaire-based methods of assessing SEP, we suggest that DNAm biomarkers may offer an accessible metric to study questions about SEP and health outcomes, acting as a personal dosimeter of exposure. However, further work remains in standardizing SEP measures across studies and evaluating consistency across domains, tissue types, and time periods. Meta-analyses of epigenetic associations with SEP are offered as one approach to confirm the replication of DNAm loci across studies. The development of DNAm biomarkers of SEP would provide a method for examining its impact on health outcomes in a more robust way, increasing the rigor of epidemiological studies.

Aggressive measures, rising inequalities, and mass formation during the COVID-19 crisis: An overview and proposed way forward

A series of aggressive restrictive measures were adopted around the world in 2020-2022 to attempt to prevent SARS-CoV-2 from spreading. However, it has become increasingly clear the most aggressive (lockdown) response strategies may involve negative side-effects such as a steep increase in poverty, hunger, and inequalities. Several economic, educational, and health repercussions have fallen disproportionately on children, students, young workers, and especially on groups with pre-existing inequalities such as low-income families, ethnic minorities, and women. This has led to a vicious cycle of rising inequalities and health issues. For example, educational and financial security decreased along with rising unemployment and loss of life purpose. Domestic violence surged due to dysfunctional families being forced to spend more time with each other. In the current narrative and scoping review, we describe macro-dynamics that are taking place because of aggressive public health policies and psychological tactics to influence public behavior, such as mass formation and crowd behavior. Coupled with the effect of inequalities, we describe how these factors can interact toward aggravating ripple effects. In light of evidence regarding the health, economic and social costs, that likely far outweigh potential benefits, the authors suggest that, first, where applicable, aggressive lockdown policies should be reversed and their re-adoption in the future should be avoided. If measures are needed, these should be non-disruptive. Second, it is important to assess dispassionately the damage done by aggressive measures and offer ways to alleviate the burden and long-term effects. Third, the structures in place that have led to counterproductive policies should be assessed and ways should be sought to optimize decision-making, such as counteracting groupthink and increasing the level of reflexivity. Finally, a package of scalable positive psychology interventions is suggested to counteract the damage done and improve humanity's prospects.

Beyond Behaviour: How Health Inequality Theory Can Enhance Our Understanding of the 'Alcohol-Harm Paradox'

There are large socioeconomic inequalities in alcohol-related harm. The alcohol harm paradox (AHP) is the consistent finding that lower socioeconomic groups consume the same or less as higher socioeconomic groups yet experience greater rates of harm. To date, alcohol researchers have predominantly taken an individualised behavioural approach to understand the AHP. This paper calls for a new approach which draws on theories of health inequality, specifically the social determinants of health, fundamental cause theory, political economy of health and eco-social models. These theories consist of several interwoven causal mechanisms, including genetic inheritance, the role of social networks, the unequal availability of wealth and other resources, the psychosocial experience of lower socioeconomic position, and the accumulation of these experiences over time. To date, research exploring the causes of the AHP has often lacked clear theoretical underpinning. Drawing on these theoretical approaches in alcohol research would not only address this gap but would also result in a structured effort to identify the causes of the AHP. Given the present lack of clear evidence in favour of any specific theory, it is difficult to conclude whether one theory should take primacy in future research efforts. However, drawing on any of these theories would shift how we think about the causes of the paradox, from health behaviour in isolation to the wider context of complex interacting mechanisms between individuals and their environment. Meanwhile, computer simulations have the potential to test the competing theoretical perspectives, both in the abstract and empirically via synthesis of the disparate existing evidence base. Overall, making greater use of existing theoretical frameworks in alcohol epidemiology would offer novel insights into the AHP and generate knowledge of how to intervene to mitigate inequalities in alcohol-related harm.

[Social inequalities in health among the elderly population: review of indicators used in Spain]

OBJECTIVE

To identify the indicators of social position used to evaluate inequalities in health among the population aged 65 and over in Spain.

METHOD

A systematic search of the literature published in English and Spanish since 2000 in health and social databases was carried out. Primary and secondary studies analyzing these inequalities in Spain were included. The indicators used were identified, as well as the advantages and limitations pointed out by the authors. The main findings were synthesized in a review of the literature.

RESULTS

We included 87 studies, described in 89 articles. The socioeconomic indicators employed were both individual and ecological. Among the former, educational level was the most analyzed socioeconomic variable (n=73). Other individual variables used were occupation (n=17), objective economic level (n=16), subjective economic level (n=4), housing and household material wealth (n=6), relationship with work activity (n=5), and mixed measures (n=5). Among the ecological indicators, simple (n=3) and complex indices (n=7) were identified. The latter had been constructed based on several indicators, such as educational level and unemployment. Inequalities in multiple health indicators were analyzed, self-perceived health being the only indicator assessed according to all the socioeconomic indicators described.

CONCLUSIONS

A wide variety of indicators is identified for the evaluation of social inequalities in health among the elderly population. There have not been sufficiently assessed from a gender perspective; this is a line of interest for future research.

Exacerbating Inequalities? Health Policy and the Behavioural Sciences

There have been calls for some time for a new approach to public health in the United Kingdom and beyond. This is consequent on the recognition and acceptance that health problems often have a complex and multi-faceted aetiology. At the same time, policies which utilise insights from research in behavioural economics and psychology ('behavioural science') have gained prominence on the political agenda. The relationship between the social determinants of health (SDoH) and behavioural science in health policy has not hitherto been explored. Given the on-going presence of strategies based on findings from behavioural science in policy-making on the political agenda, an examination of this is warranted. This paper begins by looking at the place of the SDoH within public health, before outlining, in brief, the recent drive towards utilising behavioural science to formulate law and public policy. We then examine the relationship between this and the SDoH. We argue that behavioural public health policy is, to a certain extent, blind to the social and other determinants of health. In section three, we examine ways in which such policies may perpetuate and/or exacerbate health inequities and social injustices. We argue that problems in this respect may be compounded by assumptions and practices which are built into some behavioural science methodologies. We also argue that incremental individual gains may not be enough. As such, population-level measures are sometimes necessary. In section four we defend this contention, arguing that an equitable and justifiable public health requires such measures.

