Decennial trends and inequalities in healthy life expectancy: The HUNT Study, Norway

Trends in socioeconomic inequalities in self-rated health and mental distress during four decades in a Norwegian population: a HUNT Study

BACKGROUND

Socioeconomic inequalities constitute an important focus area for public health, and it has long been established that higher educational level and longer lifespan are correlated. Little is known about decennial time trends in poor self-rated health and mental distress.

METHODS

This study linked decennial cross-sectional survey data on self-rated health and mental distress from the Trøndelag Health Study (HUNT) from 1984 to 2019 with educational registry data using personal identification numbers. Survey participation ranged from 50 807 to 77 212. Slope index of inequality (SII) and relative index of inequality (RII) were calculated using generalized linear models in Stata. Analyses were stratified by sex and age, using the age categories of 30-59 years and 60-80 years.

RESULTS

Absolute inequalities in self-rated health and mental distress between educational groups have stayed relatively stable throughout all rounds of HUNT. Relative inequalities in self-rated health and mental distress have generally increased, and both men and women with the lowest education level were more likely to experience poor self-rated health and mental distress relative to those with the highest education level. RII in self-rated health increased over time for both sexes and both age groups. RII for mental distress increased in both sexes and both age groups, except for men and women aged 60-80.

DISCUSSION

This study shows that relative inequalities in self-rated and mental health in the Norwegian population are still persistent and have increased. Further knowledge about groups with a disadvantageous health situation should have implications for health care resource allocation.

Why Female Smokers Have Poorer Long-Term Health Outcomes than Male Smokers: The Role of Cigarette Smoking During Pregnancy

Objectives: Women's health status is better than men but the opposite is true for female smokers who usually have poorer long-health outcomes than male smokers. The objectives of this study were to thoroughly reviewed and analyzed relevant literature and to propose a hypothesis that may explain this paradox phenomenon. Methods: We conducted a search of literature from three English databases (EMBASE, MEDLINE, and Google Scholar) from inception to 13 November 2023. A combination of key words and/or subject headings in English was applied, including relevant terms for cigarette smoking, sex/gender, pregnancy, and health indicators. We then performed analysis of the searched literature. Results: Based on this review/analysis of literature, we proposed a hypothesis that may explain this paradox phenomenon: female smokers have worse long-term health outcomes than male smokers because some of them smoke during pregnancy, and the adverse effects of cigarette smoking during pregnancy is much stronger than cigarette smoking during non-pregnancy periods. Conclusion: Approval of our pregnancy-amplification theory could provide additional evidence on the adverse effect on women's long-term health outcomes for cigarette smoking during pregnancy.

Disability transitions in Dutch community-dwelling older people aged 75 years or older

BACKGROUND

Recent world population predictions show that the world population aged >=65 years will increase from 10% in 2022 to 16% in 2050. Population aging is accompanied by an increase in people with disability. It is important to pay special attention to people with disability, as these people are at high risk of adverse outcomes. Our study aimed to investigate the transitions of disability among Dutch community-dwelling older people aged 75 years or older, using a follow-up of nine years. We used socio-demographic factors gender, age, marital status, education, and income, but also lifestyle, diseases, and life events to predict the disability transitions over time.

METHODS

We used a sample of 484 people that was randomly drawn from the municipality of Roosendaal (the Netherlands), a municipality with 78,000 inhabitants. A subset of people who completed part A of the Tilburg Frailty Indicator (TFI) at baseline and the Groningen Activity Restriction Scale (GARS) questionnaires was used with a nine-year follow-up. Paired Wilcoxon tests were used to compare the consecutive measurements. Socio-demographic factors gender, age, marital status, education, and income, but also lifestyle, diseases, and life events were included to predict the disability transitions over time. For the univariable and multivariable analysis of the measurements over time with the predictor variables, we used generalized estimation equations (GEE). A p-value <0.05 was considered significant. R version 3.4.4 was used for all analyses.

