Social inequalities and mortality in Europe--results from a large multi-national cohort. PLoS One. 2012;7:e39013. [PMID: 22848347 PMCID: PMC3405077 DOI: 10.1371/journal.pone.0039013]

[Mental health in the workplace - What role do socioeconomic-, gender-, and migration-related inequalities play?]

BACKGROUND

Risk factors for mental health can be found in socio-economic-, gender- and migration-specific inequalities. These factors and the extent of depression, anxiety, and somatization among employees were examined in the present study.

METHODS

As part of the Early Intervention in the Workplace Study (friaa), mentally burdened employees at five locations in Germany were surveyed on socio-demographic-, work-, migration-, and health-related content. Regression analyses were used to examine the relationship between these factors and depression (Patient-Health-Questionnaire-9, PHQ-9), anxiety (Generalized Anxiety Disorder-2, GAD-2), and somatization (Somatic Symptom Scale-8, SSS-8) in the entire sample and in people with migration background (MB). For the latter, acculturation (Frankfurt Acculturation Scale, FRACC) and the perception of burden in terms of demands of immigration (Demands of Immigration Scale, DIS) were also taken into account.

RESULTS

On average, the 550 employees (12% with MB) showed clinically relevant depression (M = 13.0, SD = 5.1) (PHQ-9 ≥ 10), anxiety (M = 3.5, SD = 1.7) (GAD ≥ 3) and somatization (M = 13.0, SD = 5.8) (SSS-8 ≥ 12). Female gender was associated with higher anxiety and somatization. Older age and night shift work were associated with higher somatization.

DISCUSSION

The results confirm the high level of mental burden among this sample of employees in Germany. In order to maintain their mental health, support measures should be offered, especially for vulnerable groups such as women, older employees, and night shift workers.

Healthy lifestyle change and all-cause and cancer mortality in the European Prospective Investigation into Cancer and Nutrition cohort

BACKGROUND

Healthy lifestyles are inversely associated with the risk of noncommunicable diseases, which are leading causes of death. However, few studies have used longitudinal data to assess the impact of changing lifestyle behaviours on all-cause and cancer mortality.

METHODS

Within the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort, lifestyle profiles of 308,497 cancer-free adults (71% female) aged 35-70 years at recruitment across nine countries were assessed with baseline and follow-up questionnaires administered on average of 7 years apart. A healthy lifestyle index (HLI), assessed at two time points, combined information on smoking status, alcohol intake, body mass index, and physical activity, and ranged from 0 to 16 units. A change score was calculated as the difference between HLI at baseline and follow-up. Associations between HLI change and all-cause and cancer mortality were modelled with Cox regression, and the impact of changing HLI on accelerating mortality rate was estimated by rate advancement periods (RAP, in years).

RESULTS

After the follow-up questionnaire, participants were followed for an average of 9.9 years, with 21,696 deaths (8407 cancer deaths) documented. Compared to participants whose HLIs remained stable (within one unit), improving HLI by more than one unit was inversely associated with all-cause and cancer mortality (hazard ratio [HR]: 0.84; 95% confidence interval [CI]: 0.81, 0.88; and HR: 0.87; 95% CI: 0.82, 0.92; respectively), while worsening HLI by more than one unit was associated with an increase in mortality (all-cause mortality HR: 1.26; 95% CI: 1.20, 1.33; cancer mortality HR: 1.19; 95% CI: 1.09, 1.29). Participants who worsened HLI by more than one advanced their risk of death by 1.62 (1.44, 1.96) years, while participants who improved HLI by the same amount delayed their risk of death by 1.19 (0.65, 2.32) years, compared to those with stable HLI.

CONCLUSIONS

Making healthier lifestyle changes during adulthood was inversely associated with all-cause and cancer mortality and delayed risk of death. Conversely, making unhealthier lifestyle changes was positively associated with mortality and an accelerated risk of death.

Exploring the contribution of lifestyle to the impact of education on the risk of cancer through Mendelian randomization analysis

Educational attainment (EA) has been linked to the risk of several types of cancer, despite having no expected direct biological connection. In this paper, we investigate the mediating role of alcohol consumption, smoking, vegetable consumption, fruit consumption and body mass index (BMI) in explaining the effect of EA on 7 cancer groupings. Large-scale genome wide association study (GWAS) results were used to construct the genetic instrument for EA and the lifestyle factors. We conducted GWAS in the UK Biobank sample in up to 335,024 individuals to obtain genetic association data for the cancer outcomes. Univariable and multivariable two-sample Mendelian randomization (MR) analyses and mediation analyses were then conducted to explore the causal effect and mediating proportions of these relations. MR mediation analysis revealed that reduced lifetime smoking index accounted for 81.7% (49.1% to 100%) of the protective effect of higher EA on lower respiratory cancer. Moreover, the effect of higher EA on lower respiratory cancer was mediated through vegetable consumption by 10.2% (4.4% to 15.9%). We found genetic evidence that the effect of EA on groups of cancer is due to behavioural changes in avoiding well established risk factors such as smoking and vegetable consuming.

Intra-generational social mobility and mortality among older men in the Concord Health and Ageing in Men Project: A cohort study

Objectives

We examined associations between intra-generational social mobility (reflected in life-course socioeconomic trajectories) and mortality, among older men.

Methods

Data came from a prospective Australian community-based cohort of older men. Social mobility was defined by socioeconomic indicators from three points in the life-course: educational attainment (late adolescence-early adulthood), occupation (mid-life), and current sources of income (older age). We defined indicators of social mobility trajectory (6 categories; reflecting the direction of social mobility) and social mobility status (2 categories; mobile or non-mobile). We used Cox regression to examine associations with mortality, adjusting for age, country of birth, and living arrangement.

Results

We followed 1568 men (mean age 76.8, SD 5.4) for a mean duration of 9.1 years, with 797 deaths recorded. Moving upward was the predominant social mobility trajectory (36.0%), followed by mixed trajectories (25.1%), downward (15.1%), stable low (12.2%), stable high (7.6%), and stable middle (4.0%). Men with downward (Hazard ratio 1.58, 95% CI 1.13 to 2.19) and stable low socioeconomic trajectories (1.77, 1.25 to 2.50) had higher mortality risks than men with stable high socioeconomic trajectories, while men with upward trajectories had similar risks to those with stable high trajectories. 76.2% of the participants were classified as having mobile status; no associations were evident between binary social mobility status and mortality.

Discussions

These findings suggest cumulative and persistent exposure to disadvantaged socioeconomic conditions across the life-course, rather than social mobility, is associated with increased mortality. For each stage of the life-course, addressing socioeconomic disadvantage may reduce inequities in mortality.

Educational patterning in biological health seven years apart: Findings from the Tromsø Study

BACKGROUND

Social-to-biological processes is one set of mechanisms underlying the relationship between social position and health. However, very few studies have focused on the relationship between social factors and biology at multiple time points. This work investigates the relationship between education and the dynamic changes in a composite Biological Health Score (BHS) using two time points seven years apart in a Norwegian adult population.

METHODS

We used data from individuals aged 30 years and above who participated in Tromsø6 (2007-2008) and Tromsø7 (2015-2016) (n = 8117). BHS was defined using ten biomarkers measured from blood samples and representing three physiological systems (cardiovascular, metabolic, inflammatory). The higher the BHS, the poorer the health status.

FINDINGS

Linear regression models carried out on BHS revealed a strong educational gradient at two distinct time points but also over time. People with lower educational attainment were at higher risk of poor biological health at a given time point (βlow education Tromsø6=0.30 [95 %-CI=0.18-0.43] and βlow education Tromsø7=0.30 [95 %-CI=0.17-0.42]). They also presented higher longitudinal BHS compared to people with higher education (βlow education = 0.89 [95 %-CI=0.56-1.23]). Certain biomarkers related to the cardiovascular system and the metabolic system were strongly socially distributed, even after adjustment for sex, age, health behaviours and body mass index.

CONCLUSION

This longitudinal analysis highlights that participants with lower education had their biological health deteriorated to a greater extent over time compared to people with higher education. Our findings provide added evidence of the biological embodiment of social position, particularly with respect to dynamic aspects for which little evidence exists.

Associations of current and childhood socioeconomic status and health outcomes amongst patients with knee or hip osteoarthritis in a Mexico City family-practice setting

OBJECTIVES

To examine the association of current and childhood socioeconomic status (SES) with patient-reported functional status, quality of life and disability in patients with knee or hip osteoarthritis (OA).

