COVID-19 and the ecological crisis: What do they have in common?

This lecture transcript is divided in four parts. First, I examine the main public-health strategies in managing the COVID-19 pandemic. Although there are numerous factors capable of explaining national differences in COVID-19 mortality that are not attributable to merits or demerits of governments, I have identified five lethal errors (lack of preparation, misinformation, medicalisation, a policy approach based on a ‘laissez-faire’ attitude to the virus and social inequity) and four vital actions (testing, tracing, isolating with support, timeliness and immunisation) that best distinguish success or failure in tackling the pandemic. In the second part, I analyse the origin of SARS-CoV-2 and major risk factors for emerging zoonotic diseases (e.g. exploitation of animal wildlife, deforestation, agricultural intensification and climate change) to be addressed to prevent future pandemics. Then, I discuss the interrelationships between the COVID-19 pandemic and the ecological crisis in the context of the so-called neoliberal variant of capitalism. Both crises are largely determined by anthropogenic risk factors influenced by a model of economic development that prioritises infinite economic growth, free trade and a global self-regulating market over any other values of society (including human survival). An alternative economic approach, capable of creating a new balance between the health of humans, animals, and the environment (by modifying their structural drivers), is the most important antidote against new spillovers and climate change. It is the humanitarian immune response we need to protect global health from future pandemics and ecological collapse.

[Effects of the COVID-19 pandemic on health inequalities and mental health: effective public policies]

The aim of this article is to examine the effects of the COVID-19 pandemic on health inequalities and mental disorders and to analyse the most effective public policies in containing them. COVID-19, in addition to causing the worst health crisis since World War II, has generated a severe economic recession and a rise in unemployment. The poorer socioeconomic classes have been most affected by infections and deaths caused by the SARS-CoV-2 virus due to inequalities in working, housing and area of ​​residence conditions, psychosocial factors, and unequal access to health care. The pandemic crisis, in addition to causing psychiatric and neurological problems in people who have been hospitalized, appears to have increased the risk of psychological problems through various mechanisms such as social distancing, loss of a loved one, unemployment, and economic difficulties. In many countries, however, there was no significant increase in suicides in 2020 and there have even been decreasing temporal trends. It is possible that the crisis, in addition to creating stress and social isolation, may have promoted reciprocity, interpersonal help, and greater motivation to take care of one's health.The most effective policies in reducing COVID-19 mortality have the potential to limit the most adverse effects of the pandemic on health inequalities and mental health. Thanks to vigorous preventive interventions on the territory, based on testing, tracing, isolating, timely, countries who managed best the pandemic avoided prolonged and repeated lockdowns, protected public health and the economy. However, more vigorous social protection measures are needed in favour of those populations most affected by the health crisis and its socioeconomic effects. This pandemic offers the opportunity to learn lessons on the protection of public health and stress the need to adopt a syndemic model oriented towards prevention.

L'associazione tra fumo di tabacco e crisi economiche in Italia

OBJECTIVES

to analyse the association between smoking behaviour and economic crises in Italy between 1993 and 2015.

DESIGN

ecological study, carried out on data of the Italian National Institute of Statistics, by means of fixed-effect panel regressions.

SETTING AND PARTICIPANTS

the rate of smoking prevalence (disaggregated by gender and age) and the unemployment rate (disaggregated by gender and referring to individuals aged 15 or more) were collected for each of the twenty Italian regions. Also, percentage fluctuations of the national real gross domestic product (GDP) were collected to identify the years of severe economic crisis.

MAIN OUTCOME MEASURES

number of people who smoke per 100 people with the same features.

RESULTS

among men, increased regional unemployment rate was associated with increased smoking behaviour only in the group aged 25-34 years. Differently, severe economic crises were associated with increased smoking in almost all age groups, except for men aged 15-24 years. A 1-point decrease in GDP was associated with 0.75 more smokers aged 15 years or more. The highest coefficient was reported among men aged 35-44 years, where a 1-point decrease in GDP was associated with 1.16 more smokers (every 100 men). This age group is also featured by the second highest prevalence of tobacco smoking (36.8%). Among women, a 1-point increase in the regional unemployment rate was associated with 0.08 less smokers every 100 women. Similarly, periods of severe economic crisis at national level were associated with reduced smoking behaviour among women aged 15 years or more, specifically those aged 15-24 years. Differently, women aged 25-34 and 65 years or more showed an association similar to that reported among men. In these groups, a 1-point decrease in GDP was associated with 0.67 and 1.08 more smokers every 100 women. While among the latter the prevalence of tobacco smoking is the lowest, among the former it is the third highest prevalence (21.69%). Therefore, increased smoking behaviour due to economic crises seems to occur especially among women aged 25-35 years old, as happens among men.

CONCLUSIONS

men in almost all age groups and women aged 25-34 and 65 years or more represent vulnerable groups in which smoking behaviour may increase in times of economic hardship. Therefore, specific policies should be implemented to prevent this occurrence, as well as the negative health outcomes of tobacco smoking.

Impact of the economic crises on suicide in Italy: the moderating role of active labor market programs

PURPOSE

To analyze the association between unemployment and suicide in Italy during the years 1990-2014, with a peculiar focus on the great recession (GR) and the role played by social protection as buffering mechanism against the negative effect on health outcomes.