RESULTS

Of the participants, 65% were younger than 80 years, 50% were married or cohabiting, 87% reported a healthy lifestyle, and 63% had no diseases or chronic disorders. Each year, more participants changed from status not disabled to disabled than vice versa. The GEE analyses showed that lifestyle ('not healthy') and diseases or chronic disorders ('two or more') were significant in the multivariable analysis for the disability score and only diseases or chronic disorders ('two or more') was significant in the multivariable analysis for the dichotomous disability score.

CONCLUSIONS

The transition of the disability score is strongly influenced by lifestyle and diseases or disorders. This applies to a lesser extent to the dichotomous disability score. There, only diseases or disorders are an important predictor. For health care professionals our study provides starting points for interventions focused on the prevention of worsening disability and for community-dwelling older people >= 75, the most important recommendation is: live healthy!

Association between engagement in cultural activities and use of general practitioner consultations: 7-year follow-up of adults from the HUNT study, Norway

OBJECTIVE

Assess whether engagement in a range of cultural activities, both 'passive' and 'active' (ie, receptive and creative) participation, is associated with later demand for general practitioner (GP) consultations.

DESIGN

Longitudinal prospective cohort study.

SETTING

Data from the population-based the third Survey of Trøndelag Health Study (2006-2008) in Norway was linked to an administrative register including service information from all GP offices nationwide.

PARTICIPANTS

This study included 17 396 (54.6%) women and 14 451 (45.4%) men aged 30-79 years.

MAIN OUTCOME MEASURES

Multilevel negative binomial regression models assessed the relationship between cultural engagement and GP consultations, and reported as rate ratios.

RESULTS

A mean of 3.57 GP visits per patient was recorded during the 7 years of follow-up. Participation in creative activities and a combination of both receptive and creative activities was associated with lower number of GP consultation. Gender-specific analyses suggest that these effects were attributable to men. The rate ratio of GP consultations among men taking part in creative activities less than once, twice and more than twice (<9 times) per week is 0.90, 0.89 and 0.87 times lower, respectively, compared with non-participants. Whereas weekly frequency of receptive and creative activity engagement showed a 0.92, 0.87 and 0.83 times lower rate ratio among engaged men. The variety of activities shows a similar pattern and participation in creative activities lowers the rate ratio among men. Engagement in a wide range/variety of activities, compared with non-engagement, was associated with lower numbers of GP consultations in men, but not women.

CONCLUSIONS

Engagement in creative or combined receptive and creative cultural activities was associated with lower numbers of GP consultations among men. Thus, facilitating and promoting a culturally engaged lifestyle, particularly in men, may affect primary healthcare use. However, this study design gives no evidence of a causal relationship between cultural engagement and use of GP consultations.

HUNT for better public health

Aims:

The Trøndelag Health Study (HUNT) has collected population data through comprehensive decennial surveys over the last four decades and has so far collected data from 240,000 participants. The participants are identified with the unique Norwegian birth number, which enables them to be followed throughout different life stages, from survey to survey, and to endpoint measures in Norwegian national health registers without attrition bias.

Methods:

The study design of HUNT offers several advantages: it provides an overview of the public health development in the population over decades, the data can be used in health services research, clinical epidemiology, studies of causation, trajectories, and consequences of diseases, and to study gene × environment interactions.

Results:

HUNT data have shown major shifts in public health trends, such as decreasing mean blood pressure and resting heart rate among adults, increasing prevalence of obesity, geographical and socioeconomic inequalities in health, increasing mental health distress among adolescents and young adults with an opposite development among the elderly. Data from HUNT have been used in several major international research projects, where data harmonization with several other population cohorts internationally has been done. HUNT has placed great emphasis on safeguarding research ethics, privacy, and data security. The Norwegian authorities established national regulations for the surveys from the time General Data Protection Regulation was introduced in 2018.

Conclusions:

Researchers can apply for HUNT data access from HUNT Research Centre provided they have obtained project approval from the Regional Committee for Medical and Health Research Ethics. Researchers not affiliated to a Norwegian research institution must collaborate with and apply through a Norwegian principal investigator. Information on the application and conditions for data access is available at www.ntnu.edu/hunt/data.

