Socioeconomic differences in mortality in Britain and the United States

The Swiss neighbourhood index of socioeconomic position: update and re-validation

BACKGROUND

The widely used Swiss neighbourhood index of socioeconomic position (Swiss-SEP 1) was based on data from the 2000 national census on rent, household head education and occupation, and crowding. It may now be out of date.

METHODS

We created a new index (Swiss-SEP 2) based on the 2012-2015 yearly micro censuses that have replaced the decennial house-to-house census in Switzerland since 2010. We used principal component analysis on neighbourhood-aggregated variables and standardised the index. We also created a hybrid version (Swiss-SEP 3), with updated values for neighbourhoods centred on buildings constructed after the year 2000 and original values for the remaining neighbourhoods.

RESULTS

A total of 1.54 million neighbourhoods were included. With all three indices, the mean yearly equivalised household income increased from around 52,000 to 90,000 CHF from the lowest to the highest index decile. Analyses of mortality were based on 33.6 million person-years of follow-up. The age- and sex-adjusted hazard ratios of all-cause mortality comparing areas in the lowest Swiss-SEP decile with areas of the highest decile were 1.39 (95% confidence interval [CI] 1.36-1.41), 1.31 (1.29-1.33) and 1.34 (1.32-1.37) using the old, new and hybrid indices, respectively.

DISCUSSION

The Swiss-SEP indices capture area-based SEP at a high resolution and allow the study of SEP when individual-level SEP data are missing or area-level effects are of interest. The hybrid version (Swiss-SEP 3) maintains high spatial resolution while adding information on new neighbourhoods. The index will continue to be useful for Switzerland's epidemiological and public health research.

Active design of built environments for increasing levels of physical activity in adults: the ENABLE London natural experiment study

Background

Low physical activity is widespread and poses a serious public health challenge both globally and in the UK. The need to increase population levels of physical activity is recognised in current health policy recommendations. There is considerable interest in whether or not the built environment influences health behaviours, particularly physical activity levels, but longitudinal evidence is limited.

Objectives

The effect of moving into East Village (the former London 2012 Olympic and Paralympic Games Athletes’ Village, repurposed on active design principles) on the levels of physical activity and adiposity, as well as other health-related and well-being outcomes among adults, was examined.

Design

The Examining Neighbourhood Activities in Built Environments in London (ENABLE London) study was a longitudinal cohort study based on a natural experiment.

Setting

East Village, London, UK.

Participants

A cohort of 1278 adults (aged ≥ 16 years) and 219 children seeking to move into social, intermediate and market-rent East Village accommodation were recruited in 2013–15 and followed up after 2 years.

Intervention

The East Village neighbourhood, the former London 2012 Olympic and Paralympic Games Athletes’ Village, is a purpose-built, mixed-use residential development specifically designed to encourage healthy active living by improving walkability and access to public transport.

Main outcome measure

Change in objectively measured daily steps from baseline to follow-up.

Methods

Change in environmental exposures associated with physical activity was assessed using Geographic Information System-derived measures. Individual objective measures of physical activity using accelerometry, body mass index and bioelectrical impedance (per cent of fat mass) were obtained, as were perceptions of change in crime and quality of the built environment. We examined changes in levels of physical activity and adiposity using multilevel models adjusting for sex, age group, ethnic group, housing sector (fixed effects) and baseline household (random effect), comparing the change in those who moved to East Village (intervention group) with the change in those who did not move to East Village (control group). Effects of housing sector (i.e. social, intermediate/affordable, market-rent) as an effect modifier were also examined. Qualitative work was carried out to provide contextual information about the perceived effects of moving to East Village.

Results

A total of 877 adults (69%) were followed up after 2 years (mean 24 months, range 19–34 months, postponed from 1 year owing to the delayed opening of East Village), of whom 50% had moved to East Village; insufficient numbers of children moved to East Village to be considered further. In adults, moving to East Village was associated with only a small, non-significant, increase in mean daily steps (154 steps, 95% confidence interval –231 to 539 steps), more so in the intermediate sector (433 steps, 95% confidence interval –175 to 1042 steps) than in the social and market-rent sectors (although differences between housing sectors were not statistically significant), despite sizeable improvements in walkability, access to public transport and neighbourhood perceptions of crime and quality of the built environment. There were no appreciable effects on time spent in moderate to vigorous physical activity or sedentary time, body mass index or percentage fat mass, either overall or by housing sector. Qualitative findings indicated that, although participants enjoyed their new homes, certain design features might actually serve to reduce levels of activity.

Conclusions

Despite strong evidence of large positive changes in neighbourhood perceptions and walkability, there was only weak evidence that moving to East Village was associated with increased physical activity. There was no evidence of an effect on markers of adiposity. Hence, improving the physical activity environment on its own may not be sufficient to increase population physical activity or other health behaviours.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 12. See the NIHR Journals Library website for further project information. This research was also supported by project grants from the Medical Research Council National Prevention Research Initiative (MR/J000345/1).

Social Determinants of Health: What's a Healthcare System to Do?

EXECUTIVE SUMMARY

A growing literature regarding the health consequences of social risks, such as substandard housing and food insecurity, combined with increased adoption of risk-based payment models have contributed to a wave of healthcare sector initiatives focused on the social determinants of health. Yet decisions about how and when to address adverse social conditions are frequently guided by limited information about potential interventions and a lack of data on their effectiveness. We describe four complementary strategies that healthcare leaders can pursue to intervene on social adversity, split between patient care and community-level approaches. Patient care strategies rely on data about patients' social risks to adapt medical care or improve patients' social circumstances directly. Community-level strategies focus on improving the broader health and well-being of the local population through a mix of direct investments in communities and collaboration through multisector partnerships. Each approach presents unique incentives and challenges, and healthcare systems wanting to address social adversity may adopt one or more. Understanding the range of potential choices may help healthcare leaders make more informed choices in response to patient needs and changing payment and policy initiatives.

Housing, neighbourhood and sociodemographic associations with adult levels of physical activity and adiposity: baseline findings from the ENABLE London study

OBJECTIVES

The neighbourhood environment is increasingly shown to be an important correlate of health. We assessed associations between housing tenure, neighbourhood perceptions, sociodemographic factors and levels of physical activity (PA) and adiposity among adults seeking housing in East Village (formerly London 2012 Olympic/Paralympic Games Athletes' Village).