On the Structure of Mortality among the Regions in the Slovak Republic

AIM

The Slovak Republic consists of eight regions which may dispose a different structure of cause-specific mortality. The aim of this study is to reveal the regions with higher risk of dying from the main categories of diseases selected according to the chapters of the International Classification of Diseases (ICD-10).

METHODS

Data were obtained from mortality reports throughout 1996-2014. We applied multinomial logistic regression analysis, where the dependent variable is death categories and the explanatory variables are regions, age, year and gender. The Bratislava region and Diseases of the circulatory system are set as the reference level.

RESULTS

We propose a spatiotemporal analysis of the relative risk ratio of dying in the Slovak Republic for every significant group of diseases from the International Statistical Classification of Diseases and Related Health Problems maintained by the World Health Organization. Moreover, we propose gender and age analysis.

CONCLUSIONS

These results could be useful for setting active prevention programs, as well as a hospital network specialising in high risk diagnoses in Slovakian regions.

Early life characteristics and late life burden of cerebral small vessel disease in the Lothian Birth Cohort 1936

It is unknown whether relations between early-life factors and overall health in later life apply to burden of cerebral small vessel disease (cSVD), a major cause of stroke and dementia. We explored relations between early-life factors and cSVD in the Lothian Birth Cohort, a healthy aging cohort. Participants were recruited at age 70 (N = 1091); most had completed a test of cognitive ability at age 11 as part of the Scottish Mental Survey of 1947. Of those, 700 participants had brain MRI that could be rated for cSVD conducted at age 73. Presence of lacunes, white matter hyperintensities, microbleeds, and perivascular spaces were summed in a score of 0-4 representing all MRI cSVD features. We tested associations with early-life factors using multivariate logistic regression. Greater SVD score was significantly associated with lower age-11 IQ (OR higher SVD score per SD age-11 IQ = .78, 95%CI 0.65-.95, p=.01). The associations between SVD score and own job class (OR higher job class, .64 95%CI .43-.95, p=.03), age-11 deprivation index (OR per point deprivation score, 1.08, 95%CI 1.00-1.17, p=.04), and education (OR some qualifying education, .60 95%CI .37-.98, p=.04) trended towards significance (p<.05 for all) but did not meet thresholds for multiple testing. No early-life factor was significantly associated with any one individual score component. Early-life factors may contribute to age-73 burden of cSVD. These relations, and the potential for early social interventions to improve brain health, deserve further study.

Undiagnosed depression: A community diagnosis

Many large provider networks are investing heavily in preventing disease within the communities that they serve. We explore the potential benefits and challenges associated with tackling depression at the community level using a unique dataset designed for one such provider network. The economic costs of having depression (increased medical care use, lower quality of life, and decreased workplace productivity) are among the highest of any disease. Depression often goes undiagnosed, yet many believe that depression can be treated or prevented altogether. We explore the prevalence, distribution, economic burden, and the psychosocial and economic factors associated with undiagnosed depression in a lower-income neighborhood in northern Manhattan. Even using state-of-the art data to "diagnose" the risk factors within a community, it can be challenging for provider networks to act against such risk factors.

Social gradient in the metabolic syndrome not explained by psychosocial and behavioural factors: evidence from the Copenhagen City Heart Study∗

BACKGROUND

Psychosocial stressors may mediate the effect of social status on the metabolic syndrome (MS). The paper explores this hypothesis in a random sample of the general population.

DESIGN

A total of 3462 women and 2576 men aged 20-97 years from the Copenhagen City Heart Study.

METHODS

An MS index was defined from the seven components: waist-hip ratio, high-density lipoprotein (HDL)-cholesterol, triglycerides, systolic blood pressure (SBP), blood glucose, C-reactive protein (CRP) and fibrinogen. Social status was measured by educational level. Psychosocial factors included fatigue and depression, perceived stress, social network and cohabitation. Behavioural factors were smoking, alcohol and physical activity.

RESULTS

There was an inverse social gradient in the prevalence of the seven components of the MS. The age-adjusted odds ratio (OR) (95% confidence interval) for occupying the most disadvantaged quintile, comparing highest with lowest educational level, were for men and women, respectively: waist-hip ratio 0.48 (0.34-0.69) and 0.48 (0.33-0.69); HDL-cholesterol 0.61 (0.45-0.84) and 0.46 (0.33-0.64); triglycerides 0.71 (0.51-0.98) and 0.37 (0.25-0.53); SBP 0.64 (0.44-0.92) and 0.76 (0.50-1.15); blood glucose 0.57 (0.41-0.80) and 0.55 (0.38-0.78); CRP 0.53 (0.37-0.74) and 0.44 (0.31-0.63), and fibrinogen 0.50 (0.35-0.70) and 0.56 (0.38-0.82). The pooled OR for having an MS index score of 3 or more was 0.32 (0.24-0.42) for highest versus lowest educational level. A higher fatigue and depression score in both sexes and a lack of social support in men were associated with the MS, as were smoking, low alcohol consumption and a lack of physical activity. However, OR for educational level were not affected by adjustment for the psychosocial or behavioural factors.

CONCLUSIONS

There is a strong inverse social gradient in the prevalence of the MS, which is not explained by psychosocial or major behavioural factors.

Socio-economic Differentials in Health

The first Whitehall Study of British civil servants demonstrated an inverse gradient in mortality. The lower the grade the higher was the mortality risk. This higher mortality risk applies to most but not all causes of death. The Whitehall II Study, set up to investigate causes of this social gradient shows similarly marked gradients in morbidity. A review of potential causes of the gradient suggests that it is due neither to health selection nor simply to differences in lifestyle, but that relative deprivation—a psychosocial concept—and the accumulation of socially-patterned exposures over the life course, must be important. Whitehall II suggests that the operation of these factors is to be found in the specific circumstances under which people grow, live and work.

Some Observations on Health and Socio economic Status

Health and socio-economic status are powerfully linked. This association cannot be attributed to social-selection effects, and the unequal distribution of behavioural risk factors, such as smoking, explains only a part of the variance. Differential exposure to physical hazards plays a role, but the persistence of health differentials into the better-off social strata and the significance of relative as well as absolute living standards suggest psychosocial factors also. We outline a conceptual model that regards the clustering of adverse physical and psychosocial factors over the life course as critical. Identifying the salient physical and psychosocial factors is a formidable research mission. In pursuing this mission we should not lose sight of the key fact that socio economic health differentials are intimately bound up with material differentials, and that remediation demands strategies that counter socio-economic disparity.