METHODS

Cross-sectional study amongst individuals seeking care for any medical reason in a primary care family-practice clinic in Mexico City. We included individuals with self-reported doctor-diagnosed arthritis, recruited through waiting-room posters and invitations by treating family physicians. We administered a survey using validated Spanish language versions of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Osteoarthritis of Lower Limbs and Quality of Life (AMICAL), and the Stanford Health Assessment Questionnaire-Disability Index (HAQ-DI). To estimate current and childhood SES, we collected data on education level and occupation type for both the patient and their parents, as well as using a validated tool to estimate income quintile.

RESULTS

We recruited 154 patients and excluded 8 patients. There was a high correlation between outcome scores. Estimated income and education levels were correlated with WOMAC, AMICAL and HAQ-DI scores, and significant differences were found in all scores by occupation type. The associations for current SES variables and outcome scores remained significant independently of age, sex, BMI, and presence of diabetes or hypertension, and were largely explained by current income in mutually adjusted models. Childhood SES - in particular as measured through maternal education - was best correlated with AMICAL scores, though its effect seemed largely mediated by its association with current SES.

CONCLUSIONS

Current Socioeconomic Status impacts functional status, quality of life and disability amongst OA patients in Mexico City. The WOMAC, AMICAL and HAQ-DI scores correlate with each other and are all potentially useful markers of disease severity. More research is needed to elucidate the relationships between childhood SES and OA outcomes. Awareness of life-course SES may be useful in identifying patients at risk for worse outcomes.

Influence of deprivation on hospital care pathways and costs for people with ischaemic stroke: A trajectory modelling study

BACKGROUND

Socioeconomic characteristics have a strong impact on the incidence of stroke. The highest levels of morbidity and mortality are associated with the lowest socioeconomic positions. Moreover, the health insurance budget for stroke is significant.

OBJECTIVES

To describe typical Hospital Care Pathways (HCPs) and their costs 1 year after acute stroke and to assess the impact of individuals' socioeconomic characteristics on HCPs and costs.

METHODS

This retrospective observational study used hospital data on people with primary ischaemic stroke in a region of France (Haute-Garonne). HCPs were identified by sequential analysis. Multinomial logistic regression was used to analyse the impact of socioeconomic characteristics on HCPs as measured using an ecological index of deprivation, and a gamma regression model was used to analyse costs.

RESULTS

The analysis identified 4 typical HCPs. The first HCP consisted exclusively of consultations, the second was composed of consultations and hospitalisations, the third included hospitalisations during the first 2 months after stroke followed by consultations, and the fourth included long-term hospitalisations. After adjustment, deprivation was associated with HCPs and determined its costs: a high level of social disadvantage determined the type of pathway and increased the costs.

CONCLUSIONS

This study is one of the first to assess the impact of social inequalities in health on post-stroke HCPs in France and their corresponding costs. Our results confirm the hypothesis that healthcare costs differ according to the level of deprivation.

Heat-related mortality in Europe during the summer of 2022

Over 70,000 excess deaths occurred in Europe during the summer of 2003. The resulting societal awareness led to the design and implementation of adaptation strategies to protect at-risk populations. We aimed to quantify heat-related mortality burden during the summer of 2022, the hottest season on record in Europe. We analyzed the Eurostat mortality database, which includes 45,184,044 counts of death from 823 contiguous regions in 35 European countries, representing the whole population of over 543 million people. We estimated 61,672 (95% confidence interval (CI) = 37,643-86,807) heat-related deaths in Europe between 30 May and 4 September 2022. Italy (18,010 deaths; 95% CI = 13,793-22,225), Spain (11,324; 95% CI = 7,908-14,880) and Germany (8,173; 95% CI = 5,374-11,018) had the highest summer heat-related mortality numbers, while Italy (295 deaths per million, 95% CI = 226-364), Greece (280, 95% CI = 201-355), Spain (237, 95% CI = 166-312) and Portugal (211, 95% CI = 162-255) had the highest heat-related mortality rates. Relative to population, we estimated 56% more heat-related deaths in women than men, with higher rates in men aged 0-64 (+41%) and 65-79 (+14%) years, and in women aged 80+ years (+27%). Our results call for a reevaluation and strengthening of existing heat surveillance platforms, prevention plans and long-term adaptation strategies.

A longitudinal study evaluating adverse childhood experiences and obesity in adulthood using the Canadian Longitudinal Study on Aging (CLSA)

BACKGROUND

Adverse childhood experiences (ACEs) are a risk factor for obesity; however, the causal mechanisms are not well understood. Objectives were to measure the impact of ACEs on adulthood obesity and to investigate whether the association was mediated by nutrition and stress.

METHODS

A longitudinal study was conducted using adults aged 46-90 years (n = 26 615) from the Canadian Longitudinal Study on Aging. Participants were asked to recall ACEs from <18 years of age. Body mass index (BMI), waist circumference and per cent body fat were measured (2015-18) and obesity was defined using standard cut points. Nutrition was measured using data from the Short Diet Questionnaire and stress was measured using allostatic load. Multinomial logistic regression was used to estimate odds ratios (ORs) and 95% CIs for each obesity measure. Causal mediation methods were used to determine whether nutrition and stress were mediators.

RESULTS

There were 66% of adults who had experienced one or more ACE. The odds of obesity defined by BMI and waist circumference increased in a dose-response manner with increasing number of ACEs (P trend <0.001). For instance, adults with four to eight ACEs, compared with none, had greater odds of obesity, defined by BMI (adjusted OR: 1.54; 95% CI: 1.28-1.75) and waist circumference (adjusted OR: 1.30; 95% CI: 1.15-1.47). There was no evidence of mediation by stress or nutrition.

CONCLUSIONS

Adversity experienced in early life is strongly associated with obesity among Canadian adults. Further research is needed to identify other mechanisms for this association to inform obesity prevention strategies.

Social engagement and allostatic load mediate between adverse childhood experiences and multimorbidity in mid to late adulthood: the Canadian Longitudinal Study on Aging

BACKGROUND

Adverse childhood experiences (ACEs) are associated with multimorbidity in adulthood. This link may be mediated by psychosocial and biological factors, but evidence is lacking. The current study evaluates this mediation model.

METHOD

We analyzed data from the Canadian Longitudinal Study of Aging (N = 27 170 community participants). Participants were 45-85 years at recruitment, when allostatic load and social engagement data were collected, and 3 years older at follow-up, when ACEs and multimorbidity data were collected. Structural equation modeling was used to test for mediation in the overall sample, and in sex- and age-stratified subsamples, all analyses adjusted for concurrent lifestyle confounds.

RESULTS

In the overall sample, ACEs were associated with multimorbidity, directly, β = 0.12 (95% confidence interval 0.11-0.13) and indirectly. Regarding indirect associations, ACEs were related to social engagement, β = -0.14 (-0.16 to -0.12) and social engagement was related to multimorbidity, β = -0.10 (-0.12 to -0.08). ACEs were related to allostatic load, β = 0.04 (0.03-0.05) and allostatic load was related to multimorbidity, β = 0.16 (0.15-0.17). The model was significant for males and females and across age cohorts, with qualifications in the oldest stratum (age 75-85).

CONCLUSIONS

ACEs are related to multimorbidity, directly and via social engagement and allostatic load. This is the first study to show mediated pathways between early adversity and multimorbidity in adulthood. It provides a platform for understanding multimorbidity as a lifespan dynamic informing the co-occurrence of the varied disease processes represented in multimorbidity.

Socioeconomic inequalities in cancer mortality between and within countries in Europe: a population-based study

Background

Reducing socioeconomic inequalities in cancer is a priority for the public health agenda. A systematic assessment and benchmarking of socioeconomic inequalities in cancer across many countries and over time in Europe is not yet available.

Methods

Census-linked, whole-of-population cancer-specific mortality data by socioeconomic position, as measured by education level, and sex were collected, harmonized, analysed, and compared across 18 countries during 1990-2015, in adults aged 40-79. We computed absolute and relative educational inequalities; temporal trends using estimated-annual-percentage-changes; the share of cancer mortality linked to educational inequalities.