SETTING

Cross-sectional analysis of adults seeking social, intermediate and market-rent housing in East Village.

PARTICIPANTS

1278 participants took part in the study (58% female). Complete data on adiposity (body mass index (BMI) and fat mass %) were available for 1240 participants (97%); of these, a subset of 1107 participants (89%) met the inclusion criteria for analyses of accelerometer-based measurements of PA. We examined associations between housing sector sought, neighbourhood perceptions (covariates) and PA and adiposity (dependent variables) adjusted for household clustering, sex, age group, ethnic group and limiting long-standing illness.

RESULTS

Participants seeking social housing had the fewest daily steps (8304, 95% CI 7959 to 8648) and highest BMI (26.0 kg/m², 95% CI 25.5kg/m² to 26.5 kg/m²) compared with those seeking intermediate (daily steps 9417, 95% CI 9106 to 9731; BMI 24.8 kg/m², 95% CI 24.4 kg/m² to 25.2 kg/m²) or market-rent housing (daily steps 9313, 95% CI 8858 to 9768; BMI 24.6 kg/m², 95% CI 24.0 kg/m² to 25.2 kg/m²). Those seeking social housing had lower levels of PA (by 19%-42%) at weekends versus weekdays, compared with other housing groups. Positive perceptions of neighbourhood quality were associated with higher steps and lower BMI, with differences between social and intermediate groups reduced by ~10% following adjustment, equivalent to a reduction of 111 for steps and 0.5 kg/m² for BMI.

CONCLUSIONS

The social housing group undertook less PA than other housing sectors, with weekend PA offering the greatest scope for increasing PA and tackling adiposity in this group. Perceptions of neighbourhood quality were associated with PA and adiposity and reduced differences in steps and BMI between housing sectors. Interventions to encourage PA at weekends and improve neighbourhood quality, especially among the most disadvantaged, may provide scope to reduce inequalities in health behaviour.

Loneliness, socio-economic status and quality of life in old age: the moderating role of housing tenure

The study investigated housing tenure as a factor moderating the effects of loneliness and socio-economic status (SES) on quality of life (control and autonomy, pleasure, and self-realisation) over a two-year period for older adults. Data from the 2010 and 2012 waves of the New Zealand Health, Work, and Retirement Study were analysed. Using case-control matching, for each tenant (N = 332) we selected a home-owner (N = 332) of the same age, gender, ethnicity, SES, working status and urban/rural residence. Structural equation modelling was employed to examine the impact of SES, housing tenure and loneliness on quality of life over time. Emotional loneliness exerted a significant negative main effect on control and autonomy and pleasure. Tenure and SES influenced control and autonomy, but not pleasure or self-realisation. Tenure moderated the effect of emotional loneliness on control and autonomy, with the negative effect of emotional loneliness weaker for home-owners compared to renters. Tenure moderated the effect of SES on control and autonomy, with the positive impact of SES stronger for home-owners. Findings suggest that owners capitalise on their material and financial resources more than tenants in terms of their quality of life. In addition, home-ownership can act as a protective factor against the harmful effects of emotional loneliness in old age.

Comparisons of depression, anxiety, well-being, and perceptions of the built environment amongst adults seeking social, intermediate and market-rent accommodation in the former London Olympic Athletes' Village

The Examining Neighbourhood Activities in Built Living Environments in London (ENABLE London) study provides a unique opportunity to examine differences in mental health and well-being amongst adults seeking social, intermediate (affordable rent), and market-rent housing in a purpose built neighbourhood (East Village, the former London 2012 Olympic Athletes' Village), specifically designed to encourage positive health behaviours. Multi-level logistic regression models examined baseline differences in levels of depression, anxiety and well-being across the housing groups. Compared with the intermediate group, those seeking social housing were more likely to be depressed, anxious and had poorer well-being after adjustment for demographic and health status variables. Further adjustments for neighbourhood perceptions suggest that compared with the intermediate group, perceived neighbourhood characteristics may be an important determinant of depression amongst those seeking social housing, and lower levels of happiness the previous day amongst those seeking market-rent housing. These findings add to the extensive literature on inequalities in health, and provide a strong basis for future longitudinal work that will examine change in depression, anxiety and well-being after moving into East Village, where those seeking social housing potentially have the most to gain.

Discovering pockets of complexity: Socioeconomic status, stress exposure, and the nuances of the health gradient

One of the most pervasive statements about stratification and health identifies the strong inverse relationship-or gradient-between socioeconomic status (SES) and poor health. We elaborate on the ways that the SES-based gradient in stress exposure contributes to nuances in the SES-health association. In analyses of the 2008 National Study of the Changing Workforce, we find some evidence that the inverse association between SES and health outcomes is finely graded-but several 'pockets of complexity' emerge. First, education and income have different associations with health and well-being. Second, those associations depend on the outcome being assessed. Education is more influential for predicting anxiety and poor health than for depression or life dissatisfaction, while income is more influential for predicting depression and, to a lesser extent, life dissatisfaction. Third, different patterns of explanation or suppression reflect resource advantage or stress of higher status dynamics. Some impactful stressors that people encounter-especially job pressure and work-family conflict-are not neatly graded in ways that corroborate the conventional SES-health narrative. Instead, these mask the size of the overall health differences between lower versus higher SES groups. Our mapping of the SES gradient in stressors extends that story and complicates the conventional view of the association between SES and health/well-being.

Socio-economic Position, Gender and Health

There is a large research literature on socio-economic inequalities in health (and explanations for these inequalities); there is also a large literature on gender differences in health (and explanations for these differences). However, the two bodies of research are rarely integrated to ask, for example, whether socio-economic inequalities vary by gender, or whether gender differences vary by socio-economic position. The separation of these two research traditions may be to the detriment of theoretical development in both of them; and in particular, asymmetrical treatment of men and women in research in inequalities in health may hinder our ability to explain the mechanisms producing inequalities. This article reviews the intersection of socio-economic position and gender, and argues for more systematic and symmetrical examination of the interaction between socio-economic position and gender in the social patterning of health.

