Interpregnancy and interbirth intervals and all-cause, cardiovascular-related and cancer-related maternal mortality: findings from a large population-based cohort study

INTRODUCTION

Scarce research is available regarding the association between interbirth intervals (IBI) and long-term maternal health outcomes, particularly cardiovascular disease (CVD) mortality. We aimed to assess whether IBIs were associated with all-cause, CVD-related and cancer-related mortality.

METHODS

We conducted a cohort study in the setting of the Jerusalem Perinatal Study. Women with at least two consecutive singleton live births in 1964-1976 (N=18 294) were followed through 2016. IBIs were calculated as the interval between women's first and second cohort birth. We estimated associations between IBIs and mortality using Cox's proportional hazards models, adjusting for age, parity, maternal education, maternal origin and paternal socioeconomic status. Date of last menstrual period was available for a subset of women. We assessed the interpregnancy interval (IPI) for these women and compared the models using IPI and IBI.

RESULTS

During 868 079 years of follow up (median follow-up: 49.0 years), 3337 women died. Women with IBIs <15 months had higher all-cause mortality rates (HR 1.18; 95% CI 1.05 to 1.33) compared to women with 33-month to 68-month IBIs (reference category). IBI and CVD mortality appeared to have a J-shaped association; IBIs of <15, 15-20, 21-2626-2632, 33-68 and ≥69 months had HRs of 1.44, 1.40, 1.33, 1.14, 1.00 and 1.30, respectively. No substantial association was found with cancer mortality. Models using IPIs and those using IBI were similar.

CONCLUSION

Our results support the WHO recommendations for IPIs of ≥24 months and add additional evidence regarding long-term CVD mortality.

Assessing horizontal equity in health care utilization in Iran: a decomposition analysis

Background

Despite the goal of horizontal equity in Iran, little is known about it. This study aimed i) to assess socioeconomic inequality and horizontal inequity in the healthcare utilization; and ii) to explore the contribution of need and non-need variables to the observed inequalities.

Methods

This study used national cross sectional dataset from Utilization of Health Services survey in 2015. Concentration Index (C), Concentration Curve (CC) and Horizontal Inequity index (HI) were calculated to measure inequality in inpatient and outpatient health care utilization. Decomposition analysis was used to determine the contribution of need and non-need factors to the observed inequalities.

Result

Results showed the pro-poor inpatient services in both rural (C = − 0.079) and non-rural areas (C = − 0.096) and the pro-rich outpatient services in both rural (C = 0.038) and non-rural (C = 0.007). After controlling for need factors, HI was positive and significant for outpatient services in rural (HI = 0.039) and non-rural (HI = 0.008), indicating that for given need, the better off especially in rural make greater use of outpatient services. The HI was pro-poor for inpatient services in both rural (HI = − 0.068) and non-rural (HI = -0.090), was significant only in non-rural area. Non-need factors were the most important contributors to explain inequalities in the decomposition analysis.

Conclusion

Disentangle the different contribution of determinants, as well as greater HI in rural areas for outpatient and in non-rural areas for inpatient services, provide helpful information for decision makers to re-design policy and re-distribute resource allocation in order to reduce the socioeconomic gradient in health care utilization.

Relationship between socioeconomic status and incidence of out-of-hospital cardiac arrest is dependent on age

Background

The association between socioeconomic status (SES) and incidence of out-of-hospital cardiac arrest (OHCA) is not fully understood. The aim of this study was to see if area-level socioeconomic differences, measured in terms of area-level income and education, are associated with the incidence of OHCA, and if this relationship is dependent on age.

Methods

We included OHCAs that occurred in Stockholm County between the 1st of January 2006 and the 31st of December 2017, the victims being confirmed residents (n=10 574). We linked the home address to a matching neighbourhood (base unit) via available socioeconomic and demographic information. Socioeconomic variables and incidence rates were assessed by using cross-sectional values at the end of each year. We used zero-inflated negative binomial regression to calculate incidence rate ratios (IRRs).

Results

Among 1349 areas with complete SES information, 10 503 OHCAs occurred between 2006 and 2017. The IRR in the highest versus the lowest SES area was 0.61 (0.50–0.75) among persons in the 0–44 age group. Among patients in the 45–64 age group, the corresponding IRR was 0.55 (0.47–0.65). The highest SES areas versus the lowest showed an IRR of 0.59 (0.50–0.70) in the 65–74 age group. In the two highest age groups, no significant association was seen (75–84 age group: 0.93 (0.80–1.08); 85+ age group: 1.05 (0.84–1.23)). Similar crude patterns were seen among both men and women.

Conclusions

Areas characterised by high SES showed a significantly lower incidence of OHCA. This relationship was seen up to the age of 75, after which the relationship disappeared, suggesting a levelling effect.

How do early-life factors explain social inequalities in adolescent mental health? Findings from the UK Millennium Cohort Study

BACKGROUND

Reducing inequalities in adolescent mental health is a public health priority, yet the pathways that link social conditions to mental health outcomes in the early years are unclear. We aimed to evaluate the extent to which early years risk factors explain social inequalities in adolescent mental health in the UK.

METHODS

We analysed data from 6509 children captured in the UK Millennium Cohort Study. Mental health was assessed through the socioemotional behavioural problems at age 14 (Strengths and Difficulties Questionnaire). The main exposure was maternal education at birth, used as a measure of childhood socioeconomic conditions (SECs), and used to calculate the relative index of inequality. Using causal mediation analysis, we assessed how perinatal, individual child, family, peer relation and neighbourhood-level factors measured up to age 3-mediated the total effect (TE) of SECs on adolescent socioemotional behavioural problems, estimating the proportion mediated and natural indirect effect (NIE) via each block of mediators, and all mediators together.

RESULTS

Children of mothers with no qualification were almost four times as likely to have socioemotional behavioural problems compared with degree plus level (relative risk (RR) 3.82, 95% CI 2.48 to 5.88). Overall, 63.9% (95% CI 50.2% to 77.6%) (NIE RR 1.97, 95% CI 1.63 to 2.37) of the TE (RR 4.40, 95% CI 3.18 to 6.07) of social inequalities on risk of adolescent socioemotional behavioural problems was mediated by early-life factors.