Findings

Everywhere in Europe, lower-educated individuals have higher mortality rates for nearly all cancer-types relative to their more highly-educated counterparts, particularly for tobacco/infection-related cancers [relative risk of lung cancer mortality for lower- versus higher-educated = 2.4 (95% confidence intervals: 2.1-2.8) among men; = 1.8 (95% confidence intervals: 1.5-2.1) among women]. However, the magnitude of inequalities varies greatly by country and over time, predominantly due to differences in cancer mortality among lower-educated groups, as for many cancer-types higher-educated have more similar (and lower) rates, irrespective of the country. Inequalities were generally greater in Baltic/Central/East-Europe and smaller in South-Europe, although among women large and rising inequalities were found in North-Europe (relative risk of all cancer mortality for lower- versus higher-educated ≥1.4 in Denmark, Norway, Sweden, Finland and the England/Wales). Among men, rate differences (per 100,000 person-years) in total-cancer mortality for lower-vs-higher-educated groups ranged from 110 (Sweden) to 559 (Czech Republic); among women from approximately null (Slovenia, Italy, Spain) to 176 (Denmark). Lung cancer was the largest contributor to inequalities in total-cancer mortality (between-country range: men, 29-61%; women, 10-56%). 32% of cancer deaths in men and 16% in women (but up to 46% and 24%, respectively in Baltic/Central/East-Europe) were associated with educational inequalities.

Interpretation

Cancer mortality in Europe is largely driven by levels and trends of cancer mortality rates in lower-education groups. Even Nordic-countries, with a long-established tradition of equitable welfare and social justice policies, witness increases in cancer inequalities among women. These results call for a systematic measurement, monitoring and action upon the remarkable socioeconomic inequalities in cancer existing in Europe.

Funding

This study was done as part of the LIFEPATH project, which has received financial support from the European Commission (Horizon 2020 grant number 633666), and the DEMETRIQ project, which received support from the European Commission (grant numbers FP7-CP-FP and 278511). SV and WN were supported by the French Institut National du Cancer (INCa) (Grant number 2018-116). PM was supported by the Academy of Finland (#308247, # 345219) and the European Research Council under the European Union's Horizon 2020 research and innovation programme (grant agreement No 101019329). The work by Mall Leinsalu was supported by the Estonian Research Council (grant PRG722).

Mediating Role of Lifestyle Behaviors in the Association between Education and Cancer: Results from the European Prospective Investigation into Cancer and Nutrition

BACKGROUND

Many studies have shown that socioeconomic position (SEP) is associated with the incidence of malignant tumors at different sites. This study aims to estimate the association between educational level (as proxy for SEP) and cancer incidence and to understand whether the observed associations might be partially explained by lifestyle behaviors.

METHODS

The analyses were performed on data from the European Prospective Investigation into Cancer and Nutrition (EPIC) study, globally and by sex. We used Cox proportional hazards models together with mediation analysis to disentangle the total effect (TE) of educational level [measured through the Relative Index of Inequality (RII)] on cancer incidence into pure direct (PDE) and total indirect (TIE) effect, unexplained and explained by mediators, respectively. PDE and TIE were then combined to compute the proportions mediated (PM).

RESULTS

After an average of 14 years of follow-up, 52,422 malignant tumors were ascertained. Low educated participants showed higher risk of developing stomach, lung, kidney (in women), and bladder (in men) cancers, and, conversely, lower risk of melanoma and breast cancer (in post-menopausal women), when compared with more educated participants. Mediation analyses showed that portions of the TE of RII on cancer could be explained by site-specific related lifestyle behaviors for stomach, lung, and breast (in women).

CONCLUSIONS

Cancer incidence in Europe is determined at least in part by a socioeconomically stratified distribution of risk factors.

IMPACT

These observational findings support policies to reduce cancer occurrence by altering mediators, such as lifestyle behaviors, particularly focusing on underprivileged strata of the population.

Assessing How Social Exposures Are Integrated in Exposome Research: A Scoping Review

BACKGROUND

Exposome research aims to describe and understand the extent to which all the exposures in human environments may affect our health over the lifetime. However, the way in which humans interact with their environment is socially patterned. Failing to account for social factors in research exploring the exposome may underestimate the magnitude of the effect of exposures or mask inequalities in the distribution of both exposures and outcomes.

OBJECTIVES

We aimed to describe the extent to which social factors appear in the exposome literature, the manner in which they are used in empirical analyses and statistical modeling, and the way in which they are considered in the overall scientific approach.

METHODS

We conducted a scoping review of the literature using three databases (PubMed, Embase, and Web of Science) up to January 2022. We grouped studies based on the way in which the social variables were used in the analyses and quantified the type and frequency of social variables mentioned in the articles. We also qualitatively described the scientific approach used by authors to integrate social variables.

RESULTS

We screened 1,001 records, and 73 studies were included in the analysis. Fifty-five (∼ 75 % ) used social variables as exposures or confounders or both, and a wide array of social variables were represented in the articles. Individual-level social variables were more often found, especially education and race/ethnicity, as well as neighborhood-level deprivation indices. Half of the studies used a hypothesis-free approach and the other half, a hypothesis-driven approach. However, in the latter group, of 35 studies, only 8 reported and discussed at least one possible social mechanism underlying the relationship observed between the social variable and the outcome.

DISCUSSION

Social factors in exposome research should be considered in a more systematic way, considering their role in structuring both the specific external and the internal exposome. Doing so could help to understand the mechanisms of construction and, potentially, alleviate social inequalities in health and mitigate the emergence of new ones. https://doi.org/10.1289/EHP11015.

Socio-demographic inequalities and excess non-COVID-19 mortality during the COVID-19 pandemic: a data-driven analysis of 1 069 174 death certificates in Mexico

BACKGROUND

In 2020, Mexico experienced one of the highest rates of excess mortality globally. However, the extent of non-COVID deaths on excess mortality, its regional distribution and the association between socio-demographic inequalities have not been characterized.

METHODS

We conducted a retrospective municipal and individual-level study using 1 069 174 death certificates to analyse COVID-19 and non-COVID-19 deaths classified by ICD-10 codes. Excess mortality was estimated as the increase in cause-specific mortality in 2020 compared with the average of 2015-2019, disaggregated by primary cause of death, death setting (in-hospital and out-of-hospital) and geographical location. Correlates of individual and municipal non-COVID-19 mortality were assessed using mixed effects logistic regression and negative binomial regression models, respectively.

RESULTS

We identified a 51% higher mortality rate (276.11 deaths per 100 000 inhabitants) compared with the 2015-2019 average period, largely attributable to COVID-19. Non-COVID-19 causes comprised one-fifth of excess deaths, with acute myocardial infarction and type 2 diabetes as the two leading non-COVID-19 causes of excess mortality. COVID-19 deaths occurred primarily in-hospital, whereas excess non-COVID-19 deaths occurred in out-of-hospital settings. Municipal-level predictors of non-COVID-19 excess mortality included levels of social security coverage, higher rates of COVID-19 hospitalization and social marginalization. At the individual level, lower educational attainment, blue-collar employment and lack of medical care assistance prior to death were associated with non-COVID-19 deaths.

CONCLUSION

Non-COVID-19 causes of death, largely chronic cardiometabolic conditions, comprised up to one-fifth of excess deaths in Mexico during 2020. Non-COVID-19 excess deaths occurred disproportionately out-of-hospital and were associated with both individual- and municipal-level socio-demographic inequalities.

The Role of Epigenetic Clocks in Explaining Educational Inequalities in Mortality: A Multicohort Study and Meta-analysis

Educational inequalities in all-cause mortality have been observed for decades. However, the underlying biological mechanisms are not well known. We aimed to assess the role of DNA methylation changes in blood captured by epigenetic clocks in explaining these inequalities. Data were from 8 prospective population-based cohort studies, representing 13 021 participants. First, educational inequalities and their portion explained by Horvath DNAmAge, Hannum DNAmAge, DNAmPhenoAge, and DNAmGrimAge epigenetic clocks were assessed in each cohort via counterfactual-based mediation models, on both absolute (hazard difference) and relative (hazard ratio) scales, and by sex. Second, estimates from each cohort were pooled through a random effect meta-analysis model. Men with low education had excess mortality from all causes of 57 deaths per 10 000 person-years (95% confidence interval [CI]: 38, 76) compared with their more advantaged counterparts. For women, the excess mortality was 4 deaths per 10 000 person-years (95% CI: -11, 19). On the relative scale, educational inequalities corresponded to hazard ratios of 1.33 (95% CI: 1.12, 1.57) for men and 1.15 (95% CI: 0.96, 1.37) for women. DNAmGrimAge accounted for the largest proportion, approximately 50%, of the educational inequalities for men, while the proportion was negligible for women. Most of this mediation was explained by differential effects of unhealthy lifestyles and morbidities of the World Health Organization (WHO) risk factors for premature mortality. These results support DNA methylation-based epigenetic aging as a signature of educational inequalities in life expectancy emphasizing the need for policies to address the unequal social distribution of these WHO risk factors.