METHODS

Fixed effects panel regressions were used to assess the association between changes in unemployment rate and suicide rates. Additional models investigated the role of active labor market programs (ALMPs) as possible moderators of the association. Analyses were carried out for both males and females, stratified by age and region.

RESULTS

The negative time-trend displayed by suicide rate in Italy until 2007 was slowed down by changes in unemployment at the beginning of the GR, when this trend reversed and the rate of suicide started increasing. Male workers aged 25-64 and women aged 55-64 years were affected by both "normal" unemployment rate fluctuations as well as severe economic crises. Women aged 35-44 were only influenced by the latter. Men benefit from ALMPs mainly in Central Italy, while women did not benefit significantly from ALMPs.

CONCLUSIONS

In Italy, economic downturns were associated with increased suicides mainly among men, while severe economic crises were associated with increased suicides among both men and women. ALMPs showed to be effective in moderating the association between unemployment and suicide among men aged 45-54 only in Central Italy. The overall small effectiveness of such programs may be due to lack of sufficient funding.

The Potential Impact of the Transatlantic Trade and Investment Partnership (TTIP) on public health

This article aims to examine the potential health effects of the Transatlantic Trade and Investment partnership (TTIP). Our review indicates that, although proponents of the TTIP claim that the treaty will produce benefits to health-enhancing determinants such as economic growth and employment, evidence shows that previous trade liberalization policies are associated with increasing economic inequities. By reducing Technical Barriers to Trade (TBT) and by promoting increased cooperation between US and EU governmental agencies in the pharmaceutical sector, the TTIP could result in improved research cooperation and reduced duplication of processes. However, the TTIP chapter on Intellectual Property (IP) and Trade-Related Aspects of Intellectual Property Rights (TRIPS) that expand and extend patent monopolies, and delay the availability of generic drugs, are likely to cause underutilization of needed medications among vulnerable populations. The TTIP's Investor to State Dispute Settlement (ISDS) arbitration system, a mechanism that allows transnational companies (TNCs) to sue governments when a policy or law reduces the value of their investment, is likely to generate a negative impact on regulations aimed at increasing access to healthcare, and reducing tobacco, alcohol consumption, and diet-related diseases. The Sanitary and Phytosanitary Standards (SPS) of the TTIP is expected to weaken regulations in the food and agricultural sectors especially in the EU, with potentially negative effects on food safety and foodborne diseases. Finally, the ISDS is likely to infringe the ability of governments to tackle environmental problems such as climate change deemed to be the most important global health threat of the century. Our review concludes by discussing policy implications and the effect of the TTIP on democracy, national sovereignty and the balance of power between large TNCs and governments. It also discusses the adoption of an evidence-based precautionary principle approach in dealing with the health impact of Free Trade Agreements (FTAs) as well as the harmonization of regulations, norms, and standards toward stronger health and environmental protection.

Impact of the economic crisis on health-related behaviors in Italy

BACKGROUND

Evidence exists supporting the impact of the Great Recession on health-related behaviors internationally, though few studies are available concerning the Italian population.

AIM

To assess the impact of the late 2000s economic crisis on health-related behaviors linked to population mental health in Italy.

METHODS

Descriptive study. Health indicators came from the Italian Institute of Statistics database (years 2000-2015). Statistics performed by means of linear regression models.

RESULTS

Increased smokers (β = 1.68, p = .03), heavy smokers, that is, people smoking 11-20 cigarettes per day (β = 2.18, p = .04) or more than 20 cigarettes per day (β = 1.04, p < .01) and mean number of smoked cigarettes per day (β = 0.56, p = .02) were noticeable. Also, prevalence of overweight increased (β = 0.91, p = .04), while the Italian families' expenditure for alcoholic beverages decreased (β = -812.80, p = .01). Alcohol consumption decreased (β = -0.60, p < .01), especially in men (β = -0.95, p < .01); binge drinking increased in years 2009-2010. No change was noticeable in the diet indicators collected.

CONCLUSION

The economic crisis may have increased smoking, overweight and binge drinking in Italy (though data on the latter phenomenon are not conclusive), and reduced overall alcohol consumption.

The influence of market deregulation on fast food consumption and body mass index: a cross-national time series analysis

OBJECTIVE

To investigate the effect of fast food consumption on mean population body mass index (BMI) and explore the possible influence of market deregulation on fast food consumption and BMI.

METHODS

The within-country association between fast food consumption and BMI in 25 high-income member countries of the Organisation for Economic Co-operation and Development between 1999 and 2008 was explored through multivariate panel regression models, after adjustment for per capita gross domestic product, urbanization, trade openness, lifestyle indicators and other covariates. The possible mediating effect of annual per capita intake of soft drinks, animal fats and total calories on the association between fast food consumption and BMI was also analysed. Two-stage least squares regression models were conducted, using economic freedom as an instrumental variable, to study the causal effect of fast food consumption on BMI.

FINDINGS

After adjustment for covariates, each 1-unit increase in annual fast food transactions per capita was associated with an increase of 0.033 kg/m2 in age-standardized BMI (95% confidence interval, CI: 0.013-0.052). Only the intake of soft drinks--not animal fat or total calories--mediated the observed association (β: 0.030; 95% CI: 0.010-0.050). Economic freedom was an independent predictor of fast food consumption (β: 0.27; 95% CI: 0.16-0.37). When economic freedom was used as an instrumental variable, the association between fast food and BMI weakened but remained significant (β: 0.023; 95% CI: 0.001-0.045).