CONCLUSIONS

About two-thirds of the social inequality in adolescent mental health was explained by early risk factors measured by age 3, highlighting the importance of public health interventions in this period.

Socioeconomic status in childhood and C reactive protein in adulthood: a systematic review and meta-analysis

BACKGROUND

Inflammation plays a central role in cardiometabolic disease and may represent a mechanism linking low socioeconomic status (SES) in early life and adverse cardiometabolic health outcomes in later life. Accumulating evidence suggests an association between childhood SES and adult inflammation, but findings have been inconsistent.

METHODS

We conducted a systematic review and meta-analysis of observational studies to quantify the association between childhood (age <18 years) SES and the inflammatory marker C reactive protein (CRP) in adulthood. Studies were identified in Medline and Embase databases, and by reviewing the bibliographies of articles published from 1946 to December 2015. Study-specific estimates were combined into meta-analyses using random-effects models.

RESULTS

15 of 21 eligible studies (n=43 629) were ultimately included in two separate meta-analyses. Compared with those from the most advantaged families, participants from the least advantaged families had 25% higher CRP levels (ratio change in geometric mean CRP: 1.25; 95% CI 1.19 to 1.32) in minimally adjusted analyses. This finding was attenuated by the inclusion of adult body mass index (BMI) in adjusted models, suggesting BMI has a strong mediating role in CRP levels.

CONCLUSIONS

We observed an inverse association between childhood SES and adulthood CRP, potentially mediated through BMI. Investigating how childhood SES is associated with childhood BMI and CRP would provide insight into the effective timing of social and clinical interventions to prevent cardiometabolic disease.

Twenty years of social capital and health research: a glossary

Research on social capital in public health is approaching its 20th anniversary. Over this period, there have been rich and productive debates on the definition, measurement and importance of social capital for public health research and practice. As a result, the concepts and measures characterising social capital and health research have also evolved, often drawing from research in the social, political and behavioural sciences. The multidisciplinary adaptation of social capital-related concepts to study health has made it challenging for researchers to reach consensus on a common theoretical approach. This glossary thus aims to provide a general overview without recommending any particular approach. Based on our knowledge and research on social capital and health, we have selected key concepts and terms that have gained prominence over the last decade and complement an earlier glossary on social capital and health.

How do individual-level sociodemographics and neighbourhood-level characteristics influence residential location behaviour in the context of the food and built environment? Findings from 25 years of follow-up in the CARDIA Study

BACKGROUND

Little is known about how diet-related and activity-related amenities relate to residential location behaviour. Understanding these relationships is essential for addressing residential self-selection bias.

METHODS

Using 25 years (6 examinations) of data from the Coronary Artery Risk Development in Young Adults (CARDIA) study (n=11 013 observations) and linked neighbourhood-level data from the 4 CARDIA baseline cities (Birmingham, Alabama; Chicago, Illinois; Minneapolis, Minnesota; Oakland, California, USA), we characterised participants' neighbourhoods as having low, average or high road connectivity and amenities using non-hierarchical cluster analysis. We then used repeated measures multinomial logistic regression with random effects to examine the associations between individual-level sociodemographics and neighbourhood-level characteristics with residential neighbourhood types over the 25-year period, and whether these associations differed by individual-level income.

RESULTS

Being female was positively associated with living in neighbourhoods with low (vs high) road connectivity and activity-related and diet-related amenities among high-income individuals only. At all income levels, a higher percentage of neighbourhood white population and neighbourhood population <18 years were associated with living in neighbourhoods with low (vs high) connectivity and amenities. Individual-level race; age; and educational attainment, neighbourhood socioeconomic status and housing prices did not influence residential location behaviour related to neighbourhood connectivity and amenities at any income level.

CONCLUSIONS

Neighbourhood-level factors appeared to play a comparatively greater role in shaping residential location behaviour than individual-level sociodemographics. Our study is an important step in understanding how residential locational behaviour relates to amenities and physical activity opportunities, and may help mitigate residential self-selection bias in built environment studies.

Sex differences in the relationship between socioeconomic status and cardiovascular disease: a systematic review and meta-analysis

BACKGROUND

Low socioeconomic status (SES) is a known risk factor for cardiovascular disease (CVD) but whether its effects are comparable in women and men is unknown.

METHODS

PubMed MEDLINE was systematically searched. Studies that reported sex-specific estimates, and associated variability, of the relative risk (RR) for coronary heart disease (CHD), stroke or CVD according to a marker of SES (education, occupation, income or area of residence), for women and men were included. RRs were combined with those derived from cohort studies using individual participant data. Data were pooled using random effects meta-analyses with inverse variance weighting. Estimates of the ratio of the RRs (RRR), comparing women with men, were computed.

RESULTS

Data from 116 cohorts, over 22 million individuals, and over 1 million CVD events, suggest that lower SES is associated with increased risk of CHD, stroke and CVD in women and men. For CHD, there was a significantly greater excess risk associated with lower educational attainment in women compared with men; comparing lowest with highest levels, the age-adjusted RRR was 1.24 (95% CI 1.09 to 1.41) and the multiple-adjusted RRR was 1.34 (1.09 to 1.63). For stroke, the age-adjusted RRR was 0.93 (0.72 to 1.18), and the multiple-adjusted was RRR 0.79 (0.53 to 1.19). Corresponding results for CVD were 1.18 (1.03 to 1.36), 1.23 (1.03 to 1.48), respectively. Similar results were observed for other markers of SES for all three outcomes.

CONCLUSIONS

Reduction of socioeconomic inequalities in CHD and CVD outcomes might require different approaches for men and women.

Residential segregation and mental health among Latinos in a nationally representative survey

BACKGROUND

Among Latinos, living in a locality with greater Latino ethnic density may be protective for mental health, although findings vary by Latino subgroup, gender and birthplace. Although little studied, Latino residential segregation may capture different pathways linking risk and protective environmental factors to mental health than local ethnic density.