Socioeconomic disparities in the health of african americans with rheumatoid arthritis from the southeastern United States

OBJECTIVE

To examine cross-sectional baseline data from the Consortium for the Longitudinal Evaluation of African Americans with Early Rheumatoid Arthritis registry for the association between socioeconomic status (SES) with clinical and self-report health outcomes.

METHODS

We analyzed data on 937 African Americans who provided comprehensive sociodemographic data in addition to self-reported health outcomes. SES measures included educational attainment, homeownership, household income, and occupation. Outcomes included measures of disease activity, joint damage, autoantibody status, and self-reported measures. Multivariable linear, logistic, and zero-inflated Poisson regression models were used to estimate associations of each SES measure with rheumatoid arthritis (RA) outcomes, controlling for sex, age, disease duration, comorbid conditions, body mass index, smoking, methotrexate/leflunomide use, and biologic agent use.

RESULTS

The mean age was 54 years, 86% were women, and the mean RA disease duration was 7.8 years. Approximately 24% had less than a high school degree, 56% had a nonprofessional occupation, 75% had a household income ≤$30,000, and 55% were nonhomeowners. In multivariable regression models, significantly increased associations of disease activity measures and self-reported health outcomes were observed with low household income (≤$30,000/year) and nonhomeownership. Education less than high school was primarily associated with self-reported health outcomes. Among participants with disease duration <2 years, associations of SES were confined to self-reported measures.

CONCLUSION

Our results indicate significant socioeconomic disparities in self-reported physical and mental health, clinical disease activity measures, and autoantibody status among African Americans with RA not explained by differences in demographics, medication use, and health behaviors.

Effects of socioeconomic position and clinical risk factors on spontaneous and iatrogenic preterm birth

BACKGROUND

The literature shows a variable and inconsistent relationship between socioeconomic position and preterm birth. We examined risk factors for spontaneous and iatrogenic preterm birth, with a focus on socioeconomic position and clinical risk factors, in order to explain the observed inconsistency.

METHODS

We carried out a retrospective population-based cohort study of all singleton deliveries in Nova Scotia from 1988 to 2003. Data were obtained from the Nova Scotia Atlee Perinatal Database and the federal income tax T1 Family Files. Separate logistic models were used to quantify the association between socioeconomic position, clinical risk factors and spontaneous preterm birth and iatrogenic preterm birth.

RESULTS

The study population included 132,714 singleton deliveries and the rate of preterm birth was 5.5%. Preterm birth rates were significantly higher among the women in the lowest (versus the highest) family income group for spontaneous (rate ratio 1.14, 95% confidence interval (CI) 1.03, 1.25) but not iatrogenic preterm birth (rate ratio 0.95, 95% CI 0.75, 1.19). Adjustment for maternal characteristics attenuated the family income-spontaneous preterm birth relationship but strengthened the relationship with iatrogenic preterm birth. Clinical risk factors such as hypertension were differentially associated with spontaneous (rate ratio 3.92, 95% CI 3.47, 4.44) and iatrogenic preterm (rate ratio 14.1, 95% CI 11.4, 17.4) but factors such as diabetes mellitus were not (rate ratio 4.38, 95% CI 3.21, 5.99 for spontaneous and 4.02, 95% CI 2.07, 7.80 for iatrogenic preterm birth).

CONCLUSIONS

Socioeconomic position and clinical risk factors have different effects on spontaneous and iatrogenic preterm. Recent temporal increases in iatrogenic preterm birth appear to be responsible for the inconsistent relationship between socioeconomic position and preterm birth.

Socioeconomic differences in alcohol-attributable mortality compared with all-cause mortality: a systematic review and meta-analysis

BACKGROUND

Factors underlying socioeconomic inequalities in mortality are not well understood. This study contributes to our understanding of potential pathways to result in socioeconomic inequalities, by examining alcohol consumption as one potential explanation via comparing socioeconomic inequalities in alcohol-attributable mortality and all-cause mortality.

METHODS

Web of Science, MEDLINE, PsycINFO and ETOH were searched systematically from their inception to second week of February 2013 for articles reporting alcohol-attributable mortality by socioeconomic status, operationalized by using information on education, occupation, employment status or income. The sex-specific ratios of relative risks (RRRs) of alcohol-attributable mortality to all-cause mortality were pooled for different operationalizations of socioeconomic status using inverse-variance weighted random effects models. These RRRs were then combined to a single estimate.

RESULTS

We identified 15 unique papers suitable for a meta-analysis; capturing about 133 million people, 3 741 334 deaths from all causes and 167 652 alcohol-attributable deaths. The overall RRRs amounted to RRR = 1.78 (95% confidence interval (CI) 1.43 to 2.22) and RRR = 1.66 (95% CI 1.20 to 2.31), for women and men, respectively. In other words: lower socioeconomic status leads to 1.5-2-fold higher mortality for alcohol-attributable causes compared with all causes.

CONCLUSIONS

Alcohol was identified as a factor underlying higher mortality risks in more disadvantaged populations. All alcohol-attributable mortality is in principle avoidable, and future alcohol policies must take into consideration any differential effect on socioeconomic groups.

Alcohol-a universal preventive agent? A critical analysis

BACKGROUND

In observational studies, moderate drinking is associated with a reduced risk of more than twenty different diseases and health problems. However, it would be premature to conclude that there is a causal relationship.

METHOD

This paper critically reviews the evidence for such associations.

FINDINGS

It was found that reasons for questioning the causal association of moderate drinking and a reduced health risk are: the lack of dose-response relationships; the characteristics and lifestyles of today's abstainers and moderate drinkers; the lack of plausible biological mechanisms; the problems in the classification of drinking groups, and; the general limitations of observational studies.

CONCLUSIONS

The evidence for the harmful effects of alcohol is undoubtedly stronger than the evidence for beneficial effects.

Independent associations of childhood and current socioeconomic status with risk of self-reported doctor-diagnosed arthritis in a family-medicine cohort of North-Carolinians

Background

Associations of socioeconomic status (SES) with the prevalence of various forms of arthritis are well documented. Increasing evidence suggests that SES during childhood is a lasting determinant of health, but its association with the onset of arthritis remains unclear.