Future trends of life expectancy by education in the Netherlands

Background

National projections of life expectancy are made periodically by statistical offices or actuarial societies in Europe and are widely used, amongst others for reforms of pension systems. However, these projections may not provide a good estimate of the future trends in life expectancy of different social-economic groups. The objective of this study is to provide insight in future trends in life expectancies for low, mid and high educated men and women living in the Netherlands.

Methods

We used a three-layer Li and Lee model with data from neighboring countries to complement Dutch time series.

Results

Our results point at further increases of life expectancy between age 35 and 85 and of remaining life expectancy at age 35 and age 65, for all education groups in the Netherlands. The projected increase in life expectancy is slightly larger among the high educated than among the low educated. Life expectancy of low educated women, particularly between age 35 and 85, shows the smallest projected increase. Our results also suggest that inequalities in life expectancies between high and low educated will be similar or slightly increasing between 2018 and 2048. We see no indication of a decline in inequality between the life expectancy of the low and high educated.

Conclusions

The educational inequalities in life expectancy are expected to persist or slightly increase for both men and women. The persistence and possible increase of inequalities in life expectancy between the educational groups may cause equity concerns of increases in pension age that are equal among all socio-economic groups.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13275-w.

Divergent decennial trends in mental health according to age reveal poorer mental health for young people: repeated cross-sectional population-based surveys from the HUNT Study, Norway

OBJECTIVES

Public health trends are formed by political, economic, historical and cultural factors in society. The aim of this paper was to describe overall changes in mental health among adolescents and adults in a Norwegian population over the three last decades and discuss some potential explanations for these changes.

DESIGN

Repeated population-based health surveys to monitor decennial changes.

SETTING

Data from three cross-sectional surveys in 1995-1997, 2006-2008 and 2017-2019 in the population-based HUNT Study in Norway were used.

PARTICIPANTS

The general population in a Norwegian county covering participants aged 13-79 years, ranging from 48 000 to 62 000 000 in each survey.

MAIN OUTCOME MEASURES

Prevalence estimates of subjective anxiety and depression symptoms stratified by age and gender were assessed using the Hopkins Symptom Checklist-5 for adolescents and the Hospital Anxiety and Depression Scale for adults.

RESULTS

Adolescents' and young adults' mental distress increased sharply, especially between 2006-2008 and 2017-2019. However, depressive symptoms instead declined among adults aged 60 and over and anxiety symptoms remained largely unchanged in these groups.

CONCLUSIONS

Our trend data from the HUNT Study in Norway indicate poorer mental health among adolescents and young adults that we suggest are related to relevant changes in young people's living conditions and behaviour, including the increased influence of screen-based media.

Healthy ageing for all? Comparisons of socioeconomic inequalities in health expectancies over two decades in the Cognitive Function and Ageing Studies I and II

Background

Despite increasing life expectancy (LE), cross-sectional data show widening inequalities in disability-free LE (DFLE) by socioeconomic status (SES) in many countries. We use longitudinal data to better understand trends in DFLE and years independent (IndLE) by SES, and how underlying transitions contribute.

Methods

The Cognitive Function and Ageing Studies (CFAS I and II) are large population-based studies of those aged ≥65 years in three English centres (Newcastle, Nottingham, Cambridgeshire), with baseline around 1991 (CFAS I, n = 7635) and 2011 (CFAS II, n = 7762) and 2-year follow-up. We defined disability as difficulty in activities of daily living (ADL), dependency by combining ADLs and cognition reflecting care required, and SES by area-level deprivation. Transitions between disability or dependency states and death were estimated from multistate models.