CONCLUSION

Fast food consumption is an independent predictor of mean BMI in high-income countries. Market deregulation policies may contribute to the obesity epidemic by facilitating the spread of fast food.

National trends in main causes of hospitalization: a multi-cohort register study of the finnish working-age population, 1976-2010

Background

The health transition theory argues that societal changes produce proportional changes in causes of disability and death. The aim of this study was to identify long-term changes in main causes of hospitalization in working-age population within a nation that has experienced considerable societal change.

Methodology

National trends in all-cause hospitalization and hospitalizations for the five main diagnostic categories were investigated in the data obtained from the Finnish Hospital Discharge Register. The seven-cohort sample covered the period from 1976 to 2010 and consisted of 3,769,356 randomly selected Finnish residents, each cohort representing 25% sample of population aged 18 to 64 years.

Principal Findings

Over the period of 35 years, the risk of hospitalization for cardiovascular diseases and respiratory diseases decreased. Hospitalization for musculoskeletal diseases increased whereas mental and behavioral hospitalizations slightly decreased. The risk of cancer hospitalization decreased marginally in men, whereas in women an upward trend was observed.

Conclusions/Significance

A considerable health transition related to hospitalizations and a shift in the utilization of health care services of working-age men and women took place in Finland between 1976 and 2010.

The financial crisis, health and health inequities in Europe: the need for regulations, redistribution and social protection

In 2009, Europe was hit by one of the worst debt crises in history. Although the Eurozone crisis is often depicted as an effect of government mismanagement and corruption, it was a consequence of the 2008 U.S. banking crisis which was caused by more than three decades of neoliberal policies, financial deregulation and widening economic inequities.

Evidence indicates that the Eurozone crisis disproportionately affected vulnerable populations in society and caused sharp increases of suicides and deaths due to mental and behavioral disorders especially among those who lost their jobs, houses and economic activities because of the crisis. Although little research has, so far, studied the effects of the crisis on health inequities, evidence showed that the 2009 economic downturn increased the number of people living in poverty and widened income inequality especially in European countries severely hit by the debt crisis. Data, however, also suggest favorable health trends and a reduction of traffic deaths fatalities in the general population during the economic recession. Moreover, egalitarian policies protecting the most disadvantaged populations with strong social protections proved to be effective in decoupling the link between job losses and suicides.

Unfortunately, policy responses after the crisis in most European countries have mainly consisted in bank bailouts and austerity programs. These reforms have not only exacerbated the debt crisis and widened inequities in wealth but also failed to address the root causes of the crisis. In order to prevent a future financial downturn and promote a more equitable and sustainable society, European governments and international institutions need to adopt new regulations of banking and finance as well as policies of economic redistribution and investment in social protection. These policy changes, however, require the abandonment of the neoliberal ideology to craft a new global political economy where markets and gross domestic product (GDP) are no longer the main national policy goals, but just means to human and health improvements.

Obesity and occupational injury: a prospective cohort study of 69,515 public sector employees

Background

Obesity and overweight are suggested to increase the risk of occupational injury but longitudinal evidence to confirm this is rare. We sought to evaluate obesity and overweight as risk factors for occupational injuries.

Methodology/Principal Findings

A total of 69,515 public sector employees (80% women) responded to a survey in 2000–2002, 2004 or 2008. Body mass index (kg/m²) was derived from self-reported height and weight and was linked to records of subsequent occupational injuries obtained from national registers. Different injury types, locations and events or exposures (the manner in which the injury was produced or inflicted) were analyzed by body mass index category adjusting for baseline socio-demographic characteristics, work characteristics, health-risk behaviors, physical and mental health, insomnia symptoms, and sleep duration. During the mean follow-up of 7.8 years (SD = 3.2), 18% of the employees (N = 12,204) recorded at least one occupational injury. Obesity was associated with a higher overall risk of occupational injury; multivariable adjusted hazard ratio (HR) 1.21 (95% CI 1.14–1.27). A relationship was observed for bone fractures (HR = 1.37; 95% CI: 1.10–1.70), dislocations, sprains and strains (HR = 1.36; 95% CI: 1.25–1.49), concussions and internal injuries (HR = 1.26; 95% CI: 1.11–1.44), injuries to lower extremities (HR = 1.62; 95%: 1.46–1.79) and injuries to whole body or multiple sites (HR = 1.37; 95%: 1.10–1.70). Furthermore, obesity was associated with a higher risk of injuries caused by slipping, tripping, stumbling and falling (HR = 1.55; 95% CI: 1.40–1.73), sudden body movement with or without physical stress (HR = 1.24; 95% CI: 1.10–1.41) and shock, fright, violence, aggression, threat or unexpected presence (HR = 1.33; 95% CI: 1.03–1.72). The magnitude of the associations between overweight and injuries was smaller, but the associations were generally in the same direction as those of obesity.

Conclusions/Significance

Obese employees record more occupational injuries than those with recommended healthy weight.