METHODS

This study evaluated the association between residential segregation and mental distress as measured by the Kessler-10 (K10) among Latino participants in the National Latino and Asian American Study (NLAAS). Census data from 2000 was used to calculate metropolitan statistical area (MSA) residential segregation using the dissimilarity and isolation indices, as well as census tract ethnicity density and poverty. Latino subgroup (Puerto Rican, Mexican American, Cuban American and other Latino subgroup), gender and generation status were evaluated as moderators.

RESULTS

Among 2554 Latino participants in NLAAS, residential segregation as measured by the isolation index was associated with less mental distress (β -0.14, 95% CI -0.26 to -0.03 log(K10)) among Latinos overall after adjustment for ethnic density, poverty and individual covariates. Residential segregation as measured by the dissimilarity index was significantly associated with less mental distress among men (β -0.56, 95% CI -1.04 to -0.08) but not among women (β -0.20, 95% CI -0.45 to 0.04, p-interaction=0.019). No modification was observed by Latino subgroup or generation.

CONCLUSIONS

Among Latinos, increasing residential segregation was associated with less mental distress, and this association was moderated by gender. Findings suggest that MSA-level segregation measures may capture protective effects associated with living in Latino communities for mental health.

Community vulnerability and symptoms of acute respiratory infection among preschool age children in the Democratic Republic of Congo, Malawi and Nigeria: evidence from Demographic and Health Surveys

BACKGROUND

As a consequence of the global spread of HIV infection in sub-Saharan Africa, the impact of the AIDS pandemic has contributed to more than 40 million orphaned and vulnerable children (OVC) in sub-Saharan Africa. The children's vulnerability is hypothesised to increase the risk of acute respiratory infection (ARI), which remains one of the major infectious causes of child mortality and morbidity in this region. This study examines the linkages between children's vulnerability and ARI symptoms, with a focus on the individual as well as community levels.

METHODS

Using population-based Demographic and Health Surveys of preschool age children (0-59 months old) from the Democratic Republic of Congo (n=7755), Malawi (n=17 559) and Nigeria (n=28 049), multilevel logistic models were conducted to establish the relationships between ARI symptoms among OVC and community-level vulnerability, adjusting for children's and household characteristics and a season variation.

RESULTS

The child's OVC status and community vulnerability were shown to be significantly associated with an increased likelihood of the child suffering from ARI symptoms in three countries. In contrast, the relationship between ARI symptoms and some selected variables associated with community development was not consistent across the 3 countries.

CONCLUSIONS

Community vulnerability demonstrates a significant influence on whether or not the child exhibits ARI symptoms. Being OVC contributes to differences in children's likelihood of ARI symptoms between communities. In addition to industrial pollution, specific components, such as community development, vary in their associations with the ARI symptoms across different countries. The large differences in childhood ARI symptoms across countries suggests that policies aimed at promoting child health need to be context specific.

Housing conditions and limitations in physical function among older adults

INTRODUCTION

Housing conditions are an important social determinant of health. However, to the best of our knowledge, no previous study has systematically assessed the association between housing conditions and physical function limitations in older adults; moreover, whether this association is independent of the socioeconomic status achieved earlier in life is still uncertain.

METHODS

Cross-sectional analysis conducted among 2012 non-institutionalised individuals aged ≥60 years, who participated in the Seniors-ENRICA cohort. Participants reported the following poor housing conditions: living in a walk-up building, lacking heating, or feeling cold frequently. We assessed lower extremity performance with the Short Physical Performance Battery (SPPB), mobility or agility limitations with standardised questions, frailty according to the Fried criteria, and disability in instrumental activities of daily living (IADL) with the Lawton and Brody questionnaire.

RESULTS

In analyses adjusting for demographic, behavioural and comorbidity variables, when compared with those living in homes without poor housing conditions, those with ≥2 poor conditions showed worse scores in the SPPB (β -1.06; 95% CI -1.46 to -0.65) and a higher frequency of agility limitation (OR 1.62; 95% CI 1.00 to 2.61) and frailty (OR 8.78; 95% CI 3.00 to 25.60). These associations held after adjustment for educational and occupational levels. Living in a walk-up building was associated with a higher frequency of frailty, while lacking heating was linked to lower scores in the 3 SPPB tests, as well as with an increased frequency of frailty and 4 of its components (exhaustion, slow walking speed, low physical activity and weakness). Feeling cold was linked to increased exhaustion. No association was found between housing conditions and IADL disability.

CONCLUSIONS

Poor housing conditions, particularly living in a walk-up building and lacking heating, are independently associated with limitations in physical function in older adults. This entails serious inequalities in functional status, which should be firmly addressed.

Development of a cross-cultural deprivation index in five European countries

BACKGROUND

Despite a concerted policy effort in Europe, social inequalities in health are a persistent problem. Developing a standardised measure of socioeconomic level across Europe will improve the understanding of the underlying mechanisms and causes of inequalities. This will facilitate developing, implementing and assessing new and more effective policies, and will improve the comparability and reproducibility of health inequality studies among countries. This paper presents the extension of the European Deprivation Index (EDI), a standardised measure first developed in France, to four other European countries-Italy, Portugal, Spain and England, using available 2001 and 1999 national census data.

METHODS AND RESULTS

The method previously tested and validated to construct the French EDI was used: first, an individual indicator for relative deprivation was constructed, defined by the minimal number of unmet fundamental needs associated with both objective (income) poverty and subjective poverty. Second, variables available at both individual (European survey) and aggregate (census) levels were identified. Third, an ecological deprivation index was constructed by selecting the set of weighted variables from the second step that best correlated with the individual deprivation indicator.

CONCLUSIONS

For each country, the EDI is a weighted combination of aggregated variables from the national census that are most highly correlated with a country-specific individual deprivation indicator. This tool will improve both the historical and international comparability of studies, our understanding of the mechanisms underlying social inequalities in health and implementation of intervention to tackle social inequalities in health.