The cancer survival index-A prognostic score integrating psychosocial and biological factors in patients diagnosed with cancer or haematologic malignancies

Objective

We aimed to investigate whether (1) psychological and social indicators influence survival in patients diagnosed with cancer or haematologic malignancies when important biological aspects are controlled for, (2) psychological, social and biological indicators can be utilised to design one collated index for survival, usable in clinical practice to identify patients at risk of shorter survival and to improve personalised healthcare provision.

Methods

In this cross‐sectional study, 2263 patients with cancer or haematologic malignancies participated. We analysed 15 biological, psychological and social indicators as risk factors for survival with a Cox proportional hazards model. Indicators significantly associated with survival were combined to compute models for the identification of patient groups with different risks of death. The training sample contained 1122 patients. Validation samples included the remaining 1141 patients, the total sample, as well as groups with different cancer entities.

Results

Five indicators were found to significantly impact survival: Cancer site (HR: 3.56), metastatic disease (HR: 1.88), symptoms of depression (HR: 1.34), female sex (HR: 0.73) and anaemia (HR: 0.48). Combining these indicators to a model, we developed the Cancer Survival Index, identifying three distinct groups of patients with estimated survival times of 47.2 months, 141 months and 198.2 months (p < 0.001). Post hoc analysis of the influence of depression on survival showed a mediating effect of the following four factors, related to both depression and survival: previous psychiatric conditions, employment status, metastatic disease and haemoglobin levels.

Conclusions

Psychosocial and biological factors impact survival in various malignancies and can be utilised jointly to compute an index for estimating the survival of each patient individually—the Cancer Survival Index.

Age-related Differences in Recall of Information and Handling of Chemotherapy-related Side Effects in Cancer Patients: The ReCap Study

Background

To prevent severe toxicity and hospital admissions, adequate management and recall of information about side effects are crucial and health literacy plays an important role. If age-related factors impact recall of given information and handling of side effects, revised ways to give information are required.

Patients and Methods

We undertook a questionnaire-based survey among 188 newly diagnosed patients with pancreatic cancer or colorectal cancer and chemo-naive patients with prostate cancer treated with adjuvant or first-line palliative chemotherapy comprising satisfaction with given information, recall of potential side effects, and handling of hypothetical side effect scenarios. We evaluated the association between baseline characteristics, ie, age, frailty (G8 score), comorbidity (Charlson Comorbidity Index), cognitive function (Mini-Cog), satisfaction, recall of information, and handling of side effects.

Results

Reduced ability to recall information about several side effects (eg, chest pain) was associated with older age (odds ratio adjusted for cancer [aOR] 0.94 [95% CI, 0.88-0.98]) and poor cognitive screening (aOR 0.56 [95% CI, 0.33-0.91]). Insufficient or dangerous handling of side effects was associated with older age (aOR 0.96 (95% CI, 0.92-0.99)) and cognitive impairment (aOR 0.70 [95% CI, 0.50-0.95]).

Conclusion

Older age and poor cognitive screening may impact patients’ ability to understand and adequately handle chemotherapy-related side effects. Cognitive screening and focus on individual ways to give information including assessment of recall and handling are needed.

Associations between social determinants of health and interpersonal violence-related injury in Cameroon: a cross-sectional study

Introduction

Risk factors for interpersonal violence-related injury (IPVRI) in low-income and middle-income countries (LMICs) remain poorly defined. We describe associations between IPVRI and select social determinants of health (SDH) in Cameroon.

Methods

We conducted a cross-sectional analysis of prospective trauma registry data collected from injured patients >15 years old between October 2017 and January 2020 at four Cameroonian hospitals. Our primary outcome was IPVRI, compared with unintentional injury. Explanatory SDH variables included education level, employment status, household socioeconomic status (SES) and alcohol use. The EconomicClusters model grouped patients into household SES clusters: rural, urban poor, urban middle-class (MC) homeowners, urban MC tenants and urban wealthy. Results were stratified by sex. Categorical variables were compared via Pearson’s χ² statistic. Associations with IPVRI were estimated using adjusted odds ratios (aOR) with 95% confidence intervals (95%CI).

Results

Among 7605 patients, 5488 (72.2%) were men. Unemployment was associated with increased odds of IPVRI for men (aOR 2.44 (95% CI 1.95 to 3.06), p<0.001) and women (aOR 2.53 (95% CI 1.35 to 4.72), p=0.004), as was alcohol use (men: aOR 2.33 (95% CI 1.91 to 2.83), p<0.001; women: aOR 3.71 (95% CI 2.41 to 5.72), p<0.001). Male patients from rural (aOR 1.45 (95% CI 1.04 to 2.03), p=0.028) or urban poor (aOR 2.08 (95% CI 1.27 to 3.41), p=0.004) compared with urban wealthy households had increased odds of IPVRI, as did female patients with primary-level/no formal (aOR 1.78 (95% CI 1.10 to 2.87), p=0.019) or secondary-level (aOR 1.54 (95% CI 1.03 to 2.32), p=0.037) compared with tertiary-level education.

Conclusion

Lower educational attainment, unemployment, lower household SES and alcohol use are risk factors for IPVRI in Cameroon. Future research should explore LMIC-appropriate interventions to address SDH risk factors for IPVRI.

Contextual Determinants in Alcohol, Tobacco and Cannabis Consumption, Mood and Bullying during Adolescence

The present study aimed to explore the differences in the consumption of alcohol, tobacco and cannabis, mood and bullying between adolescents. A cross-sectional study was carried out in five regions of Northern Spain (one in Galiza and four in central Catalonia) that share similar socioeconomic characteristics and encompass around 10,000 inhabitants each. Students living in Burela, Galiza (N = 71) were compared to those of Central Catalonia (N = 193). The independent variable was the municipality of residence. The dependent variables encompassed: weekly available pocket money, Family Affluence Scale, self-classified academic qualification, place of origin, alcohol consumption, tobacco and cannabis smoking, negative mood and bullying. The mean age and their 95% confidence intervals (95% CI) of participants were similar between the regions (Burela: 15.90 years (15.68-16.13) and Central Catalonia: 15.36 years (15.28-15.44)). More than half of the participants were females (Burela, Galiza (53.5%) and Catalonia (54.9%)). Prevalence ratios (PR) and their 95% CI were estimated using Poisson regression models. In comparison with adolescents from Burela (Galiza), those living in Central Catalonia had higher prevalence of diverse academic levels (adjusted PR = 3.92 (1.78-8.66)), tobacco consumption (adjusted PR = 2.41 (1.47-3.97)) and negative mood (adjusted PR = 5.97 (3.05-11.70)). Even when dealing with regions with similar socioeconomic characteristics and number of inhabitants, differences exist in terms of the socioeconomic level, tobacco consumption, mood and bullying, as reported by adolescents.

Could teacher-perceived parental interest be an important factor in understanding how education relates to later physiological health? A life course approach

Education is associated with later health, and notably with an indicator of physiological health measuring the cost of adapting to stressful conditions, named allostatic load. Education is itself the result of a number of upstream variables. We examined the origins of educational attainment through the lens of interactions between families and school i.e. parents’ interest in their child’s education as perceived by teachers. This study aims to examine whether parental interest during a child’s educational trajectory is associated with subsequent allostatic load, and whether education or other pathways mediate this relationship. We used data from 9 377 women and men born in 1958 in Great Britain and included in the National Child Development Study to conduct secondary data analyses. Parental interest was measured from questionnaire responses by teachers collected at age 7, 11 and 16. Allostatic load was defined using 14 biomarkers assayed in blood from a biosample collected at 44 years of age. Linear regression analyses were carried out on a sample of 8 113 participants with complete data for allostatic load, missing data were imputed. Participants whose parents were considered to be uninterested in their education by their teacher had a higher allostatic load on average in midlife in both men (β = 0,41 [0,29; 0,54]) and women (β = 0,69 [0,54; 0,83]). We examined the role of the educational and other pathways including psychosocial, material/financial, and behavioral variables, as potential mediators in the relationship between parental interest and allostatic load. The direct link between parental interest and allostatic load was completely mediated in men, but only partially mediated in women. This work provides evidence that parents’ interest in their child’s education as perceived by teachers is associated with subsequent physiological health in mid-life and may highlight a form of cultural dissonance between family and educational spheres.

Reducing socio-economic inequalities in all-cause mortality: a counterfactual mediation approach

Background

Socio-economic inequalities in mortality are well established, yet the contribution of intermediate risk factors that may underlie these relationships remains unclear. We evaluated the role of multiple modifiable intermediate risk factors underlying socio-economic-associated mortality and quantified the potential impact of reducing early all-cause mortality by hypothetically altering socio-economic risk factors.