Perceived teacher unfairness and headache in adolescence: a cross-national comparison

OBJECTIVES: The present study examines the prevalence of headache in early adolescents in 21 European and North-American countries and the role of perceived teacher unfairness in predicting this health complaint across different countries. METHODS: Data were taken from the "Health Behaviour in School-aged Children" study (HBSC), a World Health Organization cross-national survey on health behaviors in 11-, 13- and 15-year-old students. Headache and perceived teacher unfairness were measured through a self-administered questionnaire filled out by 115,212 adolescents. RESULTS: The overall prevalence of frequent headaches (at least once a week) was 28.8%, ranging from 18.9% in Slovenia to 49.4% in Israel. After adjusting for gender, grade, family affluence, school achievement, being bullied and lifestyles (drinking, smoking, eating and physical activity), teacher unfairness showed a significant association with frequent headache in all but two countries (Ukraine and Luxembourg). CONCLUSIONS: Our results show that headache is a common health symptom in European and North-American countries, even though there are substantial differences in its prevalence across countries. The study indicates that perceived teacher unfairness can be a significant predictor of frequent headache during adolescence, and this association is consistent across countries.

Social participation and maintaining recommended waist circumference: prospective evidence from the English Longitudinal Study of Aging

OBJECTIVE

To investigate whether older adults participating in social activities are more likely to maintain or achieve recommended waist circumference (WC) levels.

METHOD

A total of 4,280 older adults who participated in Wave 2 (baseline) and Wave 4 (follow-up) of the English Longitudinal Study of Ageing. WC was measured by a nurse in both study waves.

RESULTS

Participation in education, arts, music groups, evening classes, and in charitable associations was associated with maintaining recommended WC only in those men whose WC was in the recommended range at baseline. Participation in social activities was not associated with achieving recommended WC in women or men with initially large waist.

DISCUSSION

Participation in cultural and charitable activities may help in maintaining a recommended level of WC in older men with WC originally in the recommended range.

Social support and the likelihood of maintaining and improving levels of physical activity: the Whitehall II Study

Background: Evidence on the association between social support and leisure time physical activity (LTPA) is scarce and mostly based on cross-sectional data with different types of social support collapsed into a single index. The aim of this study was to investigate whether social support from the closest person was associated with LTPA. Methods: Prospective cohort study of 5395 adults (mean age 55.7 years, 3864 men) participating in the British Whitehall II study. Confiding/emotional support and practical support were assessed at baseline in 1997–99 using the Close Persons Questionnaire. LTPA was assessed at baseline and follow-up in (2002–04). Baseline covariates included socio-demographics, self-rated health, long-standing illnesses, physical functioning and common mental disorders. Results: Among participants who reported recommended levels of LTPA at baseline, those who experienced high confiding/emotional support were more likely to report recommended levels of LTPA at follow-up [odds ratio (OR): 1.39, 95% confidence interval (CI): 1.12–1.70 in a model adjusted for baseline covariates]. Among those participants who did not meet the recommended target of LTPA at baseline, high confiding/emotional support was not associated with improvement in activity levels. High practical support was associated with both maintaining (OR: 1.34, 95% CI: 1.10–1.63) and improving (OR: 1.25, 95% CI: 1.02–1.53) LTPA levels. Conclusion: These findings suggest that emotional and practical support from the closest person may help the individual to maintain the recommended level of LTPA. Practical support also predicted a change towards a more active lifestyle.

Negative aspects of close relationships as a predictor of increased body mass index and waist circumference: the Whitehall II study

OBJECTIVES

We investigated whether exposure to negative aspects of close relationships was associated with subsequent increase in body mass index (BMI) and waist circumference.

METHODS

Data came from a prospective cohort study (Whitehall II) of 9425 civil servants aged 35 to 55 years at baseline (phase 1: 1985-1988). We assessed negative aspects of close relationships with the Close Persons Questionnaire (range 0-12) at phases 1 and 2 (1989-1990). We measured BMI and waist circumference at phases 3 (1991-1994) and 5 (1997-1999). Covariates at phase 1 included gender, age, marital status, ethnicity, BMI, employment grade, smoking, physical activity, fruit and vegetable consumption, and common mental disorder.

RESULTS

After adjustment for sociodemographic characteristics and health behaviors, participants with higher exposure to negative aspects of close relationships had a higher likelihood of a 10% or greater increase in BMI and waist circumference (odds ratios per 1-unit increase 1.08 [95% confidence interval (CI) =1.02, 1.14; P = .007] and 1.09 [CI = 1.04, 1.14; P ≤ .001], respectively) as well as a transition from the overweight (25 ≤ BMI  < 30) to the obese (BMI  ≥ 0) category.

CONCLUSIONS

Adverse social relationships may contribute to weight gain.

Association of CRP and IL-6 with lung function in a middle-aged population initially free from self-reported respiratory problems: the Whitehall II study

To assess whether two inflammatory markers, C-reactive protein (CRP) and interleukin-6 (IL-6), and change in their concentrations over 12 years, are associated with lung function (FVC and FEV(1)) 12 years after baseline. Data are from over 1,500 participants free from self-reported respiratory problems in a large-scale prospective cohort study of white-collar male and female civil servants. CRP and IL-6 measured at baseline (1991-1993) and follow-up (2002-2004) and FVC and FEV(1), measured at follow-up. Results adjusted for sociodemographic and anthropometric characteristics, health behaviours, biological factors, chronic conditions and medications, and corrected for short-term variability in CRP and IL-6 concentrations. Higher baseline levels of CRP and IL-6 were strongly associated with lower FVC and FEV(1), independent of potential confounders. A 10% increase serum CRP from baseline to follow-up was associated with lower values of FVC and FEV(1) at follow-up, 4.7 and 3.0 ml, respectively. The corresponding values for a 10% increase in IL-6 were 12.6 ml for FVC and 7.3 ml for FEV(1). Systemic low-grade inflammation is associated with only slightly poorer pulmonary function in a population free from self-reported respiratory problems 12 years earlier. These data provide evidence linking inflammation to adverse outcomes beyond cardiovascular disease. Interventions targeting inflammation may prevent lung function impairment.