The supply of general practitioners across local areas: accounting for spatial heterogeneity

BACKGROUND

The geographic distribution of general practitioners (GPs) remains persistently unequal in many countries despite notable increases in overall supply. This paper explores how the factors associated with the supply of general practitioners (GPs) are aligned with the arbitrary geographic boundaries imposed by the use of spatially referenced GP supply data.

METHODS

Data on GP supply in postcodes within Australia are matched to data on the population characteristics and levels of amenities in postcodes. Tobit regression models are used that examine the associations between GP supply and postcode characteristics, whilst accounting for spatial heterogeneity.

RESULTS

The results demonstrate that GPs do not consider space in a one-dimensional sense. Location choice is related to both neighbourhood-specific factors, such as hospitals, and broader area factors, such as area income and proximity to private schools. Although the proportion of females and elderly were related to GPs supply, mortality rate was not.

CONCLUSIONS

This paper represents the first attempt to map the factors influencing GP supply to the appropriate geographic level at which GPs may be considering that factor. We suggest that both neighbourhood and broader regional characteristics can influence GPs' locational choices. This finding is highly relevant to the design and evaluation of relocation incentive programmes.

The role of material, psychosocial and behavioral factors in mediating the association between socioeconomic position and allostatic load (measured by cardiovascular, metabolic and inflammatory markers)

Lower socioeconomic position (SEP), both accumulated across the life course and at different life-stages, has been found to be associated with higher cumulative physiological burden, as measured by allostatic load. This study aimed to identify what factors mediate the association between SEP and allostatic load, as measured through combining cardiovascular, metabolic and inflammatory markers. We explored the role of material, psychological and behavioral factors, accumulated across two periods in time, in mediating the association between SEP and allostatic load. Data are from the West of Scotland Twenty-07 Study, with respondents followed over five waves of data collection from ages 35 to 55 (n=999). Allostatic load was measured by summing nine binary biomarker scores ('1'=in the highest-risk quartile) measured when respondents were 55years old (wave 5). SEP was measured by a person's accumulated social class over two periods All mediators and SEP were measured at baseline in 1987 and 20years later and combined to form accumulated measures of risk. Material mediators included car and home ownership, and having low income. The General Health Questionnaire (GHQ-12) was used as the psychosocial mediator. Behavioral mediators included smoking, alcohol consumption, physical activity and diet. Path analysis using linear regressions adjusting for sex were performed for each of the potential mediators to assess evidence of attenuation in the association between lower SEP and higher allostatic load. Analyses by mediator type revealed that renting one's home (approximately 78% attenuation) and having low income (approx. 62% attenuation) largely attenuated the SEP-allostatic load association. GHQ did not attenuate the association. Smoking had the strongest attenuating effect of all health behaviors (by 33%) with no other health behaviors attenuating the association substantially. Material factors, namely home tenure and income status, and smoking have important roles in explaining socioeconomic disparities in allostatic load, particularly when accumulated over time.

A novel socioeconomic measure using individual housing data in cardiovascular outcome research

BACKGROUND

To assess whether the individual housing-based socioeconomic status (SES) measure termed HOUSES was associated with post-myocardial infarction (MI) mortality.

METHODS

The study was designed as a population-based cohort study, which compared post-MI mortality among Olmsted County, Minnesota, USA, residents with different SES as measured by HOUSES using Cox proportional hazards models. Subjects' addresses at index date of MI were geocoded to real property data to formulate HOUSES (a z-score for housing value, square footage, and numbers of bedrooms and bathrooms). Educational levels were used as a comparison for the HOUSES index.

RESULTS

637 of the 696 eligible patients with MI (92%) were successfully geocoded to real property data. Post-MI survival rates were 60% (50-72), 78% (71-85), 72% (60-87), and 87% (81-93) at 2 years for patients in the first (the lowest SES), second, third, and fourth quartiles of HOUSES, respectively (p < 0.001). HOUSES was associated with post-MI all-cause mortality, controlling for all variables except age and comorbidity (p = 0.036) but was not significant after adjusting for age and comorbidity (p = 0.24).

CONCLUSIONS

Although HOUSES is associated with post-MI mortality, the differential mortality rates by HOUSES were primarily accounted for by age and comorbid conditions. HOUSES may be useful for health disparities research concerning cardiovascular outcomes, especially in overcoming the paucity of conventional SES measures in commonly used datasets.

Socioeconomic differentials in the immediate mortality effects of the national Irish smoking ban

BACKGROUND

Consistent evidence has demonstrated that smoking ban policies save lives, but impacts on health inequalities are uncertain as few studies have assessed post-ban effects by socioeconomic status (SES) and findings have been inconsistent. The aim of this study was to assess the effects of the national Irish smoking ban on ischemic heart disease (IHD), stroke, and chronic obstructive pulmonary disease (COPD) mortality by discrete and composite SES indicators to determine impacts on inequalities.

METHODS

Census data were used to assign frequencies of structural and material SES indicators to 34 local authorities across Ireland with a 2000-2010 study period. Discrete indicators were jointly analysed through principal component analysis to generate a composite index, with sensitivity analyses conducted by varying the included indicators. Poisson regression with interrupted time-series analysis was conducted to examine monthly age and gender-standardised mortality rates in the Irish population, ages ≥35 years, stratified by tertiles of SES indicators. All models were adjusted for time trend, season, influenza, and smoking prevalence.

RESULTS

Post-ban mortality reductions by structural SES indicators were concentrated in the most deprived tertile for all causes of death, while reductions by material SES indicators were more equitable across SES tertiles. The composite indices mirrored the results of the discrete indicators, demonstrating that post-ban mortality decreases were either greater or similar in the most deprived when compared to the least deprived for all causes of death.

CONCLUSIONS

Overall findings indicated that the national Irish smoking ban reduced inequalities in smoking-related mortality. Due to the higher rates of smoking-related mortality in the most deprived group, even equitable reductions across SES tertiles resulted in decreases in inequalities. The choice of SES indicator was influential in the measurement of effects, underscoring that a differentiated analytical approach aided in understanding the complexities in which structural and material factors influence mortality.