Methods

Data were from seven cohort studies participating in the LIFEPATH Consortium (total n = 179 090). Using both socio-economic position (SEP) (based on occupation) and education, we estimated the natural direct effect on all-cause mortality and the natural indirect effect via the joint mediating role of smoking, alcohol intake, dietary patterns, physical activity, body mass index, hypertension, diabetes and coronary artery disease. Hazard ratios (HRs) were estimated, using counterfactual natural effect models under different hypothetical actions of either lower or higher SEP or education.

Results

Lower SEP and education were associated with an increase in all-cause mortality within an average follow-up time of 17.5 years. Mortality was reduced via modelled hypothetical actions of increasing SEP or education. Through higher education, the HR was 0.85 [95% confidence interval (CI) 0.84, 0.86] for women and 0.71 (95% CI 0.70, 0.74) for men, compared with lower education. In addition, 34% and 38% of the effect was jointly mediated for women and men, respectively. The benefits from altering SEP were slightly more modest.

Conclusions

These observational findings support policies to reduce mortality both through improving socio-economic circumstances and increasing education, and by altering intermediaries, such as lifestyle behaviours and morbidities.

The Educational Gradient in Intake of Energy and Macronutrients in the General Adult and Elderly Population: The Tromsø Study 2015-2016

Worldwide, there are socioeconomic inequalities in health and diet. We studied the relationship between education and nutrient intake in 11,302 women and men aged 40-96 years who participated in the seventh survey of the population-based Tromsø Study (2015-2016), Norway (attendance 65%). Diet was assessed using a validated food-frequency questionnaire. We examined the association between education and intake of total energy and macronutrients by sex using linear and logistic regression models adjusted for age, body mass index, leisure time physical activity and smoking. The intake of macronutrients was compared with the Nordic Nutrition Recommendations 2012. There was a positive association between education and intake of fiber and alcohol, and a negative association between education and intake of total carbohydrates and added sugar in both women and men. Participants with long tertiary education had higher odds of being compliant with the recommended intake of fiber and protein and the maximum recommended level for added sugar and had lower odds of being compliant with the recommended intake of total carbohydrates and the maximum recommended level for alcohol, compared to participants with primary education. Overall, we found that participants with higher education were more compliant with the Nordic Nutrition Recommendations 2012.

Can Healthy Checkout Counters Improve Food Purchases? Two Real-Life Experiments in Dutch Supermarkets

Most snacks displayed at supermarket checkouts do not contribute to a healthy diet. We investigated the effects of introducing healthier snack alternatives at checkouts in supermarkets on purchasing behavior. In Study 1, we investigated the effect of completely substituting less healthy with healthier snacks (one supermarket). In Study 2, we investigated the effect of placing and discounting healthier snacks while the less healthy snacks remain in place (two supermarkets). In both studies, the number of purchased snacks (per 1000 customers) was used as the outcome variable. Results for Study 1 showed that the absolute number of purchased checkout snacks was 2.4 times lower (95% confidence interval (CI): 1.9-2.7) when healthier snacks instead of less healthy snacks were placed at the supermarket checkouts. Results for Study 2 showed that when additional healthier snacks were placed near the checkouts, the absolute number of healthier purchased snacks increased by a factor of 2.1 (95% CI: 1.3-3.3). When additional healthier snacks were placed near the checkouts and discounted, the absolute number of healthier purchased snacks increased by a factor of 2.7 (95% CI: 2.0-3.6), although this was not statistically significant higher than placement only (ratio: 1.1, 95% CI: 0.7-1.9). Purchases of less healthy snacks did not decline, and even slightly increased, during the intervention period (ratio: 1.3, 95% CI: 1.1-1.5). If supermarkets want to promote healthier snack purchases, additional healthier products can be positioned near the checkouts. However, this does not discourages the purchase of less healthy snacks. Therefore, to discourage unhealthy snack purchases at supermarket checkouts, a total substitution of less healthy snacks with healthier alternatives is most effective.

The mediating role of unhealthy behaviors and body mass index in the relationship between high job strain and self-rated poor health among lower educated workers

Objectives

The objective of this study is to examine the mediating role of unhealthy behaviors and body mass index (BMI) in the relationship between high job strain and self-rated poor health in workers with a low education.

Methods

A total of 8369 low educated workers, who participated in the Lifelines cohort study during the period 2012–2017, were included. Self-reported job strain, health behaviors (smoking, physical activity, and fruit and vegetable consumption), and BMI were assessed at baseline, and self-rated health after 2 years. To assess mediation by the health behaviors and BMI, structural equation modeling with logistic and multinomial regression analyses were performed.

Results

Workers with high job strain had a higher odds of poor health (OR 1.34; 95% CI 1.13–1.60) compared to those with low job strain. Workers with high job strain were more likely to have a lack of physical activity (OR 1.14; 95% CI 1.01–1.28), but were not more likely to smoke, to be overweight or obese, or to have a low fruit or vegetable consumption. Workers who smoke, have a lack of physical activity or are overweight or obese are more likely to report poor health (OR 1.37; 95% CI 1.16–1.60, OR 1.25; 95% CI 1.08–1.43, OR 1.37; 95% CI 1.16–1.61, OR 2.25; 95% CI 1.86–2.72). Indirect (mediating) effects of unhealthy behaviors and BMI in the relationship between high job strain and poor health were small and not statistically significant.

Conclusions

No mediating effects of unhealthy behaviors or BMI were found in the relationship between high job strain and self-rated poor health among workers with a low educational level.

A multi-omics approach to investigate the inflammatory response to life course socioeconomic position

Aim: Inflammation represents a potential pathway through which socioeconomic position (SEP) is biologically embedded. Materials & methods: We analyzed inflammatory biomarkers in response to life course SEP by integrating multi-omics DNA-methylation, gene expression and protein level in 178 European Prospective Investigation into Cancer and Nutrition-Italy participants. Results & conclusion: We identified 61 potential cis acting CpG loci whose methylation levels were associated with gene expression at a Bonferroni correction. We examined the relationships between life course SEP and these 61 cis-acting regulatory methylation sites individually and jointly using several scores. Less-advantaged SEP participants exhibit, later in life, a lower inflammatory methylome score, suggesting an overall increased expression of the corresponding inflammatory genes or proteins, supporting the hypothesis that SEP impacts adult physiology through inflammation.

Special Report: The Biology of Inequalities in Health: The Lifepath Consortium

Funded by the European Commission Horizon 2020 programme, the Lifepath research consortium aimed to investigate the effects of socioeconomic inequalities on the biology of healthy aging. The main research questions included the impact of inequalities on health, the role of behavioral and other risk factors, the underlying biological mechanisms, the efficacy of selected policies, and the general implications of our findings for theories and policies. The project adopted a life-course and comparative approach, considering lifetime effects from childhood and adulthood, and pooled data on up to 1.7 million participants of longitudinal cohort studies from Europe, USA, and Australia. These data showed that socioeconomic circumstances predicted mortality and functional decline as strongly as established risk factors currently targeted by global prevention programmes. Analyses also looked at socioeconomically patterned biological markers, allostatic load, and DNA methylation using richly phenotyped cohorts, unraveling their association with aging processes across the life-course. Lifepath studies suggest that socioeconomic circumstances are embedded in our biology from the outset-i.e., disadvantage influences biological systems from molecules to organs. Our findings have important implications for policy, suggesting that (a) intervening on unfavorable socioeconomic conditions is complementary and as important as targeting well-known risk factors, such as tobacco and alcohol consumption, low fruit and vegetable intake, obesity and a sedentary lifestyle, and that (b) effects of preventive interventions in early life integrate interventions in adulthood. The report has an executive summary that refers to the different sections of the main paper.

Can unhealthy food purchases at checkout counters be discouraged by introducing healthier snacks? A real-life experiment in supermarkets in deprived urban areas in the Netherlands

BACKGROUND

The checkout area in supermarkets is an unavoidable point of purchase where impulsive food purchases are likely to be made. However, the product assortment at the checkout counters is predominantly unhealthy. The aim of this real life experiment was to investigate if unhealthy food purchases at checkout counters in supermarkets in deprived urban areas in the Netherlands can be discouraged by the introduction of the Healthy Checkout Counter (HCC). In addition, we examined customers' perceptions towards the HCC.