Organisational justice and cognitive function in middle-aged employees: the Whitehall II study

BACKGROUND

Little is known about the role that work-related factors play in the decline of cognitive function. This study examined the association between perceived organisational justice and cognitive function among middle-aged men and women.

METHODS

Perceived organisational justice was measured at phases 1 (1985-8) and 2 (1989-90) of the Whitehall II study when the participants were 35-55 years old. Assessment of cognitive function at the screening clinic at phases 5 (1997-9) and 7 (2003-4) included the following tests in the screening clinic: memory, inductive reasoning (Alice Heim 4), vocabulary (Mill Hill), and verbal fluency (phonemic and semantic). Mean exposure to lower organisational justice at phases 1 and 2 in relation to cognitive function at phases 5 and 7 were analysed using linear regression analyses. The final sample included 4531 men and women.

RESULTS

Lower mean levels of justice at phases 1 and 2 were associated with worse cognitive function in terms of memory, inductive reasoning, vocabulary and verbal fluency at both phases 5 and 7. These associations were independent of covariates, such as age, occupational grade, behavioural risks, depression, hypertension and job strain.

CONCLUSIONS

This study suggests an association between perceived organisational justice and cognitive function. Further studies are needed to examine whether interventions designed to improve organisational justice would affect employees' cognition function favourably.

Justice at work and metabolic syndrome: the Whitehall II study

OBJECTIVES

Growing evidence shows that high levels of justice are beneficial for employee health, although biological mechanisms underlying this association are yet to be clarified. We aim to test whether high justice at work protects against metabolic syndrome.

METHODS

A prospective cohort study of 20 civil service departments in London (the Whitehall II study) including 6123 male and female British civil servants aged 35-55 years without prevalent coronary heart disease at baseline (1985-1990). Perceived justice at work was determined by means of questionnaire on two occasions between 1985 and 1990. Follow-up for metabolic syndrome and its components occurring from 1990 to 2004 was based on clinical assessments on three occasions over more than 18 years.

RESULTS

Cox proportional hazard models adjusted for age, ethnicity and employment grade showed that men who experienced a high level of justice at work had a lower risk of incident metabolic syndrome than employees with a low level of justice (HR 0.75; 95% CI 0.63 to 0.89). There was little evidence of an association between organisational justice and metabolic syndrome or its components in women (HR 0.88; 95% CI 0.67 to 1.17).

CONCLUSIONS

Our prospective findings provide evidence of an association between high levels of justice at work and the development of metabolic syndrome in men.

Organisational justice and markers of inflammation: the Whitehall II study

OBJECTIVES

Low organisational justice has been shown to be associated with increased risk of various health problems, but the underlying mechanisms remain unclear. We tested whether organisational injustice contributes to chronic inflammation in a population of middle-aged men and women.

METHODS

This prospective cohort study uses data from 3205 men and 1204 women aged 35-55 years at entry into the Whitehall II study (phase 1, 1985-1988). Organisational justice perceptions were assessed at phase 1 and phase 2 (1989-1990) and circulating inflammatory markers C-reactive protein (CRP) and interleukin (IL)-6 at phase 3 (1991-1993) and phase 7 (2003-2004).

RESULTS

In men, low organisational justice was associated with increased CRP levels at both follow-ups (phase 3 and 7) and increased IL-6 at the second follow-up (phase 7). The long term (phase 7) associations were largely independent of covariates, such as age, employment grade, body mass index and depressive symptoms. In women, no relationship was found between organisational justice and CRP or IL-6.

CONCLUSIONS

This study suggests that organisational injustice is associated with increased long-term levels of inflammatory markers among men.

Non-response to baseline, non-response to follow-up and mortality in the Whitehall II cohort

BACKGROUND

Little is known about the associations between non-response to follow-up surveys and mortality, or differences in these associations by socioeconomic position in studies with repeat data collections.

METHODS

The Whitehall II study of socioeconomic inequalities in health provided response status from five data collection surveys; Phase 1 (1985-88, n = 10 308), Phase 5 (1997-99, n = 6533), and all-cause mortality to 2006. Odd-numbered phases included a medical examination in addition to a questionnaire.

RESULTS

Non-response to baseline and to follow-up phases that included a medical examination was associated with a doubling of the mortality hazard in analyses adjusted for age and sex. Compared with complete responders, responders who missed one or more phases, but completed the last possible phase before they died, had a 38% excess risk of mortality. However, those who missed one or more phases including the last possible phase before death had an excess risk of 127%. There was no evidence that these associations differed by socioeconomic position.

CONCLUSION

In studies with repeat data collections, non-response to follow-up is associated with the same doubling of the mortality risk as non-response to baseline; an association that is not modified by socioeconomic position.