Methods

Cross-sectional data on 1276 participants originated from 22 family practices in North-Carolina, USA. We created 4-level (high, medium, low, lowest) current SES and childhood SES summary scores based on parental and participant education, occupation and homeownership. We investigated associations of individual SES characteristics, summary scores and SES trajectories (e.g. high/low) with self-reported arthritis in logistic regression models progressively adjusted for race and gender, age, then BMI, and clustered by family practice.

Results

We found evidence for independent associations of both childhood and current SES with the reporting of arthritis across our models. In covariate-adjusted models simultaneously including current and childhood SES, compared with high SES participants in the lowest childhood SES category (OR = 1.39 [95% CI = 1.04, 1.85]) and those in the low (OR = 1.66 [95% CI = 1.14, 2.42]) and lowest (OR = 2.08 [95% CI = 1.16, 3.74]) categories of current SES had significantly greater odds of having self-reported arthritis.

Conclusions

Current SES and childhood SES are both associated with the odds of reporting arthritis within this primary-care population, although the possibly superseding influence of existing circumstances must be noted. BMI was a likely mechanism in the association of childhood SES with arthritis onset, and research is needed to elucidate further pathways linking the socioeconomic environment across life-stages and the development of rheumatic diseases.

Socioeconomic inequalities in acute myocardial infarction incidence in migrant groups: has the epidemic arrived? analysis of nation-wide data

OBJECTIVES

We assessed socioeconomic inequalities in relation to acute myocardial infarction (AMI) incidence among major ethnic groups in The Netherlands.

METHODS

A nationwide register-based cohort study was conducted (n=2 591 170) between 1 January 1998 and 31 December 2007 among ethnic Dutch and migrant groups from Suriname, Netherlands Antilles, Indonesia, Morocco and Turkey. Standardised household disposable income was used as a proxy for socioeconomic position. Cox proportional hazard models were used to estimate the socioeconomic inequalities in AMI incidence.

RESULTS

Among ethnic Dutch, the AMI incidence was higher in the low-income group than in the high-income group: adjusted HRs were 2.05 (95% CI 2.00 to 2.10) for men and 2.33 (95% CI 2.23 to 2.43) for women. Importantly, similar socioeconomic inequalities in AMI incidence were also observed in all minority groups, with the low socioeconomic group having a higher AMI incidence than the high socioeconomic group: adjusted HR ranging from 2.07 (95% CI 1.26 to 3.40) in Moroccans to 2.73 (95% CI 1.55 to 4.80) in Antilleans in men; and from 2.17 (95% CI 1.74 to 2.71) in Indonesians to 3.88 (95% CI 2.36 to 6.38) in Turks in women.

CONCLUSIONS

Our findings demonstrate socioeconomic inequalities in AMI incidence in migrant groups and suggest a convergence towards the Dutch general population. If the AMI incidence rates of the low socioeconomic group could be reduced to the level of the high socioeconomic group, this would represent a major public health improvement for all ethnic groups.

Associations between community characteristics and psychiatric admissions in an urban area

PURPOSE

Neighbourhood characteristics are known to be associated with higher rates of hospital admission for psychiatric disorders.

METHODS

An ecological study with aggregated data was carried out. All cases for schizophrenia and depression in the 42 city districts of Augsburg were identified over a 4-year-period (2006-2009) and neighbourhood variables were obtained. Negative binomial regression adjusted the effects for year of admission and accommodation in inpatient centres.

RESULTS

There was significant association of high unemployment rate, low proportion of working population and high population density with higher rates of admission for schizophrenia. An increase of 1 % in unemployment rate [incidence rate ration (IRR) 1.0451, 95 % CI 1.0175-1.0734] was associated with 5 % raise of admission rates for schizophrenia and an increase of 1 % in working population (IRR 0.9793, 95 % CI 0.9605-0.9985) with a decrease of admission rates by 2 %. High proportion of single households and high percentage of persons eligible for social security increased admission rate for depression. Thus 1 % increase in the proportion of single households (IRR 1.0095, 95 % CI 1.0030-1.0162) and of the proportion of persons eligible for social security (IRR 1.0148, 95 % CI 1.0002-1.0297) both independently were associated with an increased rate of admission for depression of 1 %.

CONCLUSION

Our analysis demonstrated that measures of social isolation in neighbourhoods and social contacts at work influenced admission for schizophrenia and depression: in neighbourhoods with less social contacts and with a higher proportion of persons not working the admission rates increased. The problem of confounding in ecological studies need to be considered.

Independent influences of current and childhood socioeconomic status on health outcomes in a North Carolina family practice sample of arthritis patients

OBJECTIVE

Compelling evidence suggests that socioeconomic status (SES) is a determinant of health outcomes among persons with arthritis. SES in early life has likewise been associated with various aspects of health, but the connection between childhood SES and health among people with arthritis remains to be investigated. The purpose of this study was to determine the influences of current and childhood SES on self-reported disability, depression, and physical and mental health among people with self-reported doctor-diagnosed arthritis.

METHODS

Data originated from a North Carolina network of primary care centers. Participants with self-reported arthritis with complete sociodemographic and relevant health information were retained in our sample (n = 782). We created summary measures for current and childhood SES from indicators of education, occupation, and homeownership, using parental SES as a proxy for participants' childhood SES. Linear regression models were used to assess the associations between health outcomes and SES variables separately and together, adjusting for key covariates.

RESULTS

Lower childhood and current SES scores were associated with worse disability and physical health. Current SES was furthermore associated with mental health and depressive symptoms. Associations of low current and childhood SES with health outcomes remained significant when concurrently included in a linear model.

CONCLUSION

Childhood and current SES are both determinants of health among persons with arthritis. This underscores the importance of childhood SES as a determinant of adult health among individuals with arthritis. Further studies should focus on these associations in different populations and across different types of arthritis.