METHODS

The HCC was an initiative of a leading supermarket chain in the Netherlands that consisted of displays with a selection of healthier snacks that were placed at the checkouts. We used a real life quasi-experimental design with 15 intervention and 9 control supermarkets. We also performed a cross-sectional customer evaluation in 3 intervention  supermarkets using oral surveys to investigate customers' perceptions towards the HCC (n=134). The purchases of unhealthy and healthier snacks at checkouts were measured with sales data.

RESULTS

During the intervention period, customers purchased on average 1.7 (SD: 0.08) unhealthy snacks per 100 customers in the intervention supermarket and 1.4 (SD: 0.10) in the control supermarket. Linear regression analyses revealed no statistically significant difference in the change during the control and intervention period of sales of unhealthy snacks between the control and intervention supermarkets (B = - 0.008, 95% CI = - 0.15 to 0.14). The average number of healthier snacks purchased was 0.2 (SD: 0.3) items per 100 customers in the intervention supermarkets during the intervention period. Of the intervention customers, 41% noticed the HCC and 80% of them were satisfied or very satisfied with the intervention.

CONCLUSIONS

This real life experiment in supermarkets showed that the placement of healthier snacks at checkouts did not lead to the substitution of unhealthy snack purchases with healthier alternatives. Although supermarket customers positively evaluated the HCC, future studies are needed to investigate other strategies to encourage healthier food purchases in supermarkets.

Combining individual and aggregated data to investigate the role of socioeconomic disparities on cancer burden in Italy

Quantifying socioeconomic disparities and understanding the roots of inequalities are growing topics in cancer research. However, socioeconomic differences are challenging to investigate mainly due to the lack of accurate data at individual-level, while aggregate indicators are only partially informative. We implemented a multiple imputation algorithm within a statistical matching framework that combines diverse sources of data to estimate individual-level associations between income and risk of breast and lung cancer, adjusting for potential confounding factors in Italy. The framework is computationally flexible and can be adapted to similar contexts.

Special Report: The Biology of Inequalities in Health: The Lifepath Consortium

Funded by the European Commission Horizon 2020 programme, the Lifepath research consortium aimed to investigate the effects of socioeconomic inequalities on the biology of healthy aging. The main research questions included the impact of inequalities on health, the role of behavioral and other risk factors, the underlying biological mechanisms, the efficacy of selected policies, and the general implications of our findings for theories and policies. The project adopted a life-course and comparative approach, considering lifetime effects from childhood and adulthood, and pooled data on up to 1.7 million participants of longitudinal cohort studies from Europe, USA, and Australia. These data showed that socioeconomic circumstances predicted mortality and functional decline as strongly as established risk factors currently targeted by global prevention programmes. Analyses also looked at socioeconomically patterned biological markers, allostatic load, and DNA methylation using richly phenotyped cohorts, unraveling their association with aging processes across the life-course. Lifepath studies suggest that socioeconomic circumstances are embedded in our biology from the outset-i.e., disadvantage influences biological systems from molecules to organs. Our findings have important implications for policy, suggesting that (a) intervening on unfavorable socioeconomic conditions is complementary and as important as targeting well-known risk factors, such as tobacco and alcohol consumption, low fruit and vegetable intake, obesity and a sedentary lifestyle, and that (b) effects of preventive interventions in early life integrate interventions in adulthood. The report has an executive summary that refers to the different sections of the main paper.

Regional indices of socio-economic and health inequalities: a tool for public health programming

OBJECTIVES

The aim was to provide an affordable method of computing socio-economic (SE) deprivation indices at the regional level, in order to reveal the specific aspects of the relationship between SE inequalities and health outcomes. The Umbria Region Socio-Health Index (USHI) was computed and compared with the Italian National Deprivation Index at the Umbria regional level (NDI-U).

METHODS

The USHI was computed by applying factor analysis to census tract SE variables correlated with general mortality and validated through comparison with the NDI-U.

RESULTS

Overall mortality presented linear positive trends in USHI, while trends in NDI-U proved non-linear or non-significant. Similar results were obtained with regard to specific causes of death according to deprivation groups, gender and age.

CONCLUSIONS

The USHI better describes a local population in terms of health-related SE status. Policy-makers could therefore adopt this method in order to obtain a better picture of SE-associated health conditions in regional populations and to target strategies for reducing health inequalities.

Help-Seeking Experiences of Hepatitis B Patients in Transnational Medical Care: The Solution to Health Inequality Is Social Mobility

This paper tracked hepatitis B patients from Medan, Indonesia to Penang, Malaysia under transnational medical care and has an understanding of their medical history and socioeconomic status. The condition of these patients improved as a result of good compliance with medical treatment, including lifestyle adjustment and regular medication. Under the influence of the marketization of healthcare, transnational medical patients in the social structure, based on their economic ability and socioeconomic status, may be expected to experience health inequalities. People with unhealthy medical distribution and weak socioeconomic status are easily prone to diseases due to environmental and social conditions; it is easier for such patients to delay or give up their medical treatment. After continuous tracking and increasing patient exposure to medical knowledge and self-care management opportunities, increasing awareness, screening, care, and treatment, the transmission of hepatitis B can be reduced to enable them to gain upward mobility by their capacities and thus improve their health. Social mobility is deemed the main approach to reduce social inequality. There have been limited medical clinical observations and tracking confirming this theory. This paper, which uses medical observation, confirmed that social mobility is considered as the principal key to reducing inequalities in health.

Socio-economic and cultural disparities in diet among adolescents and young adults: a systematic review

OBJECTIVE

To explore dietary differences according to socio-economic and sociocultural characteristics of adolescents and young adults.

DESIGN

A systematic review was conducted.

SETTING

The main search source was MEDLINE, consulted between January 2012 and March 2017. Quality of selected studies was assessed based on dietary measurement method, sample selection, socio-economic indicator choice and statistical modelling.

PARTICIPANTS

Cross-sectional and longitudinal studies, assessing relationships between socio-economic status and dietary intake (patterns, scores and food groups) in the 10- to 40-year-old general population of high-income countries, were selected.

RESULTS

Among the 7250 reports identified, forty were selected, seventeen of which were of high quality; their conclusions, related only to adolescents, were combined and presented. The most favourable dietary patterns, higher dietary scores, greater consumption of fruits, vegetables and dairy products, and lower consumption of sugary sweetened beverages and energy-dense foods, were associated with better parental socio-economic status, particularly in terms of higher education. Migrant status was associated with plant-based patterns, greater consumption of fruits and vegetables and of sugary sweetened beverages and energy-dense foods. For the other food groups, and for young adults, very few high-quality studies were found.

CONCLUSIONS

The socio-economic gradient in adolescent diets requires confirmation by higher-grade studies of a wider set of food groups and must be extended to young adult populations. Future nutritional interventions should involve the most vulnerable adolescent populations, taking account of socio-economic status and migration.

[Various socioeconomic factors as predictors of internalizing and externalizing disorders in children and adolescents]

Various socioeconomic factors as predictors of internalizing and externalizing disorders in children and adolescents Abstract. Objective: Socioeconomic status (SES) is an important risk factor for psychiatric disorders in children and adolescents. Various SES parameters are included in research efforts. This paper investigates the predictive value of different individual SES measures and the combination thereof regarding internalizing and externalizing disorders in children and adolescents. Method: We used data from N = 381 8- to 14-year-olds who had been recruited in child and adolescent psychiatric facilities and in the general population. Based on a diagnostic parent interview (K-SADS-PL), we divided the sample into internalizing and externalizing groups and a healthy control group. The SES data of both parents were collected. Education, occupational status, and income were integrated as single factors as well as combined factor to form the SES index. Additionally, we assessed unemployment. Results: Using multivariate analyses, we controlled for age and sex. All single factors turned out to be significant risk factors for internalizing and externalizing disorders. Occupational status was the most important single factor. The explained variance for the SES index was as high as for occupational status. Unemployment was not predictive when examined simultaneously with the SES index. Conclusion: Future studies should integrate the SES as risk factor and use the SES index or occupational status as single factor. The integration of unemployment is not necessarily needed.

Early and late mortality following unscheduled admissions for severe liver disease across England and Wales

BACKGROUND

There is a known shortfall in hepatology service resources across England and Wales.

AIM

To investigate early and late mortality following unscheduled admissions for severe liver disease, overall and by cause of death, and to determine how mortality is related to admissions to transplant centres, transplant surgery, hospital size, consultant specialty, patient socio-demographics, seasonal and geographical factors.

METHODS

Cohorts of people with a first unscheduled admission for severe liver disease across England and Wales from 2004, based on record linkage of national inpatient and mortality data.