Results

Between 1991 and 2011, gains in DFLE at age 65 were greatest for the most advantaged men and women [men: 4.7 years, 95% confidence interval (95% CI) 3.3–6.2; women: 2.8 years, 95% CI 1.3–4.3]. Gains were due to the most advantaged women having a reduced risk of incident disability [relative risk ratio (RRR):0.7, 95% CI 0.5–0.8], whereas the most advantaged men had a greater likelihood of recovery (RRR: 1.8, 95% CI 1.0–3.2) and reduced disability-free mortality risk (RRR: 0.4, 95% CI 0.3–0.6]. Risk of death from disability decreased for least advantaged men (RRR: 0.7, 95% CI 0.6–0.9); least advantaged women showed little improvement in transitions. IndLE patterns across time were similar.

Conclusions

Prevention should target the most disadvantaged areas, to narrow inequalities, with clear indication from the most advantaged that reduction in poor transitions is achievable.

Trends in health expectancies: a systematic review of international evidence

OBJECTIVES

A clear understanding of whether increases in longevity are spent in good health is necessary to support ageing, health and care-related policy.

DESIGN

We conducted a systematic review to update and summarise evidence on trends in health expectancies, in Organisation for Economic Co-operation and Development (OECD) high-income countries.

DATA SOURCES

Four electronic databases (MEDLINE, 1946-19 September 2019; Embase 1980-2019 week 38; Scopus 1966-22 September 2019, Health Management Information Consortium, 1979-September 2019), and the UK Office for National Statistics website (November 2019).

ELIGIBILITY CRITERIA

English language studies published from 2016 that reported trends in healthy, active and/or disability-free life expectancy in an OECD high-income country.

DATA EXTRACTION AND SYNTHESIS

Records were screened independently by two researchers. Study quality was assessed using published criteria designed to identify sources of bias in studies reporting trends, and evidence summarised by narrative synthesis.

FINDINGS

Twenty-eight publications from 11 countries were included, covering periods from 6 to 40 years, between 1970 and 2017. In most countries, gains in healthy and disability-free life expectancy do not match the growth in total life expectancy. Exceptions were demonstrated for women in Sweden, where there were greater gains in disability-free years than life expectancy. Gains in healthy and disability-free life expectancy were greater for men than women in most countries except the USA (age 85), Japan (birth), Korea (age 65) and Sweden (age 77).

CONCLUSION

An expansion of disability in later life is evident in a number of high-income countries, with implications for the sustainability of health and care systems. The recent COVID-19 pandemic may also impact health expectancies in the longer term.

To what extent do socioeconomic inequalities in SRH reflect inequalities in burden of disease? The HELIUS study

BACKGROUND

Self-rated health (SRH), an attractive measure for health monitoring, shows persistent inequalities with regard to socioeconomic status (SES). However, knowledge on the extent to which inequalities in SRH reflect inequalities in disease burden is lacking.

METHODS

Data come from the multi-ethnic HEalthy LIfe in an Urban Setting study (Dutch, South-Asian Surinamese, African Surinamese, Ghanaian, Turkish or Moroccan origin, N = 19 379, aged 18-70). SES was defined by educational and occupational level. Disease burden was operationalized as chronic diseases, physical and mental functioning (measured with SF-12) and depressive symptoms (measured with PHQ-9). We applied logistic regression analyses and reported average marginal effects (AME).

RESULTS

Dutch origin participants with low educational or low occupational level had higher probabilities of reporting fair/poor SRH, compared to the highest levels (AME = 0.20 95% CI: 0.13;0.27; and 0.12 (0.09;0.15), respectively). Associations were attenuated after adjusting for all disease burden indicators, to AME = 0.03 (0.01;0.04) and AME = 0.02 (-0.00;0.04). In all the non-Dutch origin groups, a larger part of the inequalities remained after adjustment.

CONCLUSION

Socioeconomic inequalities in SRH are for a large part explained by higher disease burden in lower socioeconomic groups, but less so in those with non-Dutch origin. Future research should examine if our conclusions also hold for trend data on inequalities in SRH.

Trends in self-rated health among the elderly population in Germany from 1995 to 2015 - the influence of temporal change in leisure time physical activity

BACKGROUND

Against the backdrop of rising statutory retirement age in Germany, we analyzed time trends in self-rated health (SRH) among the elderly population between 50 and 70 years of age and explored the mediating role of leisure time physical activity (LTPA) on the relationship between time period and self-rated health (SRH).