Educational differences in healthy behavior changes and adherence among middle-aged Americans

Although the better-educated are more likely to practice healthy behaviors when measured at one point in time, there is no clear evidence regarding whether more educated people are more likely to initiate healthy behavior changes in the face of new chronic conditions and whether they are better able to adhere to these healthy changes, once made. I use data from the Health and Retirement Study (HRS) (1992-2010) to examine smoking cessation and starting physical activity by educational attainment over an 18-year period among 16,606 respondents ages 50 to 75. The more-educated are the least likely to smoke and most likely to be physically active in middle age. They are also most likely to make healthy changes overall and better adhere to them. Education also shapes behavior change after a new diagnosis, which likely contributes to socioeconomic status differences in chronic disease management and health outcomes.

A new method for determining why length of life is more unequal in some populations than in others

Why is there greater variability in individual longevity in some populations than in others? We propose a decomposition method designed to address that question by quantifying the effects of population differences in the spread, allocation, and timing of the principal causes of death. Applying the method to the United States and Sweden, we find that spread effects account for about two-thirds of the greater variance in age at death among American adults, meaning that two-thirds of the U.S.-Sweden difference would persist if the two countries differed only with respect to within-cause variance among adults. The remainder of the difference is due largely to allocation effects, with the greater incidence of homicides and fatal traffic accidents alone accounting for more than one-fourth of the greater variance in age at death among adults in the United States.

Relations among Socioeconomic Status Indicators and Health for African-Americans and Whites

This investigation explored the relationship of socioeconomic status (SES) to physical and mental health in two nationally representative samples of whites and African-Americans. We examined the interrelations among SES variables and assessed their contribution to health for the two racial groups. Throughout, we assessed the contribution of a less traditional indicator of SES-wealth-in the SES-health relationship. As we expected, African-Americans had lower levels of education, household income, and wealth than whites. Unexpectedly, however, the strength of the interrelationships among the three SES indicators did not differ for African-Americans and whites. In addition, we found that SES operated to affect health in a very similar fashion for African-Americans and whites. We found that wealth, in addition to more traditional indicators of SES (education and household income), made a unique and significant contribution to explaining both physical and mental health. Examining relations of different SES indicators to health across groups is critical to eliminating persistent social inequalities in health.

Social epidemiology: Definition, history, and research examples

Social epidemiology is a branch of epidemiology that focuses particularly on the effects of social-structural factors on states of health. Social epidemiology assumes that the distribution of advantages and disadvantages in a society reflects the distribution of health and disease. It proposes to identify societal characteristics that affect the pattern of disease and health distribution in a society and to understand its mechanisms. The central and initial question of social epidemiology to be answered is what effect do social factors have on individual and population health. However, the new focus on this theme using current epidemiological methods is a relatively recent phenomenon. There are several significant concepts in the field of social epidemiology: 1) the bio-psychosocial paradigm, 2) the population perspective, 3) use of new statistical approaches such as multilevel analysis, and 4) significance of theory.The relationship between social class and health has been a major research field since the beginning of public health history. Many studies have identified the disparities in health among social classes and developed several theories, such as social selection theory and socio-biological translation theory. However, despite the long history of this research field, the effect of social class on health is not yet fully understood.Income distribution and health is a relatively new field within social epidemiology. Three possible mechanisms for the consequences of income distribution on health are 1) disinvestment of human capital, 2) disinvestment of social capital, and 3) psychological process. Refining theories of income distribution is a major challenge in research on income distribution.

Social gradients in child and adolescent antisocial behavior: a systematic review protocol

BACKGROUND

The relationship between social position and physical health is well-established across a range of studies. The evidence base regarding social position and mental health is less well developed, particularly regarding the development of antisocial behavior. Some evidence demonstrates a social gradient in behavioral problems, with children from low-socioeconomic backgrounds experiencing more behavioral difficulties than children from high-socioeconomic families. Antisocial behavior is a heterogeneous concept that encompasses behaviors as diverse as physical fighting, vandalism, stealing, status violation and disobedience to adults. Whether all forms of antisocial behavior show identical social gradients is unclear from previous published research. The mechanisms underlying social gradients in antisocial behavior, such as neighborhood characteristics and family processes, have not been fully elucidated. This review will synthesize findings on the social gradient in antisocial behavior, considering variation across the range of antisocial behaviors and evidence regarding the mechanisms that might underlie the identified gradients.

METHODS

In this review, an extensive manual and electronic literature search will be conducted for papers published from 1960 to 2011. The review will include empirical and quantitative studies of children and adolescents (<=18 years old) recruited from the general population, which include measures of both social position and antisocial behavior. A standardized data extraction form and quality appraisal checklist will be used to retrieve essential information and critically appraise each study and the inter-rater reliability of the quality scores will be assessed. If practical, meta-analysis will be used to synthesize the data. However, it is expected that the selected studies will be heterogeneous, in which case narrative synthesis will be applied. Separate conclusions may be drawn for logically grouped studies on the basis of their quality score, scope or methodology.

DISCUSSION

This systematic review has been proposed in order to synthesize cross-disciplinary evidence of the social gradient in antisocial behavior and mechanisms underlying this effect. The results of the review will inform social policies aiming to reduce social inequalities and levels of antisocial behavior, and identify gaps in the present literature to guide further research.

Is the high-risk strategy to prevent cardiovascular disease equitable? A pharmacoepidemiological cohort study

BACKGROUND

Statins are increasingly prescribed to prevent cardiovascular disease (CVD) in asymptomatic individuals. Yet, it is unknown whether those at higher CVD risk - i.e. individuals in lower socio-economic position (SEP) - are adequately reached by this high-risk strategy. We aimed to examine whether the Danish implementation of the strategy to prevent cardiovascular disease (CVD) by initiating statin (HMG-CoA reductase inhibitor) therapy in high-risk individuals is equitable across socioeconomic groups.

METHODS

DESIGN

Cohort study.

SETTING AND PARTICIPANTS

Applying individual-level nationwide register information on socio-demographics, dispensed prescription drugs and hospital discharges, all Danish citizens aged 20+ without previous register-markers of CVD, diabetes or statin therapy were followed during 2002-2006 for first occurrence of myocardial infarction (MI) and a dispensed statin prescription (N = 3.3 mill).