FINDINGS

Mortality for alcoholic liver disease and hepatic failure was 23.4% and 35.4% respectively at 60 days and 61.8% and 57.1% at 5 years. Standardised mortality ratios (SMRs) were extremely high at 60 days (184 and 117 respectively) and remained highly increased at 5 years (16.7 and 6.3). Mortality at 5 years was most elevated from liver disease, viral hepatitis and varices. The 60-day mortality was significantly lower for patients seen by consultant hepatologists and gastroenterologists. Both early and late mortality were significantly reduced for patients admitted to transplant centres or larger hospitals, who received a liver transplant, or were resident in London. Early mortality was significantly higher for patients admitted in winter and autumn, while elevated mortality among the most vs least deprived quintile increased with longer follow-up.

CONCLUSIONS

The study shows a very poor prognosis for people with unscheduled hospitalisation for severe liver disease. The findings suggest that access to specialist expertise and services improves survival, both in the short and long term.

Theorising social class and its application to the study of health inequalities

The literature on health inequalities often uses measures of socio-economic position pragmatically to rank the population to describe inequalities in health rather than to understand social and economic relationships between groups. Theoretical considerations about the meaning of different measures, the social processes they describe, and how these might link to health are often limited. This paper builds upon Wright's synthesis of social class theories to propose a new integrated model for understanding social class as applied to health. This model incorporates several social class mechanisms: social background and early years' circumstances; Bourdieu's habitus and distinction; social closure and opportunity hoarding; Marxist conflict over production (domination and exploitation); and Weberian conflict over distribution. The importance of discrimination and prejudice in determining the opportunities for groups is also explicitly recognised, as is the relationship with health behaviours. In linking the different social class processes we have created an integrated theory of how and why social class causes inequalities in health. Further work is required to test this approach, to promote greater understanding of researchers of the social processes underlying different measures, and to understand how better and more comprehensive data on the range of social class processes these might be collected in the future.

Are There Changes in Inequalities in Injuries? A Review of Evidence in the WHO European Region

Decreases in injury rates globally and in Europe in the past decades, although encouraging, may mask previously reported social inequalities between and within countries that persist or even increase. European research on this issue has not been systematically reviewed, which is the aim of this article. Between and within-country studies from the WHO European Region that investigate changes in social inequalities in injuries over time or in recent decades were sought in PubMed, Scopus, and Web of Science. Of the 27 studies retained, seven were cross-country and 20 were country-specific. Twelve reported changes in inequalities over time and the remaining 15 shed light on other aspects of inequalities. A substantial downward trend in injuries is reported for all causes and cause-specific ones—alongside persisting inequalities between countries and, in a majority of studies, within countries. Studies investigate diverse questions in different population groups. Depending on the social measure and injury outcome considered, many report inequalities in injuries albeit to a varying degree. Despite the downward trends in risk levels, relative social inequalities in injuries remain a persisting public health issue in the European Region.

Knowledge, attitudes, and practices about homelessness and willingness-to-pay for housing-first across 8 European countries: a survey protocol

Background

Most European countries report rising numbers of people experiencing homelessness. For those with mental disorders, interventions are centered on achieving mental health and drug rehabilitation alongside housing readiness, often to the detriment of access to housing. Notwithstanding, more European countries are investing in a new model, Housing First (HF), which postulates immediate access to permanent housing with no initial requirements for treatment. While results of the European HF programs are published on individual-level data, little is known about the opinions of the general population about homelessness and the societal value of the HF model, which can represent barriers to the model's dissemination. Therefore, we present the protocol of a study designed for the following objectives: 1) to explore the knowledge, attitudes, and practices (KAP) about homelessness within the general population of 8 European countries, 2) to assess the valuation of the HF model by European citizens, and 3) to estimate the lifetime prevalence of homelessness in the targeted countries.

Methods

A telephone survey was conducted from March to December 2017 among adults selected from opt-in panels from France, Ireland, Italy, the Netherlands, Portugal, Spain, Poland, and Sweden. A total sample of 5600 interviews was expected, with 700 per country. The interviews included three sections: first, the KAP about homelessness; second, the valuation of the HF model by measuring a respondent's willingness-to-pay (WTP) through the contingent valuation method; and third, an assessment of the lifetime prevalence of homelessness among the general population. Descriptive analyses and comparisons between countries will be conducted. KAP indicators will be created and their psychometric properties assessed. Determinants of WTP will be assessed through regression models.

Discussion

This survey will highlight Europeans' views of homelessness, especially their level of tolerance towards homelessness, potential misconceptions and the most important barriers for the implementation of the HF model. Additionally, the results on the valuation of the HF model by citizens could be instrumental for key stakeholders in understanding the level of support from the general population. Ethics approval has been obtained from the Aix-Marseille University Ethics Committee (n° 2016-01-02-01) for this study, which is part of HOME_EU: Reversing Homelessness in Europe H2O20-SC6-REVINEQUAL-2016/GA726997.

Psycho-oncology

Medical progress, the improvement of general living conditions, and an increase in life expectancy have led to an increase in the general prevalence of oncologic disease. More importantly, more and more patients survive cancer or live with the disease for long periods of time. While the battle for survivorship is continuously being fought, improving patients' quality of life has come to the fore. Psychosocial issues may modulate the course of the disease, but mainly have a deep impact on patients' physical and mental wellbeing. Psycho-oncology has risen as a relatively new interdisciplinary field with the aim of addressing these issues and providing support for patients confronting numerous challenges throughout the different stages of the disease. In this article, we provide an overview of the current knowledge of body-mind interactions in cancer and an outline of the broad spectrum of psycho-oncologic care, with a special focus on the treatment of pain, fatigue, sexual issues, and fear of progression.

The epigenetics of inflammaging: The contribution of age-related heterochromatin loss and locus-specific remodelling and the modulation by environmental stimuli

A growing amount of evidences indicates that inflammaging - the chronic, low grade inflammation state characteristic of the elderly - is the result of genetic as well as environmental or stochastic factors. Some of these, such as the accumulation of senescent cells that are persistent during aging or accompany its progression, seem to be sufficient to initiate the aging process and to fuel it. Others, like exposure to environmental compounds or infections, are temporary and resolve within a (relatively) short time. In both cases, however, a cellular memory of the event can be established by means of epigenetic modulation of the genome. In this review we will specifically discuss the relationship between epigenetics and inflammaging. In particular, we will show how age-associated epigenetic modifications concerned with heterochromatin loss and gene-specific remodelling, can promote inflammaging. Furthermore, we will recall how the exposure to specific nutritional, environmental and microbial stimuli can affect the rate of inflammaging through epigenetic mechanisms, touching also on the recent insight given by the concept of trained immunity.

Big Data and the Study of Social Inequalities in Health: Expectations and Issues

Understanding the construction of the social gradient in health is a major challenge in the field of social epidemiology, a branch of epidemiology that seeks to understand how society and its different forms of organization influence health at a population level. Attempting to answer these questions involves large datasets of varied heterogeneous data suggesting that Big Data approaches could be then particularly relevant to the study of social inequalities in health. Nevertheless, real challenges have to be addressed in order to make the best use of the development of Big Data in health for the benefit of all. The main purpose of this perspective is to discuss some of these challenges, in particular: (i) the perimeter and the particularity of Big Data in health, which must be broader than a vision centerd solely on care, the individual and his or her biological characteristics; (ii) the need for clarification regarding the notion of data, the validity of data and the question of causal inference for various actors involved in health, such data as researchers, health professionals and the civilian population; (iii) the need for regulation and control of data and their uses by public authorities for the common good and the fight against social inequalities in health. To face these issues, it seems essential to integrate different approaches into a close dialog, integrating methodological, societal, and ethical issues. This question cannot escape an interdisciplinary approach, including users or patients.

[Social environment, biological embedding and social inequalities in health]

The social gradient in health refers to the fact that the higher individuals rise in the social hierarchy, the better is their health. Understanding the construction of this gradient is a major challenge in social epidemiology. An original approach consists in looking at how the different exposures (chemical, physical, behavioural, psychosocial…) associated with the social environment are ultimately expressed at the biological level influencing health positively or negatively, referring to the concept of biological embedding. Data from animal models and life course epidemiology have shed new light on the biological mechanisms potentially at play. Recent discoveries from the field of epigenetics provide a better understanding of how the social environment, especially the early environment, can influence biological functioning over the long term or even over several generations. The work on the biological embedding of the social environment in connection with epigenetics still needs to be very largely consolidated, but could constitute a change of perspective in human biology, particularly by reconsidering the influence of the environment on biological functioning, which is not without consequences in terms of public health interventions.