Income inequality within urban settings and depressive symptoms among adolescents

BACKGROUND

Although recent evidence has shown that area-level income inequality is related to increased risk for depression among adults, few studies have tested this association among adolescents.

METHODS

We analysed the cross-sectional data from a sample of 1878 adolescents living in 38 neighbourhoods participating in the 2008 Boston Youth Survey. Using multilevel linear regression modelling, we: (1) estimated the association between neighbourhood income inequality and depressive symptoms, (2) tested for cross-level interactions between sex and neighbourhood income inequality and (3) examined neighbourhood social cohesion as a mediator of the relationship between income inequality and depressive symptoms.

RESULTS

The association between neighbourhood income inequality and depressive symptoms varied significantly by sex, with girls in higher income inequality neighbourhood reporting higher depressive symptom scores, but not boys. Among girls, a unit increase in Gini Z-score was associated with more depressive symptoms (β=0.38, 95% CI 0.28 to 0.47, p=0.01) adjusting for nativity, neighbourhood income, social cohesion, crime and social disorder. There was no evidence that the association between income inequality and depressive symptoms was due to neighbourhood-level differences in social cohesion.

CONCLUSIONS

The distribution of incomes within an urban area adversely affects adolescent girls' mental health; future work is needed to understand why, as well as to examine in greater depth the potential consequences of inequality for males, which may have been difficult to detect here.

Socioeconomic differences in the benefits of structured physical activity compared with health education on the prevention of major mobility disability in older adults: the LIFE study

BACKGROUND

Evidence is lacking on whether health-benefiting community-based interventions differ in their effectiveness according to socioeconomic characteristics. We evaluated whether the benefit of a structured physical activity intervention on reducing mobility disability in older adults differs by education or income.

METHODS

The Lifestyle Interventions and Independence for Elders (LIFE) study was a multicentre, randomised trial that compared a structured physical activity programme with a health education programme on the incidence of mobility disability among at-risk community-living older adults (aged 70-89 years; average follow-up of 2.6 years). Education (≤ high school (0-12 years), college (13-17 years) or postgraduate) and annual household income were self-reported (<$24 999, $25 000 to $49 999 and ≥$50 000). The risk of disability (objectively defined as loss of ability to walk 400 m) was compared between the 2 treatment groups using Cox regression, separately by socioeconomic group. Socioeconomic group×intervention interaction terms were tested.

RESULTS

The effect of reducing the incidence of mobility disability was larger for those with postgraduate education (0.72, 0.51 to 1.03; N=411) compared with lower education (high school or less (0.93, 0.70 to 1.24; N=536). However, the education group×intervention interaction term was not statistically significant (p=0.54). Findings were in the same direction yet less pronounced when household income was used as the socioeconomic indicator.

CONCLUSIONS

In the largest and longest running trial of physical activity amongst at-risk older adults, intervention effect sizes were largest among those with higher education or income, yet tests of statistical interactions were non-significant, likely due to inadequate power.

TRIAL REGISTRATION NUMBER

NCT01072500.

Association between maternal education and objectively measured physical activity and sedentary time in adolescents

Background

Investigating socioeconomic variation in physical activity (PA) and sedentary time is important as it may represent a pathway by which socioeconomic position (SEP) leads to ill health. Findings on the association between children's SEP and objectively assessed PA and/or sedentary time are mixed, and few studies have included international samples.

Objective

Examine the associations between maternal education and adolescent's objectively assessed PA and sedentary time.

Methods

This is an observational study of 12 770 adolescents (10–18 years) pooled from 10 studies from Europe, Australia, Brazil and the USA. Original PA data were collected between 1997 and 2009. The associations between maternal education and accelerometer variables were examined using robust multivariable regression, adjusted for a priori confounders (ie, body mass index, monitor wear time, season, age and sex) and regression coefficients combined across studies using random effects meta-analyses. Analyses were conducted in March 2014.

Results

Adolescents of university educated mothers spent more time sedentary (9.5 min/day, p=0.005) and less time in light activity (10 min/day, p<0.001) compared with adolescents of high school educated mothers. Pooled analysis across two studies from Brazil and Portugal (analysed separately because of the different coding of maternal education) showed that children of higher educated mothers (tertiary vs primary/secondary) spent less time in moderate to vigorous PA (MVPA) (6.6 min/day, p=0.001) and in light PA (39.2 min/day: p<0.001), and more time sedentary (45.9 min/day, p<0.001).

Conclusions

Across a number of international samples, adolescents of mothers with lower education may not be at a disadvantage in terms of overall objectively measured PA.

Socioeconomic position in childhood and cancer in adulthood: a rapid-review

Background

The relationship of childhood socioeconomic position (SEP) to adult cancer has been inconsistent in the literature and there has been no review summarising the current evidence focused solely on cancer outcomes.

Methods and results

We performed a rapid review of the literature, which identified 22 publications from 13 studies, primarily in the UK and northern European countries that specifically analysed individual measures of SEP in childhood and cancer outcomes in adulthood. Most of these studies adjusted for adult SEP as a critical mediator of the relationship of interest.

Conclusions

Results confirm that childhood socioeconomic circumstances have a strong influence on stomach cancer and are likely to contribute, along with adult circumstances, to lung cancer through cumulative exposure to smoking. There was also some evidence of increased risk of colorectal, liver, cervical and pancreatic cancers with lower childhood SEP in large studies, but small numbers of cancer deaths made these estimates imprecise. Gaps in knowledge and potential policy implications are presented.

Childhood conscientiousness predicts the social gradient of smoking in adulthood: a life course analysis

BACKGROUND AND AIMS

The social gradient in smoking is well known, with higher rates among those in less advantaged socioeconomic position. Some recent research has reported that personality characteristics partly explain this gradient. However, the majority of existing work is limited by cross-sectional designs unsuitable to determine whether differences in conscientiousness are a predictor or a product of social inequalities. Adopting a life course perspective, we investigated in the current paper the influence of conscientiousness in early and mid-life on the social gradient in smoking and the role of potential confounding factors in a large longitudinal cohort study.