MAIN OUTCOME MEASURES

Stratified by gender, 5-year age-groups and socioeconomic position (SEP), incidence of MI was applied as a proxy for statin need. Need-standardized statin incidence rates were calculated, applying MI incidence rate ratios (IRR) as need-weights to adjust for unequal needs across SEP.Horizontal equity in initiating statin therapy was tested by means of Poisson regression analysis. Applying the need-standardized statin parameters and the lowest SEP-group as reference, a need-standardized statin IRR > 1 translates into horizontal inequity favouring the higher SEP-groups.

RESULTS

MI incidence decreased with increasing SEP without a parallel trend in incidence of statin therapy. According to the regression analyses, the need-standardized statin incidence increased in men aged 40-64 by 17%, IRR 1.17 (95% CI: 1.14-1.19) with each increase in income quintile. In women the proportion was 23%, IRR 1.23 (1.16-1.29). An analogous pattern was seen applying education as SEP indicator and among subjects aged 65-84.

CONCLUSION

The high-risk strategy to prevent CVD by initiating statin therapy seems to be inequitable, reaching primarily high-risk subjects in lower risk SEP-groups.

The implications of megatrends in information and communication technology and transportation for changes in global physical activity

Physical inactivity accounts for more than 3 million deaths per year, most from non-communicable diseases in low-income and middle-income countries. We used reviews of physical activity interventions and a simulation model to examine how megatrends in information and communication technology and transportation directly and indirectly affect levels of physical activity across countries of low, middle, and high income. The model suggested that the direct and potentiating eff ects of information and communication technology, especially mobile phones, are nearly equal in magnitude to the mean eff ects of planned physical activity interventions. The greatest potential to increase population physical activity might thus be in creation of synergistic policies in sectors outside health including communication and transportation. However, there remains a glaring mismatch between where studies on physical activity interventions are undertaken and where the potential lies in low-income and middle-income countries for population-level effects that will truly affect global health.

The contribution of educational inequalities to lifespan variation

Background

Studies of socioeconomic inequalities in mortality consistently point to higher death rates in lower socioeconomic groups. Yet how these between-group differences relate to the total variation in mortality risk between individuals is unknown.

Methods

We used data assembled and harmonized as part of the Eurothine project, which includes census-based mortality data from 11 European countries. We matched this to national data from the Human Mortality Database and constructed life tables by gender and educational level. We measured variation in age at death using Theil's entropy index, and decomposed this measure into its between- and within-group components.

Results

The least-educated groups lived between three and 15 years fewer than the highest-educated groups, the latter having a more similar age at death in all countries. Differences between educational groups contributed between 0.6% and 2.7% to total variation in age at death between individuals in Western European countries and between 1.2% and 10.9% in Central and Eastern European countries. Variation in age at death is larger and differs more between countries among the least-educated groups.

Conclusions

At the individual level, many known and unknown factors are causing enormous variation in age at death, socioeconomic position being only one of them. Reducing variations in age at death among less-educated people by providing protection to the vulnerable may help to reduce inequalities in mortality between socioeconomic groups.

Socioeconomic status, labour market connection, and self-rated psychological health: the role of social capital and economic stress

AIMS

To investigate the association between socioeconomic status, unemployment and self-rated psychological health, taking economic stress and horizontal trust into account.

DESIGN/SETTING/PARTICIPANTS/MEASUREMENTS

The 2008 public health survey in Skåne is a cross-sectional postal questionnaire study with a 55% participation rate. A random sample was invited and 28,198 persons aged 18-80 participated. Logistic regression models were used to investigate associations between socioeconomic status by occupation (SES), labour market connection and self-rated psychological health (GHQ12). The multiple regression analyses included age, country of birth, education, economic stress and generalized (horizontal) trust.

RESULTS

13.8% of the men and 18.2% of the women had poor psychological health. Poor psychological health was more common among the young, among those born abroad, among those with lower education, with economic stress, and low horizontal trust. There were no significant differences between the employed and self-employed groups. However, the people who had retired early, the unemployed and those on long-term sick leave had significantly higher odds ratios of poor psychological health than higher non-manual employees throughout the analyses.

CONCLUSIONS

There were no differences in psychological health between non-manual employees in higher positions and other employed and self-employed SES groups among men or women. In contrast, the early retired, the unemployed and the category on long-term sick leave had significantly higher odds ratios of poor psychological health among both men and women throughout the multiple analyses. Both economic stress and trust affected this association (i.e., lowered the odds ratios of poor psychological health), but affected by economic stress to a somewhat higher extent.

Environmental risk conditions and pathways to cardiometabolic diseases in indigenous populations

This review examines environments in relation to cardiometabolic diseases in Indigenous populations in developed countries. Environmental factors are framed in terms of context (features of places) and composition (features of populations). Indigenous peoples are seen to have endured sociopolitical marginalization and material disadvantage spanning generations. Past adverse collective experiences, modified by culture, are reflected by current heterogeneity in environmental context and composition. As risk conditions, unfavorable contextual and compositional exposures influence the expression of cardiometabolic risk for individuals. Minimal research has evaluated heterogeneity in risk conditions against heterogeneity in cardiometabolic diseases between or within Indigenous populations. Thus far, the features of populations, not of places themselves, have been implicated in relation to cardiometabolic diseases. Behavioral, psychosocial, and stress-axis pathways may explain the relationships between risk conditions and cardiometabolic diseases. Implications of environmental factors and their pathways as well as important research needs are discussed in relation to ecological prevention to reduce cardiometabolic diseases.

Investigating quality of life and depressive symptoms in the postpartum period

BACKGROUND

Mood disturbances represent the most frequent form of maternal psychiatric morbidity in the postpartum period. Nevertheless, few studies have examined the impact of postpartum depression on the mother's quality of life. RESEARCH QUESTION OR PROBLEM: The present study aims to assess the quality of life of a sample of mothers in Southern Brazil, in order to investigate the association between postpartum depression and quality of life (QoL) standards.

PARTICIPANTS AND METHODS

This study investigates a sample of 101 adult volunteers who completed the Portuguese version World Health Organization Quality of Life Assessment-Bref (WHOQOL-Bref) and Multicultural Quality of Life Index (MQLI) questionnaires. Postnatal depressive symptoms were evaluated through the Postpartum Depression Screening Scale (PDSS) and Edinburgh Postnatal Depression Scale (EPDS). Multiple regression analyses were conducted to predict the overall PDSS and EPDS scores. Pearson Product-Moment Correlation coefficients were computed between the global scores of the quality of life measurements and the screening questionnaires for postnatal depression.