Globalisation and health: the need for a global vision

The reduction of health inequities is an ethical imperative, according to the WHO Commission on Social Determinants of Health (CSDH). Drawing on detailed multidisciplinary evidence assembled by the Globalization Knowledge Network that supported the CSDH, we define globalisation in mainly economic terms. We consider and reject the presumption that globalisation will yield health benefits as a result of its contribution to rapid economic growth and associated reductions in poverty. Expanding on this point, we describe four disequalising dynamics by which contemporary globalisation causes divergence: the global reorganisation of production and emergence of a global labour-market; the increasing importance of binding trade agreements and processes to resolve disputes; the rapidly increasing mobility of financial capital; and the persistence of debt crises in developing countries. Generic policies designed to reduce health inequities are described with reference to the three Rs of redistribution, regulation, and rights. We conclude with an examination of the interconnected intellectual and institutional challenges to reduction of health inequities that are created by contemporary globalisation.

Work-place social capital and smoking cessation: the Finnish Public Sector Study

AIMS

To examine whether high social capital at work is associated with an increased likelihood of smoking cessation in baseline smokers.

DESIGN

Prospective cohort study.

SETTING

Finland.

PARTICIPANTS

A total of 4853 employees who reported to be smokers in the baseline survey in 2000-2002 (response rate 68%) and responded to a follow-up survey on smoking status in 2004-2005 (response rate 77%).

MEASUREMENTS

Work-place social capital was assessed using a validated and psychometrically tested eight-item measure. Control variables included sex, age, socio-economic position, marital status, place of work, heavy drinking, physical activity, body mass index and physician-diagnosed depression.

FINDINGS

In multi-level logistic regression models adjusted for all the covariates, the odds for being a non-smoker at follow-up were 1.26 [95% confidence interval (CI)=1.03-1.55] times higher for baseline smokers who reported high individual-level social capital than for their counterparts with low social capital. In an analysis stratified by socio-economic position, a significant association between individual-level social capital and smoking cessation was observed in the high socio-economic group [odds ratio (OR) (95% CI)=1.63 (1.01-2.63)], but not in intermediate [(OR=1.10 (0.83-1.47)] or low socio-economic groups [(OR=1.28 (0.86-1.91)]. Work unit-level social capital was not associated with smoking cessation.

CONCLUSIONS

If the observed associations are causal, these findings suggest that high perceived social capital at work may facilitate smoking cessation among smokers in higher-status jobs.

Primary headache in Italian early adolescents: the role of perceived teacher unfairness

BACKGROUND

The impact of perceived teacher unfairness on headache incidence has previously been insufficiently investigated.

OBJECTIVE

The aims of the study are to analyze the prevalence of headache among Italian early adolescents as well as to examine the role of perceived teacher unfairness and classmate social support in predicting this health outcome.

METHODS

Data were taken from the "Health Behaviour in School Aged Children," a cross-sectional survey investigating health behaviors among early adolescents in selected European countries. Headache, perceived teacher unfairness, and classmate social support were measured through a self-administered questionnaire filled out by a representative sample of 4386 (48.4% males) Italian students (11, 13, and 15 years old). Covariates included demographic characteristics (age, gender) and socioeconomic status (parental educational attainment), and other confounding psychological factors (eg, family empowerment, bullying).

RESULTS

Prevalence of frequent headaches (at least once a week) was about 40%. Girls were more likely to report frequent headaches compared with boys. Prevalence of frequent headaches increased with age. After adjusting for age and gender, teacher unfairness showed a significant association with frequent headache (P < .001). This relationship remained significant even after additional adjustment for several psychosocial factors. Classmate social support seems to act as a protective factor, but not as a buffering mechanism against the negative effects of teacher unfairness.

CONCLUSIONS

Italian early adolescents show a quite high prevalence of frequent headache. Results show that characteristics of the school setting, such as teacher unfairness and classmate social support, can be significant predictors of frequent headache among early adolescents. Longitudinal research is needed to delineate causal relationships between school factors and recurrent headache.

Positive and negative affect and risk of coronary heart disease: Whitehall II prospective cohort study

OBJECTIVE

To examine the associations between positive and negative affect and subsequent coronary heart disease events independently of established risk factors.

DESIGN

Prospective cohort study with follow-up over 12 years.

SETTING

20 civil service departments originally located in London.

PARTICIPANTS

10,308 civil servants aged 35-55 years at entry into Whitehall II study in 1985.

MAIN OUTCOME MEASURES

Fatal coronary heart disease, clinically verified incident non-fatal myocardial infarction, and definite angina (n=619, mean follow-up 12.5 years).

RESULTS

In Cox regression analysis adjusted for age, sex, ethnicity, and socioeconomic position, positive affect (hazard ratio=1.01, 95% confidence interval 0.82 to 1.24) and the balance between positive and negative affect, referred to as the affect balance score (hazard ratio=0.89, 0.73 to 1.09), were not associated with coronary heart disease. Further adjustment for behaviour related risk factors (smoking, alcohol consumption, daily fruit and vegetable intake, exercise, body mass index), biological risk factors (hypertension, blood cholesterol, diabetes), and psychological stress at work did not change these results. However, participants in the highest third of negative affect had an increased incidence of coronary events (hazard ratio=1.32, 1.09 to 1.60), and this association remained unchanged after adjustment for multiple confounders.

CONCLUSIONS

Positive affect and affect balance did not seem to be predictive of future coronary heart disease in men and women who were free of diagnosed coronary heart disease at recruitment to the study. A weak positive association between negative affect and coronary heart disease was found and needs to be confirmed in further studies.

Negative aspects of close relationships and heart disease

BACKGROUND

The aims of the study were to (1) analyze the association between negative aspects of close relationships and increased risk for coronary heart disease and (2) examine whether the association is stronger among women and people of lower social position.