METHODS

Using data from the 1958 National Child Development Study, we examined the extent to which two measures of conscientiousness, one assessed with a personality questionnaire at age 50 and one derived from three related items at 16 years in childhood, explained the social gradient of smoking at age 50 by comparing nested logistic regression models that included social class at birth, cognitive ability, attention and conduct problems at age 7, and educational qualification.

RESULTS

Childhood conscientiousness was a significant predictor of smoking at 50 years (OR=0.86, CI (95%) 0.84 to 0.88), explaining 5.0% of the social gradient independent of all other variables. Childhood conscientiousness was a stronger predictor than adult conscientiousness, statistically accounting for the observed direct association of adult conscientiousness with smoking.

CONCLUSIONS

Conscientiousness may be a predictor rather than a product of social differences in smoking. Inclusion of personality measures and adoption of a life course perspective add significantly to our understanding of health inequalities.

Spatial social polarisation: using the Index of Concentration at the Extremes jointly for income and race/ethnicity to analyse risk of hypertension

BACKGROUND

Growing spatial social and economic polarisation may be an important societal determinant of health, but only a few studies have used the recently developed Index of Concentration at the Extremes (ICE) to analyse the impact of joint concentrations of privilege and privation on health outcomes. We explore use of the ICE to investigate risk of hypertension in an urban, multiracial/ethnic, and predominantly working-class study population of US adults.

METHODS

We generated novel ICE measures at the census tract level that jointly assess extreme concentrations of both income and racial/ethnic composition. We then linked the ICE measures to data from two observational, cross-sectional studies conducted in the Boston metropolitan area (2003-2004; 2008-2010; N=2145).

RESULTS

The ICE measure for extreme concentrations of white compared with black residents was independently associated with lower odds of hypertension (OR=0.76; 95% CI 0.62 to 0.93), controlling for race/ethnicity, age, gender, smoking, body mass index, household income, education and self-reported exposure to racial discrimination. Even stronger associations were observed for the ICE measures that compared concentrations of high-income white residents versus low-income residents of colour (OR=0.61; 95% CI 0.40 to 0.96) and high-income white versus low-income black residents (OR=0.48; 95% CI 0.29 to 0.81).

CONCLUSIONS

Results suggest public health studies should explore the joint impact of racial/ethnic and economic spatial polarisation on population health.

Educational differentials in disability vary across and within welfare regimes: a comparison of 26 European countries in 2009

BACKGROUND

Social differentials in disability prevalence exist in all European countries, but their scale varies markedly. To improve understanding of this variation, the article focuses on each end of the social gradient. It compares the extent of the higher disability prevalence in low social groups (referred to as disability disadvantage) and of the lower prevalence in high social groups (disability advantage); country-specific advantages/disadvantages are discussed regarding the possible influence of welfare regimes.

METHODS

Cross-sectional disability prevalence is measured by longstanding health-related activity limitation (AL) in the 2009 European Statistics on Income and Living Conditions (EU-SILC) across 26 countries classified into four welfare regime groups. Logistic models adjusted by country, age and sex (in all 30-79 years and in three age-bands) measured the country-specific ORs across education, representing the AL-disadvantage of low-educated and AL-advantage of high-educated groups relative to middle-educated groups.

RESULTS

The relative AL-disadvantage of the low-educated groups was small in Sweden (eg, 1.2 (1.0-1.4)), Finland, Romania, Bulgaria and Spain (youngest age-band), but was large in the Czech Republic (eg, 1.9 (1.7-2.2)), Denmark, Belgium, Italy and Hungary. The high-educated groups had a small relative AL-advantage in Denmark (eg, 0.9 (0.8-1.1)), but a large AL-advantage in Lithuania (eg, 0.5 (0.4-0.6)), half of the Baltic and Eastern European countries, Norway and Germany (youngest age-band). There were notable differences within welfare regime groups.

CONCLUSIONS

The country-specific disability advantages/disadvantages across educational groups identified here could help to identify determining factors and the efficiency of national policies implemented to tackle social differentials in health.

Chronic kidney disease among adult participants of the ELSA-Brasil cohort: association with race and socioeconomic position

BACKGROUND

There is increased interest in understanding why chronic kidney disease (CKD) rates vary across races and socioeconomic groups. We investigated the distribution of estimated glomerular filtration rate (eGFR), urinary albumin-creatinine ratio (ACR) and CKD according to these factors in Brazilian adults.

METHODS

Using baseline data (2008-2010) of 14,636 public sector employees (35-74 years) enrolled in the Brazilian Longitudinal Study of Adult Health (ELSA)-Brasil multicentre cohort, we estimated the prevalence of CKD by sex, age, race and socioeconomic factors. CKD was defined as ACR ≥ 30 mg/g and/or eGFR < 60 mL/min/1.73 m(2). GFR was estimated by CKD epidemiology collaboration without correction for race. We used logistic regression to estimate the association of race and socioeconomic position (education, income, social class and occupational nature) with CKD after adjusting for sex, age and several health-related factors.

RESULTS

The prevalence of high ACR or low eGFR, in isolation and combined, increased with age, and was higher in individuals with lower socioeconomic position and among black individuals and indigenous individuals. The overall prevalence of CKD was 8.9%. After full adjustments, it was similar in men and women (OR=0.90; 95% CI 0.79 to 1.02) and increased with age (OR=1.07; 95% CI 1.06 to 1.08). Compared to white individuals, black individuals (OR=1.23; 95% CI 1.03 to 1.47), 'pardos' (OR=1.16; 95% CI 1.00 to 1.35) and Indigenous (OR=1.72; 95% CI 1.07 to 2.76) people had higher odds for CKD. Having high school (OR=1.15; 95% CI 1.00 to 1.34) or elementary education (OR=1.23; 95% CI 1.03 to 1.47) increased the odds for CKD compared to those having a university degree.