RESULTS

Both socio-economic status and quality of life have influenced significantly the depressive symptomatology and correlated epiphenomena. Significant correlations were observed among scores of postpartum depression screening tools and quality of life questionnaires. The socio-economic status of research participants was only significantly correlated to the scores generated by the WHOQOL-Bref questionnaire.

CONCLUSIONS

These findings confirm that socio-economic deficiencies and low quality of life can facilitate the expression of depressive symptomatology during the postpartum period. The results also emphasize the salience of psychosocial risk factors in the diathesis of postnatal depression.

Walking pace, leisure time physical activity, and resting heart rate in relation to disease-specific mortality in London: 40 years follow-up of the original Whitehall study. An update of our work with professor Jerry N. Morris (1910-2009)

PURPOSE

To examine the association of leisure time physical activity, walking pace and resting heart rate with disease-specific mortality in a prospective cohort study by reporting updated analyses of an earlier report we produced with the British epidemiologist, Jerry N. Morris (1910-2009).

METHODS

In the original Whitehall study, 19,019 male, nonindustrial, London-based government employees, aged from 40 to 69 years in 1967 and 1970, participated in a medical examination during which data on leisure time physical activity (N = 6715), self-rated walking pace (N = 6729), and resting heart rate (N = 1183) were collected. Cox proportional hazards analyses were used to estimate hazard ratios for the relation between these exposures and disease-specific mortality.

RESULTS

In models adjusted for a range of covariates including socioeconomic status, smoking, and obesity, high resting heart rate was associated with a modestly elevated rate of mortality from all causes (hazard ratio; 95% confidence interval: tertile 3 vs. tertile 1: 1.17; 0.99, 1.37 p[trend]: 0.07) and respiratory disease (1.69; 1.04, 2.76 p[trend]: 0.03). Of the two markers of physical activity, walking pace was inversely related to mortality ascribed to all causes (slow vs. high walking pace 1.71; 1.53, 1.91 p[trend]: <0.001]), coronary heart disease (2.03; 1.68, 2.47 p[trend]: <0.001), and total cancers (1.25; 0.98, 1.59 p[trend]: 0.04). The corresponding associations for leisure time activity were typically weaker. For other mortality endpoints-respiratory disease (walking pace: 1.96; 1.48, 2.60 p[trend]: <0.001]), hematopoietic cancer (walking pace: 1.36; 0.52, 3.51 p[trend]: 0.03), stomach cancer (inactive versus active leisure time: 1.53; 0.88, 2.64 p[trend]: 0.04), and rectal cancer (walking pace: 4.85; 1.70, 13.8 p[trend]: 0.007)-individual activity indices revealed effects, but not both.

CONCLUSIONS

Higher levels of physical activity indexed by the various markers herein appeared to confer protection against a range of mortality outcomes.

Socioeconomic and behavioral risk factors for mortality in a national 19-year prospective study of U.S. adults

Many demographic, socioeconomic, and behavioral risk factors predict mortality in the United States. However, very few population-based longitudinal studies are able to investigate simultaneously the impact of a variety of social factors on mortality. We investigated the degree to which demographic characteristics, socioeconomic variables and major health risk factors were associated with mortality in a nationally-representative sample of 3617 U.S. adults from 1986 to 2005, using data from the 4 waves of the Americans' Changing Lives study. Cox proportional hazard models with time-varying covariates were employed to predict all-cause mortality verified through the National Death Index and death certificate review. The results revealed that low educational attainment was not associated with mortality when income and health risk behaviors were included in the model. The association of low income with mortality remained after controlling for major behavioral risks. Compared to those in the "normal" weight category, neither overweight nor obesity was significantly associated with the risk of mortality. Among adults age 55 and older at baseline, the risk of mortality was actually reduced for those were overweight (hazard rate ratio = 0.83) and those who were obese (hazard rate ratio = 0.68), controlling for other health risk behaviors and health status. Having a low level of physical activity was a significant risk factor for mortality (hazard rate ratio = 1.58). The results from this national longitudinal study underscore the need for health policies and clinical interventions focusing on the social and behavioral determinants of health, with a particular focus on income security, smoking prevention/cessation, and physical activity.

Extent of social inequalities in disability in the elderly: results from a population-based study of British men

PURPOSE

Little is known about social inequalities in disability in the elderly. We examined the extent and determinants of socioeconomic inequalities in disability and functional limitation in elderly men in Britain.

METHODS

Disability was ascertained as problems with activities of daily living (ADLs) and instrumental ADL in a socioeconomically representative sample of 3,981 men from 24 British towns who were between 63 to 82 years of age in 2003. We also examined functional limitation. Measures of socioeconomic position were social class, age at leaving full-time education, and car and house ownership.

RESULTS

Men in lower social classes had greater risks of both ADL and instrumental ADL disability and functional limitation compared with higher social classes; odds ratios (95% CI) for social class V compared with I were 3.13 (1.64-5.97), 2.87 (1.49-5.51), and 2.65 (1.31-5.35), respectively. Behavioral risk factors (smoking, body mass index, physical activity) and particularly co-morbidity attenuated these differences; together, they reduced relative risks to 1.11 (0.49-2.51), 1.01 (0.45-2.25), and 1.05 (0.46-2.42). Age at leaving full-time education had no relation to functional limitations after taking social class into account. Men who were not house or car owners had greater odds of functional limitation and ADL disability compared with house or car owners, independent of behavioural risk factors, comorbidities and social class.

CONCLUSION

Strong socioeconomic inequalities in disability exist in the elderly, which were considerably explained by behavioral factors and comorbidity. Policy efforts are needed to reduce the social disparities in disability in the elderly.

Framing the biosocial pathways underlying associations between place and cardiometabolic disease

Causal inference regarding the impact of place on health is constrained by limited attention to the biological plausibility of associations. The utility of such evidence also requires demonstrating that place-based exposures precede effects on health. We propose a conceptual framework that integrates time and two plausible biosocial pathways by which the geospatial clustering of social disadvantage might be viewed as causally related to the development of cardiovascular and glycemic disease. The framework distinguishes environmental risk conditions that condition the expression of individual behavioural and psychosocial characteristics, and socioeconomic and material conditions that influence regulatory systems through conscious and non-conscious mechanisms.