METHODS

Prospective cohort study of 9011 British civil servants (6114 men and 2897 women). Negative aspects of close relationships and other social support measures (confiding/emotional and practical) were assessed with the Close Persons Questionnaire during phase 2 (1989-1990) or phase 1 (1985-1988). Associations between negative aspects of close relationships and incident coronary events were determined during an average follow-up period of 12.2 years. Covariates included sociodemographic characteristics (age, sex, marital status, and employment grade), biological factors (obesity, hypertension, diabetes mellitus, and cholesterol level), psychosocial factors (negative affectivity, depression, and work stress), and health behaviors (smoking, alcohol intake, exercise, and fruit and vegetable consumption).

RESULTS

After adjustment for sociodemographic characteristics, biological factors, and other dimensions of social support, individuals who experienced negative aspects of close relationships had a higher risk of incident coronary events (hazard ratio, 1.34; 95% confidence interval, 1.10-1.63). The association was attenuated but remained statistically significant after additional adjustment for negative affectivity and depression (hazard ratio, 1.25; 95% confidence interval, 1.02-1.55). Although women and men in a lower employment grade were more likely to be exposed to negative aspects of close relationships, sex and social position had no statistically significant interaction effects. Confiding/emotional and practical support were not associated with incident coronary events.

CONCLUSION

Adverse close relationships may increase the risk of heart disease.

Unfairness and the social gradient of metabolic syndrome in the Whitehall II Study

OBJECTIVES

Little work has investigated the relationship between unfairness and risk factors for heart disease. We examine the role of unfairness in predicting the metabolic syndrome and explaining the social gradient of the metabolic syndrome.

METHODS

The design is a prospective study with an average follow-up of 5.8 years. Participants were 4128 males and 1715 females of 20 civil service departments in London (Whitehall II study). Sociodemographics, unfairness, employment grade, behavioral risk factors, and other psychosocial factors were measured at baseline (Phase 3, 1991-1993). Waist circumference, triglycerides, high-density lipoprotein (HDL) cholesterol, fasting glucose, and hypertension were used to define metabolic syndrome at follow-up (Phase 5, 1997-2000), according to the National Cholesterol Education Program/Adult Treatment Panel III guidelines.

RESULTS

Unfairness is positively associated with waist circumference, hypertension, triglycerides, and fasting glucose and negatively associated with serum HDL cholesterol. High levels of unfairness are also associated with the metabolic syndrome [odds ratio (OR)=1.72, 95% CI=1.31-2.25], after adjustment for age and gender. After additional adjustment for employment grade, behavioral risk factors, and other psychosocial factors, the relationship between high unfairness and metabolic syndrome weakened but remained significant (OR=1.37, 95% CI=1.00-1.93). When adjusting for unfairness, the social gradient of metabolic syndrome was reduced by approximately 10%.

CONCLUSION

Unfairness may be a risk factor for the metabolic syndrome and its components. Future research is needed to study the biological mechanisms linking unfairness and the metabolic syndrome.

Low organisational justice and heavy drinking: a prospective cohort study

OBJECTIVES

To investigate whether low perceived organisational injustice predicts heavy drinking among employees.

METHODS

Data from a prospective occupational cohort study, the 10-Town Study, on 15 290 Finnish public sector local government employees nested in 2432 work units, were used. Non-drinkers were excluded. Procedural, interactional and total organisational justice, heavy drinking (>/=210 g of absolute alcohol per week) and other psychosocial factors were determined by means of questionnaire in 2000-2001 (phase 1) and 2004 (phase 2). Multilevel logistic regression analyses taking into account the hierarchical structure of the data were conducted and adjustments were made for sex, age, socio-economic status, marital status, baseline heavy drinking, psychological distress and other psychosocial risk factors such as job strain and effort/reward imbalance.

RESULTS

After adjustments, participants who reported low procedural justice at phase 1 were approximately 1.2 times more likely to be heavy drinkers at phase 2 compared with their counterparts reporting high justice. Low perceived justice in interpersonal treatment and low perceived total organisational justice were associated with increased prevalence of heavy drinking only in the model adjusted for sociodemographics.

CONCLUSIONS

This is the first longitudinal study to show that low procedural justice is weakly associated with an increased likelihood of heavy drinking.

Parenting-related stressors and self-reported mental health of mothers with young children

OBJECTIVES

We assessed whether there were associations between maternal mental health and individual and co-occurring parenting stressors related to social and financial factors and child health care access.

METHODS

We used cross-sectional data from the 2000 National Survey of Early Childhood Health. The 5-item Mental Health Inventory was used to measure self-reported mental health.

RESULTS

After we controlled for demographic covariates, we found that the following stressors increased the risk of poor maternal mental health: lack of emotional (odds ratio [OR] = 3.4; 95% confidence interval [CI] = 2.0, 5.9) or functional (OR=2.2; 95% CI=1.3, 3.7) social support for parenting, too much time spent with child (OR=3.5; 95% CI=2.0, 6.1), and difficulty paying for child care (OR=2.3; 95% CI=1.4, 3.9). In comparison with mothers without any parenting stressors, mothers reporting 1 stressor had 3 times the odds of poor mental health (OR = 3.1; 95% CI = 2.1, 4.8), and mothers reporting 2 or more stressors had nearly 12 times the odds (OR = 11.7; 95% CI = 7.1, 19.3).