Development and initial testing of a new socioeconomic status measure based on housing data

Socioeconomic status (SES) has been associated with many health outcomes. Commonly used datasets such as medical records often lack data on SES but do include address information. The authors sought to determine whether an SES measure derived from housing characteristics is associated with other SES measures and outcomes known to be associated with SES. The data come from a telephone survey of parents/guardians of children aged 1-17 years who resided in Olmsted County, Minnesota, and Jackson County, Missouri. Seven variables related to housing and six neighborhood characteristics obtained from local government assessor's offices in Olmsted County, Minnesota, were appended to survey responses. An SES index derived from housing characteristics (hereafter, HOUSES) was constructed using principal components factor analysis. For criterion validity, we assessed Pearson's correlation coefficients between HOUSES and other SES measures, including self-reported parents' educational levels, income, Hollingshead Index, and Nakao-Treas Index. For construct validity, we determined the association between HOUSES and outcomes, risks of low birth weight, overweight, and smoking exposure at home. We applied HOUSES to subjects in another community by formulating HOUSES from housing data of subjects in Jackson County, Missouri, using the same statistical algorithm as HOUSES for subjects in Olmsted County, Minnesota. We found that HOUSES had modest to good correlation with other SES measures. Overall, as hypothesized, HOUSES was inversely associated with outcome measures assessed among subjects from both counties. HOUSES may be a useful surrogate measure of individual SES in epidemiologic research, especially when SES measures for individuals are not available.

Effect of socioeconomic status and parents' education at birth on risk of schizophrenia in offspring

Although it is known that schizophrenia is associated with social class, controversy exists as to the nature of this association. The authors studied the incidence of schizophrenia in relation to social class at birth in a population-based cohort of 88,829 offspring born in Jerusalem in 1964-1976. They constructed a six-point scale to index social class, based on paternal occupation at the time of birth, with each of 108 occupations being ranked by mean education. Cox proportional hazards methods were used in adjusting for sex, parents' ages, duration of marriage and birth order. Linkage with Israel's Psychiatric Registry identified 637 people admitted to psychiatric care facilities with schizophrenia-related diagnoses, before 1998. There was no gradient of risk for schizophrenia associated with social class at birth; however, offspring of fathers in the lowest social class showed a modest increase in risk (adjusted Relative Risk = 1.4; 95% Confidence interval = 1.1-1.8, P = 0.002). These data suggest that in contrast to many other health outcomes, there is not a continuous gradient for increasing schizophrenia with decreasing social class of origin. Instead, a modest increase in risk for schizophrenia was observed only for those born at the bottom of the social ladder.

Early childbearing, marital status, and women's health and mortality after age 50

This article examines the relationship between a woman's childbearing history and her later health and mortality, with primary focus on whether the association between them is due to early and later socioeconomic status. Data are drawn from the Health and Retirement Study birth cohort of 1931-1941. Results indicate that, conditional on reaching midlife and controlling for early and later socioeconomic status, a first birth before age 20 is associated with a higher hazard of dying. In addition, having an early birth is associated with a higher prevalence of reported heart disease, lung disease, and cancer in 1994. Being unmarried at the time of the first birth is associated with earlier mortality, but this association disappears when midlife socioeconomic status is controlled. The number of children ever born does not significantly affect mortality but is associated with prevalence of diabetes.

Inequalities in mortality by education and socio-economic transition in Lithuania: equal opportunities?

AIM

The aim of this study was to examine the changes in mortality differentials by level of education during the period of socio-economic transition in Lithuania.

METHODS

This analysis was based on routine mortality statistics and census data for 1989 and 2001 for the entire country.

RESULTS

Despite a general improvement in the level of education in the Lithuanian population, some negative educational patterns were observed amongst its young members. Increasing inequalities in mortality by education have occurred due to a declining mortality rate in people with higher educational achievements and, conversely, an increasing mortality rate in people with a low level of education. Mortality inequalities by education amongst females exceeded those amongst males in 2001, particularly in middle-aged groups and due to external causes. The results of this survey predict an unfavourable forecast of increasing health inequalities in Lithuania in the near future.

CONCLUSIONS

General policies for health promotion and disease prevention should be based on the realities faced by lower educated groups, rather than on experiences that are general for the total population or the class of society that has at least achieved an average education. Inequalities in health by the level of education should plateau as the society-at-large enters into a more stable stage of social and economic development.

Socioeconomic gradients in cardiorespiratory disease and diabetes in the 1960s: baseline findings from the GPO study

OBJECTIVES

To describe the socioeconomic distribution of risk factors for cardiorespiratory disease and diabetes in employed women and men in the late 1960s.

STUDY DESIGN AND METHODS

Cross-sectional data were collected from 3345 General Post Office (GPO) employees in London, via a questionnaire and clinical examination, between October 1966 and April 1967.

RESULTS

Our occupational grade classification conformed to expected patterns of greater car ownership and gardening among higher-grade women and men, and greater height in higher-grade men (highest-lowest grade 175.0-170.7 cm, P<0.001). A strong inverse grade gradient in bronchitis (2.1-9.4%, P<0.001) and a strong positive gradient in FEV1 (3.10-2.58l, P<0.001) were observed in men, although smoking was less consistently associated with grade. There was no consistent inverse association between grade and any cardiovascular risk factor in either sex, but strong inverse gradients in prevalence of impaired glucose tolerance (IGT) (5.1-18.2%, P<0.001) and 2-h glucose (4.14-4.25 mmol/l, P<0.001) in non-diabetic men. Using car ownership as an alternative measure of socioeconomic position, findings in men were replicated for respiratory measures, IGT and 2-h glucose prevalence. Inverse gradients were additionally observed for blood pressure, cholesterol and electrocardiogram abnormalities.

CONCLUSIONS

The GPO study confirms existing evidence of socioeconomic gradients in respiratory risk factors and provides new evidence of gradients in risk factors for diabetes in men. Although there was no conclusive evidence of an occupational gradient in any cardiovascular risk factor, car ownership was a good indicator of lower risk in men. No socioeconomic gradients in cardiorespiratory or diabetic risk factors were observed in women.

Inequalities in health: a comparative study between ethnic Norwegians and Pakistanis in Oslo, Norway

BACKGROUND

The objective of the study was to observe the inequality in health from the perspective of socio-economic factors in relation to ethnic Pakistanis and ethnic Norwegians in Oslo, Norway.