I think therefore I am: perceived ideal weight as a determinant of health

OBJECTIVES

We examined whether stress related to negative body image perception and the desire to lose weight explained some of the body mass index-health gradient.

METHODS

We used 2003 Behavioral Risk Factor Surveillance System data to examine the impact of desired body weight, independent of actual body mass index, on the amount of physically and mentally unhealthy days by race, ethnicity, and gender.

RESULTS

The difference between actual and desired body weight was a stronger predictor than was body mass index (BMI) of mental and physical health. When we controlled for BMI and age, men who wished to lose 1%, 10%, and 20% of their body weight respectively suffered a net increase of 0.1, 0.9, and 2.7 unhealthy days per month relative to those who were happy with their weight. For women, the corresponding numbers were 0.1, 1.6, and 4.3 unhealthy days per month. The desire to lose weight was more predictive of unhealthy days among women than among men and among Whites than among Blacks or Hispanics.

CONCLUSIONS

Our results raise the possibility that some of the health effects of the obesity epidemic are related to the way we see our bodies.

Baseline health, socioeconomic status, and 10-year mortality among older middle-aged Americans: findings from the Health and Retirement Study, 1992 2002

OBJECTIVE

This study analyzed whether socioeconomic status in older middle age continues to be associated with 10-year survival after data are controlled for baseline health status.

METHODS

We confirmed deaths through 2002 for 9,759 participants in the Health and Retirement Study, aged 51 to 61 in 1992. We used discrete time survival models to examine hazard ratios over 10 years of follow-up. We examined associations of demographic characteristics and socioeconomic status measures before and after adjustment by health status and behavioral risk factors.

RESULT

The 10-year mortality rate was 10.9%, ranging from 4.7% for respondents reporting excellent health to 35.8% for those reporting poor health at baseline. Lower levels of education, income, and wealth were strongly associated with higher mortality risk after we controlled for just demographic characteristics. After further adjustment for health status and behavioral risk factors, only household income remained significant.

DISCUSSION

Baseline health by age 50 is an important pathway in the association between midlife socioeconomic status and mortality risk to age 70. The continuing effect of low household income on mortality risk was concentrated among respondents reporting excellent to good health at baseline. Socioeconomic disparities in middle-age health continue to limit disability-free life expectancy at older ages.

Socioeconomic status and perinatal outcomes in a setting with universal access to essential health care services

BACKGROUND

The health care system in Canada provides essential health services to all women irrespective of socioeconomic status. Our objective was to determine whether perinatal and infant outcomes varied by family income and other socioeconomic factors in this setting.

METHODS

We included all 92,914 women who delivered in Nova Scotia between 1988 and 1995 following a singleton pregnancy. Family income was obtained for 76,440 of these women through a confidential link to income tax records and was divided into 5 groups. Outcomes studied included pregnancy complications, preterm birth, small-for-gestational-age live birth, perinatal death, serious neonatal morbidity, postneonatal death and infant death. Logistic regression models were used to adjust for potential confounders.

RESULTS

Compared with women in the highest family income group, those in the lowest income group had significantly higher rates of gestational diabetes (crude rate ratio [RR] 1.44, 95% confidence interval [CI] 1.21-1.73), preterm birth (crude RR 1.20, 95% CI 1.06-1.35), small-for-gestational-age live birth (crude RR 1.81, 95% CI 1.66-1.97) and postneonatal death (crude RR 5.54, 95% CI 2.21-13.9). The opposite was true for rates of perinatal death (crude RR 0.74, 95% CI 0.56-0.96), and there was no significant difference between the 2 groups in the composite of perinatal death or serious neonatal morbidity (crude RR 1.01, 95% CI 0.82-1.24). Adjustment for behavioural and lifestyle factors accentuated or attenuated socioeconomic differences.

INTERPRETATION

Lower family income is associated with increased rates of gestational diabetes, small-for-gestational-age live birth and postneonatal death despite health care services being widely available at no out-of-pocket expense.

Modifiable risk factors have an impact on socio-economic differences in coronary heart disease events

OBJECTIVES

To investigate the association of socio-economic status, defined by occupational class, income and education, with coronary heart disease (CHD) morbidity and mortality, and further to analyse to which extent modifiable risk factors may explain socio-economic differences in CHD risk.

DESIGN

A population-based prospective cohort study including 9,061 men and 10,211 women aged 35-64 at baseline who participated in a cardiovascular risk factor survey in 1982, 1987, 1992 or 1997 in Finland. The subjects were followed for CHD events up till the end of 2001. Cox's proportional hazards model was used in the analysis.

RESULTS

Male manual workers had a double risk of CHD death compared with upper-level employees (HR=2.00, 95% CI 1.35-2.97). This excess risk was reduced by 31% when adjusted for traditional cardiovascular risk factors and most of this reduction was due to smoking.

CONCLUSIONS

Modifiable risk factors explained about a third of the excess CHD mortality between manual workers and upper-level employees in men. Among women the differences between socio-economic groups were not statistically significant.

Socioeconomic status as an independent predictor of physiological biomarkers of cardiovascular disease: evidence from NHANES

BACKGROUND

C-reactive protein, homocysteine, cholesterol, and fibrinogen are known to vary by socioeconomic status (SES). Using a nationally representative study, we examined whether these factors vary independently of all other known risk factors, such as diet, exercise, and genetic predisposition.

METHODS

We analyzed the 1999-2002 National Health Examination and Nutrition Survey using logistic regression models.

RESULTS

We found that high-density lipoprotein cholesterol blood levels increase with income and educational attainment after controlling all known risk factors for elevated cholesterol (e.g., diet, exercise, and family history). Blood levels of C-reactive protein are inversely associated with income and education. Homocysteine blood levels are inversely associated with income even after controlling for blood folate level. A non-significant inverse relationship between homocysteine levels and educational attainment was also observed. Blood levels of low-density lipoprotein cholesterol and fibrinogen were not significantly associated with income or education.

CONCLUSIONS

Levels of "good" (high density lipoprotein) cholesterol increase with income and education even after controlling for factors known to place people at risk of high cholesterol. Stress differences by social class may play a role.