CONCLUSIONS

There were marked discrepancies in the increases in reduced eGFR and high ACR with age and race. The higher prevalences of CKD in individuals with lower educational status and in non-whites were not explained by differences in health-related factors.

Wealth and mortality at older ages: a prospective cohort study

Background

Despite the importance of socioeconomic position for survival, total wealth, which is a measure of accumulation of assets over the life course, has been underinvestigated as a predictor of mortality. We investigated the association between total wealth and mortality at older ages.

Methods

We estimated Cox proportional hazards models using a sample of 10 305 community-dwelling individuals aged ≥50 years from the English Longitudinal Study of Ageing.

Results

2401 deaths were observed over a mean follow-up of 9.4 years. Among participants aged 50–64 years, the fully adjusted HRs for mortality were 1.21 (95% CI 0.92 to 1.59) and 1.77 (1.35 to 2.33) for those in the intermediate and lowest wealth tertiles, respectively, compared with those in the highest wealth tertile. The respective HRs were 2.54 (1.27 to 5.09) and 3.73 (1.86 to 7.45) for cardiovascular mortality and 1.36 (0.76 to 2.42) and 2.53 (1.45 to 4.41) for other non-cancer mortality. Wealth was not associated with cancer mortality in the fully adjusted model. Similar but less strong associations were observed among participants aged ≥65 years. The use of repeated measurements of wealth and covariates brought about only minor changes, except for the association between wealth and cardiovascular mortality, which became less strong in the younger participants. Wealth explained the associations between paternal occupation at age 14 years, education, occupational class, and income and mortality.

Conclusions

There are persisting wealth inequalities in mortality at older ages, which only partially are explained by established risk factors. Wealth appears to be more strongly associated with mortality than other socioeconomic position measures.

How stakeholder participation can contribute to systematic reviews of complex interventions

Although patient and public involvement in research is a requirement for research funding in many countries, the knowledge base for how to effectively involve people—and evidence of the effectiveness of involvement—is weak. This article describes how methods used in participatory health research were used to involve patients, clients, providers and community health workers across all stages of a realist review. Sustained involvement enabled better identification of the components of the complex intervention of community-based peer support. It also challenged assumptions of how peer support is constructed, leading the review team to question whether the process of designing and implementing interventions has more influence on effectiveness than previously recognised in empirical studies. We conclude with a discussion on when sustained involvement should be used, and the challenges of incorporating it into the traditional researcher-led approach to systematic reviews.

Pinpointing the sources of the Asian mortality advantage in the USA

BACKGROUND

Asian-Americans outlive whites by an average of nearly 8 years. By determining the sources of the Asian mortality advantage, we can pinpoint where there is the greatest potential for raising the life expectancy of whites and other groups in the USA.

METHODS

Our analyses include all Asian and white deaths in the USA between 2006 and 2010, from the Center for Disease Control. Using the International Classification of Diseases (V.10), we code causes of deaths into 19 categories, based on the most common causes as well as causes particularly relevant to racial differences. We then create life tables and apply a newly-developed demographic method to determine whether Asians have longer life expectancy because they are less likely than whites to die of causes of death that strike at younger ages, or because they tend to outlive whites regardless of cause of death.

RESULTS

Nearly 90% of the Asian-white life expectancy gap is attributable to the fact that Asians tend to outlive whites regardless of the cause of death. The causes that contribute the most to the gap are heart disease (24%) and cancers (18%). Men contribute somewhat more to the gap than women do (55% vs 45%), primarily because Asian-white differences in mortality are greater among men than among women with respect to suicide, traffic accidents and accidental poisoning.

CONCLUSIONS

For almost all causes of death, Asian victims tend to be older than white victims. The greatest potential for raising the life expectancy of whites to that of Asians, then, resides in efforts that effectively increase whites' average age at death for the most common causes of death.

Spatial social polarisation: using the Index of Concentration at the Extremes jointly for income and race/ethnicity to analyse risk of hypertension

BACKGROUND

Growing spatial social and economic polarisation may be an important societal determinant of health, but only a few studies have used the recently developed Index of Concentration at the Extremes (ICE) to analyse the impact of joint concentrations of privilege and privation on health outcomes. We explore use of the ICE to investigate risk of hypertension in an urban, multiracial/ethnic, and predominantly working-class study population of US adults.

METHODS

We generated novel ICE measures at the census tract level that jointly assess extreme concentrations of both income and racial/ethnic composition. We then linked the ICE measures to data from two observational, cross-sectional studies conducted in the Boston metropolitan area (2003-2004; 2008-2010; N=2145).

RESULTS

The ICE measure for extreme concentrations of white compared with black residents was independently associated with lower odds of hypertension (OR=0.76; 95% CI 0.62 to 0.93), controlling for race/ethnicity, age, gender, smoking, body mass index, household income, education and self-reported exposure to racial discrimination. Even stronger associations were observed for the ICE measures that compared concentrations of high-income white residents versus low-income residents of colour (OR=0.61; 95% CI 0.40 to 0.96) and high-income white versus low-income black residents (OR=0.48; 95% CI 0.29 to 0.81).

CONCLUSIONS

Results suggest public health studies should explore the joint impact of racial/ethnic and economic spatial polarisation on population health.

Social disparities in Disease Management Programmes for coronary heart disease in Germany: a cross-classified multilevel analysis

Background

Disease Management Programmes (DMPs) aim to improve effectiveness and equity of care but may suffer from selective enrolment. We analysed social disparities in DMP enrolment among elderly patients with coronary heart disease (CHD) in Germany, taking into account contextual effects at municipality and primary care practice levels.

Methods

Cross-sectional analysis of effects of educational attainment and regional deprivation on physician-reported DMP enrolment in a subsample of a large population-based cohort study in Germany, adjusting for individual-level, practice-level and area-level variables. We calculated OR and their 95% CIs (95% CI) in cross-classified, multilevel logistic regression models.