Higher breast cancer prevalence associated with higher socioeconomic status in the South Korean population; Has it resulted from overdiagnosis?

Recently, breast cancer prevalence has increased in South Korea. In this study, we investigated the correlation between breast cancer prevalence and socioeconomic status. This study enrolled 27,331 people who participated in the Korean National Health and Nutrition Examination Survey (KNHANES) IV–VI (2007–2015). In addition, we obtained data from the Korean Statistical Information Service (KSIS) on the breast cancer age-standardized incidence rate (AIR), the age-standardized mortality rate (AMR), the number of women screened, and the number of newly diagnosed patients. The KHANES data showed that breast cancer prevalence was significantly associated with educational level (odds ratio [OR], 2.02; 95% confidence interval [CI], 1.08–3.77 for 10–12 vs. ≤ 6 years of education, and OR, 2.36; 95% CI, 1.10–5.06 for ≥ 13 vs. ≤ 6 years of education). However, there was no significant association of breast cancer prevalence with monthly household income. In a separate analysis of the AIR, AMR, and number of women screened for breast cancer, the AIR increased with the number of women screened, whereas the AMR did not. Furthermore, the number of newly diagnosed patients in all age groups increased over time. The present results demonstrate that the recently increased breast cancer prevalence documented in South Korea may be attributable to earlier detection rather than to a real increase in prevalence, and that breast cancer may be overdiagnosed.

Increased risk of premature death following teenage abortion and childbirth-a longitudinal cohort study

Background

Teenage pregnancy is associated with an increased risk of premature death. However, it is not known whether the outcome of pregnancy, i.e. induced abortion or childbirth, affects this risk.

Methods

A Finnish population-based register study involving a cohort of 13 691 nulliparous teenagers who conceived in 1987-89; 6652 of them underwent induced abortion and 7039 delivered. The control group consisted of 41 012 coeval women without teenage pregnancy. Follow-up started at the end of pregnancy and lasted until 6th June 2013.

Results

Women with teenage pregnancy had a higher risk of overall mortality vs. controls (mortality rate ratio [MRR] 1.6, [95% CI 1.4-1.8]) and were more likely to die prematurely as a result of suicide, alcohol-related causes, circulatory diseases and motor vehicle accidents. A low educational level appeared to explain these excess risks, except for suicide (adj. MRR 1.5, [95% CI 1.1-2.0]). After adjusting for confounders, the childbirth group faced lower risks of suicide (adj. MRR 0.5, [95% CI 0.3-0.9]) and dying from injury and poisoning (adj. MRR 0.6, [95% CI 0.4-0.8]) compared with women who had undergone abortion.

Conclusions

A low educational level is associated with the increased risk of premature death among women with a history of teenage pregnancy, except for suicide. Extra efforts should be made to encourage pregnant teenagers to continue education, and to provide psychosocial support to teenagers who undergo induced abortion.

Allostatic load and subsequent all-cause mortality: which biological markers drive the relationship? Findings from a UK birth cohort

The concept of allostatic load (AL) refers to the idea of a global physiological 'wear and tear' resulting from the adaptation to the environment through the stress response systems over the life span. The link between socioeconomic position (SEP) and mortality has now been established, and there is evidence that AL may capture the link between SEP and mortality. In order to quantitatively assess the role of AL on mortality, we use data from the 1958 British birth cohort including eleven year mortality in 8,113 adults. Specifically, we interrogate the hypothesis of a cumulative biological risk (allostatic load) reflecting 4 physiological systems potentially predicting future risk of death (N = 132). AL was defined using 14 biomarkers assayed in blood from a biosample collected at 44 years of age. Cox proportional hazard regression analysis revealed that higher allostatic load at 44 years old was a significant predictor of mortality 11 years later [HR = 3.56 (2.3 to 5.53)]. We found that this relationship was not solely related to early-life SEP, adverse childhood experiences and young adulthood health status, behaviours and SEP [HR = 2.57 (1.59 to 4.15)]. Regarding the ability of each physiological system and biomarkers to predict future death, our results suggest that the cumulative measure was advantageous compared to evaluating each physiological system sub-score and biomarker separately. Our findings add some evidence of a biological embodiment in response to stress which ultimately affects mortality.

Inequalities in smoking and obesity in Europe predicted to 2050: Findings from the EConDA project

AIMS

The aim of this study was to project educational inequalities in obesity and smoking prevalence to 2050 based on past obesity and smoking trends by education level.

METHODS

Data on obesity (body mass index ≥ 30) and smoking prevalence (current smokers) by education level (tertiary education and less than tertiary) from nationally representative cross-sectional surveys were collected for the following six countries participating in the Economics of Chronic Diseases project (EConDA): England, Finland, Lithuania, the Netherlands, Poland (obesity only) and Portugal (obesity only). A nonlinear multivariate regression model was fitted to the data to create longitudinal projections to 2050. Inequalities were measured with a prevalence ratio and a prevalence difference using projected obesity/smoking prevalence.

RESULTS

Educational inequalities in obesity prevalence are projected to increase in Finland, Lithuania and England for men, and in Lithuania and Poland for women, by 2050. Obesity prevalence is projected to increase faster among the more advantaged groups in England, Portugal, Finland and the Netherlands among women, and Portugal and the Netherlands among men, narrowing inequalities. In contrast to obesity, smoking prevalence is projected to continue declining in most of the countries studied. The decline is projected to be faster in relative terms among more advantaged groups; therefore, relative educational inequalities in smoking prevalence are projected to increase in all countries.

CONCLUSIONS

Widening educational inequalities in obesity and smoking prevalence are expected in several European countries if current trends in obesity and smoking prevalence are unaltered. This will impact on inequalities in morbidity and mortality of associated diseases such as diabetes, coronary heart disease and chronic obstructive pulmonary disease.

The relation between household income and surgical outcome in the Dutch setting of equal access to and provision of healthcare

Background

The impact of socioeconomic disparities on surgical outcome in the absence of healthcare inequality remains unclear. Therefore, we set out to determine the association between socioeconomic status (SES), reflected by household income, and overall survival after surgery in the Dutch setting of equal access and provision of care. Additionally, we aim to assess whether SES is associated with cause-specific survival and major 30-day complications.

Methods

Patients undergoing surgery between March 2005 and December 2006 in a general teaching hospital in the Netherlands were prospectively included. Adjusted logistic and cox regression analyses were used to assess the independent association of SES–quantified by gross household income–with major 30-day complications and long-term postoperative survival.

Results

A total of 3929 patients were included, with a median follow-up of 6.3 years. Low household income was associated with worse survival in continuous analysis (HR: 1.05 per 10.000 euro decrease in income, 95% CI: 1.01–1.10) and in income quartile analysis (HR: 1.58, 95% CI: 1.08–2.31, first [i.e. lowest] quartile relative to the fourth quartile). Similarly, low income patients were at higher risk of cardiovascular death (HR: 1.26 per 10.000 decrease in income, 95% CI: 1.07–1.48, first income quartile: HR: 3.10, 95% CI: 1.04–9.22). Household income was not independently associated with cancer-related mortality and major 30-day complications.

Conclusions

Low SES, quantified by gross household income, is associated with increased overall and cardiovascular mortality risks among surgical patients. Considering the equality of care provided by this study setting, the associated survival hazards can be attributed to patient and provider factors, rather than disparities in healthcare. Increased physician awareness of SES as a risk factor in preoperative decision-making and focus on improving established SES-related risk factors may improve surgical outcome of low SES patients.

Social adversity and epigenetic aging: a multi-cohort study on socioeconomic differences in peripheral blood DNA methylation

Low socioeconomic status (SES) is associated with earlier onset of age-related chronic conditions and reduced life-expectancy, but the underlying biomolecular mechanisms remain unclear. Evidence of DNA-methylation differences by SES suggests a possible association of SES with epigenetic age acceleration (AA). We investigated the association of SES with AA in more than 5,000 individuals belonging to three independent prospective cohorts from Italy, Australia, and Ireland. Low SES was associated with greater AA (β = 0.99 years; 95% CI 0.39,1.59; p = 0.002; comparing extreme categories). The results were consistent across different SES indicators. The associations were only partially modulated by the unhealthy lifestyle habits of individuals with lower SES. Individuals who experienced life-course SES improvement had intermediate AA compared to extreme SES categories, suggesting reversibility of the effect and supporting the relative importance of the early childhood social environment. Socioeconomic adversity is associated with accelerated epigenetic aging, implicating biomolecular mechanisms that may link SES to age-related diseases and longevity.