CONCLUSIONS

If parenting stressors such as those examined here are to be addressed, changes may be required in community support systems, and improvements in relevant social policies may be needed.

Unfairness and health: evidence from the Whitehall II Study

OBJECTIVE

To examine the effects of unfairness on incident coronary events and health functioning.

DESIGN

Prospective cohort study. Unfairness, sociodemographics, established coronary risk factors (high serum cholesterol, hypertension, obesity, exercise, smoking and alcohol consumption) and other psychosocial work characteristics (job strain, effort-reward imbalance and organisational justice) were measured at baseline. Associations between unfairness and incident coronary events and health functioning were determined over an average follow-up of 10.9 years.

PARTICIPANTS

5726 men and 2572 women from 20 civil service departments in London (the Whitehall II Study).

MAIN OUTCOME MEASURES

Incident fatal coronary heart disease, non-fatal myocardial infarction and angina (528 events) and health functioning.

RESULTS

Low employment grade is strongly associated with unfairness. Participants reporting higher levels of unfairness are more likely to experience an incident coronary event (HR 1.55, 95% CI 1.11 to 2.17), after adjustment for age, gender, employment grade, established coronary risk factors and other work-related psychosocial characteristics. Unfairness is also associated with poor physical (OR 1.46, 95% CI 1.20 to 1.77) and mental (OR 1.54, 95% CI 1.19 to 1.99) functioning at follow-up, controlling for all other factors and health functioning at baseline.

CONCLUSIONS

Unfairness is an independent predictor of increased coronary events and impaired health functioning. Further research is needed to disentangle the effects of unfairness from other psychosocial constructs and to investigate the societal, relational and biological mechanisms that may underlie its associations with health and heart disease.

The lack of social gradient of health behaviors and psychosocial factors in Northern Italy

OBJECTIVES

To examine inequalities in health behaviors and psychosocial factors in Northern Italy.

METHODS

The study was based on a computer-assisted telephone interview (CATI) of 4 002 non-institutionalized adults living in the Veneto region of Italy.

RESULTS

Cigarette smoking, binge drinking, fruit and vegetables consumption and stress failed to show a social gradient. Only physical activity was significantly associated with social class. Stress was a significant predictor of physical inactivity, smoking and low fruit and vegetable intake. Lack of emotional support was associated with smoking and physical inactivity among males, and low fruit and vegetable intake for both genders.

CONCLUSIONS

Three proposed explanations may account for the lack of consistent social gradient of health behaviors in Northern Italy: a) socio-economic context; b) uncompleted epidemiological transition of behavioral risk factors across social classes; c) lack of systematic health promotion efforts. Future research is needed to examine the plausibility of such explanations.

Potential impact of adjustment policies on vulnerability of women and children to HIV/AIDS in sub-Saharan Africa

This paper evaluates the potential impact of adjustment policies of the International Monetary Fund and the World Bank on the vulnerability of women and children to HIV/AIDS in sub-Saharan Africa. A conceptual framework, composed of five different pathways of causation, is used for the evaluation. These five pathways connect changes at the macro level (e.g. removal of food subsidies) with effects at the meso (e.g. higher food prices) and micro levels (e.g. exposure of women and children to commercial sex) that influence the vulnerability of women and children to HIV/AIDS. Published literature on adjustment policies and socioeconomic determinants of HIV/AIDS among women and children in sub-Saharan Africa was reviewed to explore the cause-effect relationships included in the theoretical framework. Evidence suggests that adjustment policies may inadvertently produce conditions facilitating the exposure of women and children to HIV/AIDS. Complex research designs are needed to further investigate this relationship. A shift in emphasis from an individual approach to a socioeconomic approach in the study of HIV infection among women and children in the developing world is suggested. Given the potential for adjustment policies to exacerbate the AIDS pandemic among women and children, a careful examination of the effects of these policies on maternal and child welfare is urgently needed.

Has the relation between income inequality and life expectancy disappeared? Evidence from Italy and top industrialised countries

OBJECTIVE

To investigate the relation between income inequality and life expectancy in Italy and across wealthy nations.

DESIGN AND SETTING

Measure correlation between income inequality and life expectancy at birth within Italy and across the top 21 wealthy countries. Pearson correlation coefficients were calculated to study these relations. Multivariate linear regression was used to measure the association between income inequality and life expectancy at birth adjusting for per capita income, education, and/or per capita gross domestic product.

DATA SOURCES

Data on the Gini coefficient (income inequality), life expectancy at birth, per capita income, and educational attainment for Italy came from the surveys on Italian household on income and wealth 1995-2000 and the National Institute of Statistics information system. Data for industrialised nations were taken from the United Nations Development Program's human development indicators database 2003.

RESULTS

In Italy, income inequality (beta = -0.433; p<0.001) and educational attainment (beta = 0.306; p<0.001) were independently associated with life expectancy, but per capita income was not (beta = 0.121; p>0.05). In cross national analyses, income inequality had a strong negative correlation with life expectancy at birth (r = -0.864; p<0.001).

CONCLUSIONS

In Italy, a country where health care and education are universally available, and with a strong social safety net, income inequality had an independent and more powerful effect on life expectancy at birth than did per capita income and educational attainment. Italy had a moderately high degree of income inequality and an average life expectancy compared with other wealthy countries. The cross national analyses showed that the relation between income inequality and population health has not disappeared.