Results

Among N=1280 individuals with CHD (37.3% women), DMP enrolment rates were 22.2% (women) and 35% (men). The odds of DMP enrolment were significantly higher for male patients (OR=1.98 (1.50 to 2.62)), even after adjustment for potential confounding by individual-level, practice-level and area-level variables (range: OR=1.60 (1.08 to 2.36) to 2.16 (1.57 to 2.98)). Educational attainment was not significantly associated with DMP enrolment. Compared to patients living in least-deprived municipalities, the adjusted propensity of DMP enrolment was statistically significantly lower for patients living in medium-deprived municipalities (OR=0.41 (0.24 to 0.71)), and it also tended to be lower for patients living in the most-deprived municipalities (OR=0.70 (0.40 to 1.21)). Models controlling for the social situation (instead of health-related behaviour) yielded comparable effect estimates (medium-deprived/most-deprived vs least-deprived areas: OR=0.45 (0.26 to 0.78)/OR=0.68 (0.33 to 1.19)). Controlling for differences in comorbidity attenuated the deprivation effect estimates.

Conclusions

We found evidence for marked gender, but not educational disparities in DMP enrolment among patients with CHD. Small-area deprivation was associated with DMP enrolment, but the effects were partly explained by differences in comorbidity. Future studies on DMPs should consider contextual effects when analysing programme effectiveness or impacts on equity and efficiency.

Socioeconomic inequalities in smoking cessation in 11 European countries from 1987 to 2012

BACKGROUND

During the 1990s, inequalities in smoking prevalence by socioeconomic status (SES) have widened in Europe. Since then, many tobacco control policies have been implemented. Yet, European overviews of recent trends in smoking inequalities are lacking. This paper aims to provide an overview of long-term trends of socioeconomic inequalities in smoking cessation in Europe.

METHODS

We used data for 11 countries taken from Eurobarometer surveys from 1987 to 1995 and 2002-2012, with a total study sample of 63 737 respondents. We performed multilevel logistic regression to model associations of the quit ratio (proportion former smokers of ever smokers) with SES, measured by education and occupation separately, with adjustments for age, sex and time.

RESULTS

We found a significant, positive association for education and occupation with the quit ratio. The strength of the association decreased slightly from 1987 to 1995 and increased again from 2002 to 2012. Inequalities increased between the two periods in most countries and decreased in only one country. While in 1987-1995, the quit ratio increased among all SES groups and most strongly among the low SES group, in 2002-2012 it increased only among the high-education group (OR=1.38, 95% CI 1.02 to 1.87), and non-manual occupation group (OR=1.59, 95% CI 1.19 to 2.12).

CONCLUSIONS

Socioeconomic inequalities in smoking cessation rates have strongly increased since the 1990s and during the 2000s. This suggests that the tobacco control policies implemented during the 2000s have not been able to counter the trend in increasing inequalities.

Social inequalities in childcare quality and their effects on children's development at school entry: findings from the Longitudinal Study of Australian Children

BACKGROUND

Higher quality childcare in the years before school may help narrow developmental gaps between the richest and poorest children in our societies, but specific evidence is limited and inconsistent. We address this issue by examining whether higher quality childcare is associated with better developmental outcomes at school entry for children from lower than higher income families.

METHODS

The sample from the Longitudinal Study of Australian Children included children attending childcare from 2 to 3 years (n=980-1187, depending on outcome). Childcare quality was measured using carers assessment of their relationship with the child. Children's receptive vocabulary was directly assessed in the child's home, and behavioural difficulties were measured by teachers and parents at 4-5 years. We assessed additive and multiplicative income-related effect measure modification of the quality of carer-child relationship on developmental outcomes.

RESULTS

After adjusting for confounding, there was some evidence of effect measure modification on the additive and multiplicative scales of childcare quality by income. Children experiencing higher quality relationships and lower income had almost the same risk of poorer receptive vocabulary as children in higher quality relationships and higher incomes (relative excess risk due to interaction=0.18; 95% CI -0.20 to 0.52), ratio of relative risks=1.11 (1.04 to 1.17)). These patterns were similar for teacher-reported and parent-reported behavioural difficulties.

CONCLUSIONS

The effects of higher quality childcare, in terms of quality relationships with carers, on children's cognitive and behavioural development at school entry were stronger among children from lower income families. This provides some evidence that higher quality relationships in childcare may be especially important in helping reduce developmental gaps for children from lower income families.

Occupational position, work stress and depressive symptoms: a pathway analysis of longitudinal SHARE data

Background

Several studies tested whether stressful work mediates the association between socioeconomic position (SEP) and health. Although providing moderate support, evidence is still inconclusive, partly due to a lack of theory-based measures of SEP and work stress, and because of methodological limitations. This contribution aims at overcoming these limitations.

Methods

We conduct pathway analysis and investigate indirect effects of SEP on mental health via stressful work. Data are derived from the first two waves of the ‘Survey of Health, Ageing and Retirement in Europe’ (SHARE) with information from employed men and women aged 50–64 across 11 European countries (N=2798). SEP is measured according to two alternative measures of occupational position: occupational class (focus on employment relations) and occupational status (focus on prestige). We assess work stress according to the effort-reward imbalance and the demand-control model (wave 1), and we use newly occurring depressive symptoms as health outcome (wave 2).

Results

Effort-reward imbalance and, less consistently, low control mediate the effect of occupational class and occupational status on depressive symptoms.

Conclusions

Our findings point to two important aspects of work stress (effort-reward imbalance and low control) in explaining socioeconomic differences in health. Further, we illustrate the significance of two alternative dimensions of occupational position, occupational class and occupational status.

Associations of financial strain and income with depressive and anxiety disorders

BACKGROUND

Previous research has shown socioeconomic inequality in prevalence and onset of depressive disorders. It is not yet clear whether perceived financial strain is associated with depressive and/or anxiety disorders in addition to an objective indicator, such as income. This study examines whether financial strain is associated with the prevalence and onset/recurrence of depressive and/or anxiety disorders, above income.