METHOD

Data was collected by using an open and structured questionnaire, as a part of the Oslo Health Study 2000-2001. Accordingly 13581 ethnic Norwegians (45% of the eligible) participated as against 339 ethnic Pakistanis (38% of the eligible).

RESULTS

The ethnic Pakistanis reported a higher prevalence of poor self-rated health 54.7% as opposed to 22.1% (p < 0.001) in ethnic Norwegians, 14% vs. 2.6% (p < 0.001) in diabetes, and 22.0% vs. 9.9% (p < 0.001) in psychological distress. The socio-economic conditions were inversely related to self-rated health, diabetes and distress for the ethnic Norwegians. However, this was surprisingly not the case for the ethnic Pakistanis. Odd ratios did not interfere with the occurrence of diabetes, even after adjusting all the markers of socio-economic status in the multivariate model, while self-reported health and distress showed moderate reduction in the risk estimation.

CONCLUSION

There is a large diversity of self-rated health, prevalence of diabetes and distress among the ethnic Pakistanis and Norwegians. Socio-economic status may partly explain the observed inequalities in health. Uncontrolled variables like genetics, lifestyle factors and psychosocial factors related to migration such as social support, community participation, discrimination, and integration may have contributed to the observed phenomenon. This may underline the importance of a multidisciplinary approach in future studies.

Are rich people or poor people more likely to be ill? Lay perceptions, by social class and neighbourhood, of inequalities in health

Research in the UK has suggested that people in lower social classes or from poorer neighbourhoods are less likely than their more socially advantaged counterparts to agree that health and life expectancy are worse among more deprived population groups. The small body of previous research has either used qualitative approaches or coded open-ended responses to survey questions about causes of health and illness or of inequalities between areas. We examined lay perceptions by asking a direct question and using a quantitative, multivariate approach. Residents in three age groups (25, 45 and 65 years old) living in two socially contrasting localities in Glasgow, Scotland, were asked who were more likely to have accidents, cancer, heart disease, mental illness, to be fitter, and to live longer: rich people, poor people, or both equally. Across all the health categories, those in lower social classes or from poorer neighbourhoods were equally or less likely than their more socially advantaged counterparts to say the poor had worse health. In a model containing age, sex, class and locality, those in lower social classes and in the poorer locality were significantly less likely to say that richer people live longer (OR: 0.5). We have therefore confirmed earlier observations that those most at risk of ill health may be less likely to acknowledge the social gradient in health. We suggest a need to examine this apparent paradox in other contexts and in more detail, using both quantitative and qualitative approaches.

Cumulative deprivation and cause specific mortality. A census based study of life course influences over three decades

OBJECTIVE

To examine whether increasing cumulative deprivation has an incremental effect on total as well as cause specific mortality.

DESIGN

Census data on housing conditions as indicators of deprivation from 1960, 1970, and 1980 were linked to 1990-98 death registrations. Relative indices of inequalities were computed for housing conditions to measure the cumulative impact of differences in social conditions.

PARTICIPANTS

97 381 (71.1%) 30-49 year old and 70701 (80.0%) 50-69 year old inhabitants of Oslo, Norway, in 1990 with census information on housing conditions and recorded length of education.

MAIN RESULTS

Mortality risk was increased when all censuses' housing conditions were summed in both age groups and sex. The cause specific analysis indicated such an effect particularly for coronary heart disease, chronic obstructive lung disease, and smoking related cancers. Violent deaths were essentially associated with housing conditions closer to the time of death in men in both age groups and in young women.

CONCLUSIONS

To fully account for socially mediated risk of death, a full life course approach should be adopted. The relative importance of each stage seems to vary by cause of death.

Socio-economic mortality differentials in Sydney over a quarter of a century, 1970-94

OBJECTIVE

To examine trends in socio-economic differentials in all-cause mortality in Sydney over a 25-year period (1970-94).

METHODS

Five measures of single indicators (two for occupation, two for education and one for income) and a composite measure of socio-economic disadvantage based on Census data (the Australian Bureau of Statistics' Index of Relative Socio-Economic Disadvantage) were used as indicators of socio-economic status by local govemment area. The relationship between mortality and socio-economic status was examined using quintiles based on these six measures of socio-economic status.

RESULTS

Socio-economic differentials in mortality were evident for males and females for all periods, and over the 25-year period the relative socio-economic differentials did not decline. For males, the socio-economic status differential in mortality widened, irrespective of socio-economic status indicator used, whereas for females it widened only when certain socio-economic indicators were used: occupation (unemployment measure) and income, but was not significant for the other single indicators or for the composite indicator.

CONCLUSIONS

Sydney trends of widening inequalities are generally similar to those reported for Britain and for other industrialised countries, suggesting that this is a common phenomenon and that policies to reduce health inequalities over the past quarter of a century have not been effective.

Social inequalities in health within countries: not only an issue for affluent nations

While interest in social disparities in health within affluent nations has been growing, discussion of equity in health with regard to low- and middle-income countries has generally focused on north-south and between-country differences, rather than on gaps between social groups within the countries where most of the world's population lives. This paper aims to articulate a rationale for focusing on within- as well as between-country health disparities in nations of all per capita income levels, and to suggest relevant reference material, particularly for developing country researchers. Routine health information can obscure large inter-group disparities within a country. While appropriately disaggregated routine information is lacking, evidence from special studies reveals significant and in many cases widening disparities in health among more and less privileged social groups within low- and middle- as well as high-income countries: avoidable disparities are observed not only across socioeconomic groups but also by gender, ethnicity, and other markers of underlying social disadvantage. Globally, economic inequalities are widening and, where relevant information is available, generally accompanied by widening or stagnant health inequalities. Related global economic trends, including pressures to cut social spending and compete in global markets, are making it especially difficult for lower-income countries to implement and sustain equitable policies. For all of these reasons, explicit concerns about equity in health and its determinants need to be placed higher on the policy and research agendas of both international and national organizations in low-, middle-, and high-income countries. International agencies can strengthen or undermine national efforts to achieve greater equity. The Primary Health Care strategy is at least as relevant today as it was two decades ago: but equity needs to move from being largely implicit to becoming an explicit component of the strategy, and progress toward greater equity must be carefully monitored in countries of all per capita income levels. Particularly in the context of an increasingly globalized world, improvements in health for privileged groups should suggest what could, with political will, be possible for all.