METHODS

We used longitudinal survey data (n = 23,161) from a national panel study (GSOEP) to analyze time trends in SRH and regular LTPA (at least once a week) by means of Generalized Estimation Equation (GEE) analysis for logistic regression. The Karlson-Holm-Breen (KHB) method was applied for decomposing trend effects into direct and indirect parts via LTPA. In addition to odds ratios (OR), we illustrated the results by means of predicted probabilities and average partial effects (APE).

RESULTS

Over time, the predicted probabilities of good SRH and regular LTPA increased while those of poor SRH decreased. After adjusting for socioeconomic status (SES) 53.4% of the trend in good SRH in women (OR = 1.34 / APE = 6.8%-points) could be attributed to the rise in regular LTPA. In men, the remaining smaller effect (OR = 1.13 / APE = 2.7%) could be fully assigned to temporal changes in regular LTPA. With respect to poor health we found a suppression effect of LTPA in the adjusted model, indicating that without improvements in regular LTPA over time an increase in poor SRH would have occurred.

CONCLUSIONS

The increase of regular LTPA accounted for improved SRH from 1995 to 2015 among the elderly, indicating that promoting LTPA might be a key factor to raise healthy working life expectancy.

Trends in good self-rated health in Germany between 1995 and 2014: do age and gender matter?

OBJECTIVES

This study analyzes longitudinal trends in self-rated health (SRH) by taking age- and gender-specific differences into account.

METHODS

Data of 29,251 women and 26,967 men were obtained from the German Socio-Economic Panel between 1995 and 2014. Generalized Estimation Equation analysis for logistic regression was used to estimate changes in odds of (very) good SRH over time. Development of (un)healthy life expectancy was calculated by applying the Sullivan method.

RESULTS

While in women, the odds of good SRH increased significantly over time for the ages 41-50 to 71-80 years, improvements among men were most apparent for the ages 61-70 and 71-80 years. By contrast, for both genders, no improvements in SRH were found in the youngest (31-40 years) and eldest age group (81-90 years) and in men aging 51-60 years. Over time, healthy life expectancy at age 31 increased by 3 years in women and 2 years in men, leading to a reduced but not eliminated gender gap in SRH.

CONCLUSIONS

Our findings support the hypothesis of relative compression of morbidity. However, trends in SRH differed according to age and gender, calling for health promotion efforts that meet diverse needs at different stages of life.

Improving the Pharmacology Curriculum at a German Medical School: A Structured Plan Based on a Student-Guided Large-Scale Study

With rapid progress in medicine, a thorough understanding of pharmacology remains crucial. Currently, lecturers are implementing competency-based learning objectives in medical curricula around the world. Advancing teaching modalities need to be integrated into pharmacology courses in a reasonable way. At Ludwig-Maximilians-Universität (LMU) Munich Medical Faculty, a systematic evidence-based approach was used to modernize pharmacology classes. The needs assessment was conducted by final-year students. It included focus groups and a large-scale online survey, which was distributed among all medical students at LMU, with 1018 students participating (response rate 20%). Survey results showed that most of the students (92%) aimed to become pharmacology-adept doctors. Also, a majority (88%) stated that their goal was to understand the material most critical to application of pharmacology concepts as well as prescribing practice. Only 38% of the students reported satisfaction with the current curriculum, and 93% supported modernization. Thus far, pharmacology teaching at LMU Munich had mainly consisted of lectures attended by 200 students. Now, students advocated for a stronger integration of clinical pharmacology teaching into clinical subjects in the last 2 years of medical school. Specifically, they called for classes with smaller groups of students including problem-based learning as well as video podcasts. These results provided the foundation for change in curriculum at the LMU medical school. In conclusion, a structured approach for curriculum development that considers students' views is feasible and can reveal their actual goals and demands. The approach has proven successful at LMU Munich and is transferrable to other universities.