Factors affecting health status in African Americans living with HIV/AIDS

This study surveyed face-to-face 111 African American newly diagnosed and living with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) from the Washington D.C. area, to ascertain the use of, and need for, early intervention services. The survey instrument included sections on demographics, level of health functioning and health indicators, social and financial support, and needed services. This article constructs a health status proxy variable from survey items and examines its relationship to biological and social variables. Variables found to have a significant relationship with health status are gender, type of health insurance, employment, receiving Social Security Disability Income, and level of education. A log-linear model for selection of parsimony found that the type of health insurance was most highly predictive of health status, when controlling for other variables. Persons who receive Medicaid report no better levels of health status than those without health insurance. Having private health insurance is associated with a 5.3-fold greater chance of having good or excellent health status.

Pathways of disadvantage? Walking as a mode of transport among low-income mothers

Research shows that lack of car ownership is associated with poorer health. It is often assumed that the reason for this observed relationship is that access to a car--or not--reflects access to household assets. Consequently, lack of car ownership is used as a standard marker of low socio-economic status. However, little attention has been paid to the experience of carlessness in the context of disadvantaged lives. This paper argues that "no access to a car" is not only an indicator of low socio-economic status but of walking as a mode of transport. These arguments are illustrated by data from a study of 30 low-income mothers with young children. Although walking is promoted as both an excellent and inexpensive form of exercise, these data suggest that reliance on walking can have negative effects on the welfare of families. The paper draws on qualitative data to describe the ways in which carlessness restricts access to health and social care resources such as food shops, health-care services and social networks. It also explores the impact of walking on the well being of mothers and their day-to-day relationships with children. This is compounded by walking through areas that are neglected and depressed. The paper concludes that strategies to reduce social exclusion must recognise the contradictory health effects of walking and aim to regenerate the physical fabric of social housing estates as well as improve public transport options.

Inequalities in life expectancy in Lithuania by level of education

The purpose of this study was to examine educational inequalities in life expectancy of the Lithuanian population. The life-tables by level of education were calculated on the basis of the individual records of the 1989 census, which were linked to the death records of males and females, aged 25-70 years. In comparison with the group with university education, the life expectancy of males with primary or lower education was 11.7 years shorter, and of females 4.3 years shorter. The greatest impact of educational differentials on life expectancy was the inequality found in the mortality of the population, aged 25-44 years. Sex differences in life expectancy were greatest among those with primary or lower education. External causes of death contributed most to educational differences in life expectancy of males, whereas cardiovascular diseases had a major impact to educational differences in females.

Inequality in health: socioeconomic differentials in mortality in Rome, 1990-95

STUDY OBJECTIVE

Population groups with a lower socioeconomic status (SES) have a greater risk of disease and mortality. The aim of this study was to investigate the relation between SES and mortality in the metropolitan area of Rome during the six year period 1990-1995, and to examine variations in mortality differentials between 1990-92 and 1993-95.

DESIGN

Rome has a population of approximately 2,800,000, with 6100 census tracts (CTs). During the study period, 149,002 deaths occurred among residents. The cause-specific mortality rates were compared among four socioeconomic categories defined by a socioeconomic index, derived from characteristics of the CT of residence.

MAIN RESULTS

Among men, total mortality and mortality for the major causes of death showed an inverse association with SES. Among 15-44 year old men, the strong positive association between total mortality and low SES was attributable to AIDS and overdose mortality. Among women, a positive association with lower SES was observed for stomach cancer, uterus cancer and cardiovascular disease, whereas mortality for lung and breast cancers was higher in the groups with higher SES. Comparing the periods 1990-92 and 1993-95, differences in total mortality between socioeconomic groups widened in both sexes. Increasing differences were observed for tuberculosis and lung cancer among men, and for uterus cancer, traffic accidents, and overdose mortality among women.

CONCLUSIONS

The use of an area-based indicator of SES limits the interpretations of the findings. However, despite the possible limitations, these results suggest that social class differences in mortality in Rome are increasing. Time changes in lifestyle and in the prevalence of risk behaviours may produce differences in disease incidence. Moreover, inequalities in the access to medical care and in the quality of care may contribute to an increasing differentials in mortality.

Do housing tenure and car access predict health because they are simply markers of income or self esteem? A Scottish study

OBJECTIVE

To investigate relations between health (using a range of measures) and housing tenure or car access; and to test the hypothesis that observed relations between these asset based measures and health are simply because they are markers for income or self esteem.

DESIGN

Analysis of data from second wave of data collection of West of Scotland Twenty-07 study, collected in 1991 by face to face interviews conducted by nurse interviewers.

SETTING

The Central Clydeside Conurbation, in the West of Scotland.

SUBJECTS

785 people (354 men, 431 women) in their late 30s, and 718 people (358 men, 359 women) in their late 50s, participants in a longitudinal study.

MEASURES

General Health Questionnaire scores, respiratory function, waist/hip ratio, number of longstanding illnesses, number of symptoms in the last month, and systolic blood pressure; household income adjusted for household size and composition; Rosenberg self esteem score; housing tenure and care access.

RESULTS

On bivariate analysis, all the health measures were significantly associated with housing tenure, and all except waist/hip ratio with car access; all except waist/hip ratio were related to income, and all except systolic blood pressure were related to self esteem. In models controlling for age, sex, and their interaction, neither waist/hip ratio nor systolic blood pressure remained significantly associated with tenure or care access. Significant relations with all the remaining health measures persisted after further controlling for income or self esteem.

CONCLUSIONS

Housing tenure and car access may not only be related to health because they are markers for income or psychological traits; they may also have some directly health promoting or damaging effects. More research is needed to establish mechanisms by which they may influence health, and to determine the policy implications of their association with health.

The relationship among income, other socioeconomic indicators, and functional level in older persons

Socioeconomic status (SES) is well established as a cause of morbidity and mortality, but relatively few studies have investigated the relationship between SES and functional level. Functional level is closely related to the use of long-term care services and is a more salient indicator of quality of life than specific diseases. We used data from 1,570 respondents in the Growing Older in New York City Study, a probability sample of people age 65 and older, to examine this relationship. The association between income and function was seen throughout the full gradient of income and remained significant when controlling for age, gender, race/ethnicity, household size, education, occupation, age of immigration, and locus of control. Education and residential environment, but not occupation, were independently associated with functional level. These findings support both the association between SES and functional limitation and the hypothesis that the SES and health association continues into old age.

Social differences in health: life-cycle effects between ages 23 and 33 in the 1958 British birth cohort

OBJECTIVES

The purpose of this study was to determine whether social differences in health persist or widen during early adulthood.

METHODS

A longitudinal follow-up of the 1958 British birth cohort was investigated, using social class at birth and six health measures at ages 23 and 33. A slope of inequality was estimated to represent social differences in health.

RESULTS

Social gradients in health were evident by age 23: the prevalence of poor health increased with decreasing social position. This was observed for several but not all health indicators. Social gradients persisted to age 33. The slope of inequality was greatest for malaise (odds ratio [OR] = 3.37 for men, 3.21 for women) and obesity (OR = 4.80 for men and 2.84 for women), both at age 23, and for self-rated health in women at age 23 (OR = 2.94) and age 33 (OR = 3.22). Inequality increased significantly between ages 23 and 33 for limiting illness in men, and lessened, although not significantly, for malaise, overweight, and obesity; social gradients remained constant for self-rated health, respiratory symptoms, and asthma or wheezing.

CONCLUSIONS

Social gradients in health evident in this sample by age 23 persisted to age 33. Inequalities did not appear to widen consistently, but variable findings for several health measures suggest that inequalities reproduce through different pathways.

The Black Report and beyond: what are the issues?

This paper provides an overview of the Black Report, published in Britain in 1980. It outlines its place in the history of British concern about socio-economic differentials in death rates since the mid-19th century, and suggests continuities in suggested explanations for these, a particularly persistent thread being debates between environmentalists, hereditarians, and those emphasising personal ignorance or irresponsibility. It introduces a distinction between "hard" "soft" versions of the Black Report's four explanatory models for inequalities in health (artefact, selection, behavioural and materialist), points out that the working group rejected the "hard" rather than the "soft" versions of the first three and espoused the "soft" version of the last, and suggests that the rather polarised debate about these explanations that followed can be understood in the light of the contemporary political context and a tendency to confuse the "hard" and "soft" versions. Methodological and empirical developments since the report are summarised, attention being drawn to seven themes which raise important issues for future research: the ubiquity of socio-economic differentials across industrialised countries, continuing or increasing differentials, stepwise gradients, interest in psychosocial mechanisms, the hypothesis of biological programming in utero or infancy, controls for behaviour, and evaluations of interventions. The overall conclusion is that we need more detailed studies of the mechanisms which generate and maintain social inequalities in health, and of interventions to reduce such inequalities.

The regionalization of perinatal care in Wales and Washington State

OBJECTIVES

The purpose of this study was to compare perinatal regionalization and neonatal mortality in Wales and Washington State.

METHODS

The 28 hospitals in Wales and the 80 hospitals in Washington State that offered maternity services and the 218,326 births that occurred in these hospitals in 1989 and 1990 were studied. Surveys were used to identify the neonatal technology and the referral policies of each hospital, and linked data from birth and death certificates were used to examine birthweight-specific neonatal mortality rates for all babies born in these hospitals.

RESULTS

Welsh district general hospitals (broadly equivalent to Level II perinatal centers in the United States) have more sophisticated neonatal technology than their Washington State counterparts and appear less likely to refer small or preterm babies to regional or subregional centers. Neonatal mortality rates were quite similar in the two settings.

CONCLUSIONS

Perinatal care in Wales appears to be less regionalized than in a similar region in the United States. The relative lack of perinatal regionalization in Wales may contribute to duplication and underutilization of expensive neonatal technologies. National health care systems do not, in and of themselves, lead to optimal regionalization of services.

Tracking community sentinel events: breast cancer mortality and neighborhood risk for advanced-stage tumors in Denver

OBJECTIVES

The incidence of related sentinel events--breast cancer mortality and neighborhood-specific morbidity for advanced stage at diagnosis--were calculated for women likely to use a community health center in Denver, Colo.

METHODS

For the center's service area, neighborhoods (n = 37) were defined by program use. Mortality rates and proportional hazards regression models were estimated for 4189 breast cancer cases recorded between 1979 and 1990. Neighborhood-specific standard morbidity ratios of advanced-stage tumors were based on age-specific rates applied to the entire community.

RESULTS

Service area residents were more likely to present with advanced tumors (odds ratio [OR] = 1.4; 95% [CI] = 1.2, 1.5). After adjustment, advanced-stage disease and socioeconomic-demographic status, but not race-ethnicity, contributed significantly to survival. Two neighborhoods (6.5% of the population at risk) with standard morbidity ratios of 2.1 (95% CI = 1.3, 3.4) and 1.7 (95% CI = 1.2, 2.5) accounted for 42% of the excess cases of advanced-stage tumors between 1986 and 1990.

CONCLUSIONS

Neighborhood variation in advanced-stage cancer can serve as the basis for efforts to improve access to breast cancer screening.

Socioeconomic differentials in mortality risk among men screened for the Multiple Risk Factor Intervention Trial: II. Black men

OBJECTIVES

This study examined socioeconomic differentials in risk of death from a number of causes in a large cohort of Black men in the United States.

METHODS

For 20 224 Black men screened for the Multiple Risk Factor Intervention Trial between 1973 and 1975, data were collected on median family income of Black households in zip code of residence, age, cigarette smoking, blood pressure, serum cholesterol, previous heart attack, and drug treatment for diabetes. The 2937 deaths that occurred over the 16-year follow-up period were grouped into specific causes and related to median Black family income.

RESULTS

There was an inverse association between age-adjusted all-cause mortality and median family income. There was no attenuation of this association over the follow-up period, and the association was similar for the 22 clinical centers carrying out the screening. The gradient was seen for most of the specific causes of death, although the strength of the association varied. Median income was markedly lower for the Black men screened than for the White men, but the relationship between income and all-cause mortality was similar.

CONCLUSIONS

Socioeconomic position is an important determinant of mortality risk for Black men. Even though Blacks lived in areas with substantially lower median family income than Whites, the association of income with mortality was similar for Blacks and Whites.

Is general practitioner decision making associated with patient socio-economic status?

This paper presents a preliminary exploration into the relationship between decisions made by general practitioners (GPs) and the socio-economic status (SES) of patients. There is a large literature on the association between SES, health state and the use of health services, but relatively little has been published on the association between SES and decisions by clinicians once a patient is in the health system. The associations between GP decision making and the patient's SES, health status, gender and insurance status are examined using logit analysis. Three sets of binary choices are analysed: the decision to follow up; to prescribe; and to perform or to order a diagnostic test. Secondary data on consultations for a check up/examination were used to explore these relationships. The results suggest that SES is associated independently with the decision to test and the decision to prescribe but not with the decision to follow up. Patients of high SES are, ceteris paribus, more likely to be tested and less likely to receive a prescription compared with patients of low SES. Women are more likely to be tested and to receive a prescription than men. These findings have implications for the pursuit of equity as a goal of health services policy.

Socioeconomic indices and suicide rate in Queensland

Suicides identified from a suicide register were classified according to socioeconomic indices of statistical local areas. Suicide rates were correlated with socioeconomic disadvantage, as measured by the proportion of persons of low income, low education and high unemployment living in an area. Suicide rates were inversely related to the proportion of families on high income, who owned their homes and who had large houses. Suicide rates of older people (55 years and over) were least influenced by these factors. For females, only the most disadvantaged areas had higher suicide rates. In other age and sex groupings, relationships were mostly linear.

Assessing equity in access to health care provision in the UK: does where you live affect your chances of getting a coronary artery bypass graft?

STUDY OBJECTIVES

Equity should be monitored routinely for all health care services, but ideal studies for each service would be prohibitively expensive and time consuming. A simple, quick, and cheap method for the preliminary exploration of equity in health care provision using routine data was devised. This method was illustrated by examining whether coronary artery bypass graft (CABG) operations reflect socioeconomic differences in ischaemic heart disease (IHD) mortality.

DESIGN

Ecological comparison of operation rates was undertaken for CABG for 1991 and IHD mortality for 1981-85 by quartiles of Townsend deprivation score.

SETTING

North East Thames Regional Health Authority, London, UK.

SUBJECTS

All residents of this region aged 35-74 were the denominator population. Numerators were 26,834 IHD deaths and 1041 CABG operations for the defined time periods.

MAIN RESULTS

IHD mortality showed a steady, significant increase with increasing area deprivation scores for both men and women. CABG rate ratios increased linearly for women, while for men there was a U shaped pattern, being lowest for the second and third quartiles. This pattern was attenuated, but not abolished, when adjusted for geographical proximity to cardiothoracic surgical units. The ratio of CABG operations to IHD mortality by deprivation was relatively constant in women suggesting equitable provision. In men, this ratio was significantly lower for the third quartile.

CONCLUSIONS

Inequities may exist in the provision of CABG operations for men in this region and this finding should be the stimulus for further detailed studies. Other health care systems should also examine equity in provision.

Income, race, and mortality

This study was undertaken to clarify the complex relationship between poverty and race with disease-specific mortality. Data from the 1987 National Health Interview Survey and the 1986 National Mortality Followback Survey were used to estimate standardized mortality ratios (SMRs) for various categories (all causes, all cancers, noncancerous medical causes, lung and breast cancers, ischemic heart disease, and cerebrovascular disease) associated with income below the poverty line and were compared with those with adequate or better than adequate income. All SMRs were substantially elevated. The SMRs were not appreciably affected by adjustments for confounding by alcohol consumption, occupation, or smoking. Sex-specific SMRs of blacks relative to whites with the exception of ischemic heart disease were significantly elevated for males but not for females with the exception of the SMR for all causes. However, when adjusted for per capita income within the family, black mortality never significantly exceeded that of whites. These results strongly support the conclusion that mortality differences between blacks and whites are due to differences in income and related factors. However, it is unclear why poverty should be associated with elevation in cancer relative risk.

Race and survival time with AIDS: a synthesis of the literature

OBJECTIVE

This study summarizes the evidence concerning the association of Black and White race with acquired immunodeficiency syndrome (AIDS) survival time.

METHODS

English-language articles measuring survival time with AIDS for Black and White persons were reviewed. Each article was assigned to one of three groups based on the method of subject accrual.

RESULTS

Of the nine eligible studies identified, five studies had inclusive methods of accruing study subjects, and four of these five showed decreased survival time among Black persons. In the studies with more restrictive accrual methods, survival time for Blacks was not decreased.

CONCLUSIONS

Although the published studies vary in their results, this variation appears to be systematic according to the method of accruing study subjects. If the accrual method serves to minimize socioeconomic differences between Blacks and Whites, there is no difference in survival time by race. However, if a more inclusive method is used, a significant decrease in AIDS survival time is observed among Blacks. This analysis suggests that, in some studies, race may function as a marker for socioeconomic factors and/or access to health care and that AIDS patients in the lowest socioeconomic or access group have significantly shorter survival times.

Health status by social class and/or minority status: implications for environmental equity research

Much of the epidemiologic research in the United States has been based only on the categories of age, sex and race; thus, race has often been used in health statistics as a surrogate for social and economic disadvantage. Few multivariate analyses distinguish effects of components of social class (such as economic level) from the relative, joint, and independent effects of sociocultural identifiers such as race or ethnicity. This paper reviews studies of social class and minority status differentials in health, with a particular emphasis on health status outcomes which are known or suspected to be related to environmental quality and conditions which increase susceptibility to environmental pollutants. Sociodemographic data are presented for the U.S. population, including blacks, Asian American/Pacific Islanders, American Indian/Alaska Natives, and Hispanics. Four areas of health status data are addressed: mortality, health of women of reproductive age, infant and child health, and adult morbidity. Conceptual and methodological issues surrounding various measures of position in the system of social strata are discussed, including the multidimensionality of social class, in the context of the importance of these issues to public health research. Whenever possible, multivariate studies that consider the role of socioeconomic status in explaining racial/ethnic disparities are discussed.