METHODS

Data are from the Netherlands Study of Depression and Anxiety. Associations between financial strain, income and presence of depressive and/or anxiety disorder at baseline were assessed among 2937 participants (18-65 years). Impact of financial strain and income on 4-year onset/recurrence of depressive and/or anxiety disorders were examined among 1250 participants without a depressive or anxiety disorder at baseline. Depressive and anxiety disorders were determined with the Composite-International-Diagnostic-Interview. Financial strain and income were assessed in an interview.

RESULTS

Participants with mild or severe financial strain had higher odds of being depressed (OR=1.68, 95% CI 1.35 to 2.09; OR=3.88, 95% CI 2.58 to 5.81) or remitted (OR=1.56, 95% CI 1.24 to 1.96; OR=1.99, 95% CI 1.27 to 3.11) at baseline compared with healthy controls, after adjusting for income. Mild or severe financial strain was not associated with onset/recurrence of depressive and/or anxiety disorders during follow-up (OR=1.08, 95% CI 0.83 to 1.42; OR=1.05, 95% CI 0.64 to 1.73).

CONCLUSIONS

Financial strain was associated with having a depressive and/or anxiety disorder, above the effect of income. Healthcare and social services should be alert to this association, even for higher income households. However, financial strain and income were not related with 4-year onset/recurrence of depressive and/or anxiety disorders.

Political party affiliation, political ideology and mortality

BACKGROUND

Ecological and cross-sectional studies have indicated that conservative political ideology is associated with better health. Longitudinal analyses of mortality are needed because subjective assessments of ideology may confound subjective assessments of health, particularly in cross-sectional analyses.

METHODS

Data were derived from the 2008 General Social Survey-National Death Index data set. Cox proportional analysis models were used to determine whether political party affiliation or political ideology was associated with time to death. Also, we attempted to identify whether self-reported happiness and self-rated health acted as mediators between political beliefs and time to death.

RESULTS

In this analysis of 32,830 participants and a total follow-up time of 498,845 person-years, we find that political party affiliation and political ideology are associated with mortality. However, with the exception of independents (adjusted HR (AHR)=0.93, 95% CI 0.90 to 0.97), political party differences are explained by the participants' underlying sociodemographic characteristics. With respect to ideology, conservatives (AHR=1.06, 95% CI 1.01 to 1.12) and moderates (AHR=1.06, 95% CI 1.01 to 1.11) are at greater risk for mortality during follow-up than liberals.

CONCLUSIONS

Political party affiliation and political ideology appear to be different predictors of mortality.

Socioeconomic inequalities in cause-specific mortality in 15 European cities

BACKGROUND

Socioeconomic inequalities are increasingly recognised as an important public health issue, although their role in the leading causes of mortality in urban areas in Europe has not been fully evaluated. In this study, we used data from the INEQ-CITIES study to analyse inequalities in cause-specific mortality in 15 European cities at the beginning of the 21st century.

METHODS

A cross-sectional ecological study was carried out to analyse 9 of the leading specific causes of death in small areas from 15 European cities. Using a hierarchical Bayesian spatial model, we estimated smoothed Standardized Mortality Ratios, relative risks and 95% credible intervals for cause-specific mortality in relation to a socioeconomic deprivation index, separately for men and women.

RESULTS

We detected spatial socioeconomic inequalities for most causes of mortality studied, although these inequalities differed markedly between cities, being more pronounced in Northern and Central-Eastern Europe. In the majority of cities, most of these causes of death were positively associated with deprivation among men, with the exception of prostatic cancer. Among women, diabetes, ischaemic heart disease, chronic liver diseases and respiratory diseases were also positively associated with deprivation in most cities. Lung cancer mortality was positively associated with deprivation in Northern European cities and in Kosice, but this association was non-existent or even negative in Southern European cities. Finally, breast cancer risk was inversely associated with deprivation in three Southern European cities.

CONCLUSIONS

The results confirm the existence of socioeconomic inequalities in many of the main causes of mortality, and reveal variations in their magnitude between different European cities.

Environmental influences on children's physical activity

BACKGROUND

This paper aims to assess whether 7-year-olds' physical activity is associated with family and area-level measures of the physical and socioeconomic environments.

METHODS

We analysed the association of environments with physical activity in 6497 singleton children from the UK Millennium Cohort Study with reliable accelerometer data (≥2 days and ≥10 h/day). Activity levels were assessed as counts per minute; minutes of moderate to vigorous activity (MVPA); and whether meeting recommended guidelines (≥60 min/day MVPA).

RESULTS

Higher levels of children's physical activity were associated with households without use of a car and with having a television in a child's bedroom (for counts per minute only). Aspects of the home socioeconomic environment that were associated with more children's physical activity were lone motherhood, lower maternal socioeconomic position and education, family income below 60% national median, and not owning the home. Children's activity levels were higher when parents perceived their neighbourhood as poor for bringing up children and also when families were living in the most deprived areas. Relationships were independent of characteristics such as child's body mass index and ethnic group. When adjusted for physical and socioeconomic correlates, the factors remaining significant in all outcomes were: household car usage and maternal education.

CONCLUSIONS

Although physical and socioeconomic environments are associated with children's physical activity, much of the variation appears to be determined by the child's home socioeconomic circumstances rather than the wider environment where they live.

Socioprofessional trajectories and mortality in France, 1976-2002: a longitudinal follow-up of administrative data

BACKGROUND

Occupying a low socioeconomic position is associated with increased mortality risk. To disentangle this association, previous studies considered various dimensions of socioeconomic trajectories across the life course. However, they used a limited number of stages. We simultaneously examined various dimensions of the whole professional trajectory and its association with mortality.

METHODS

We used a large sample (337,706 men and 275,378 women) of the data obtained by linking individuals' annual occupation (collected in 1976-2002 from a representative panel of the French salaried population in the semipublic and private sectors) with causes of death obtained from registries. All-cause and cause-specific HRs were estimated using Cox's regression models adjusted for the occupational class at the beginning of the follow-up, the current occupational class, the transition rates between occupational categories and the duration of time spent in occupational categories.

RESULTS

An increase in the time spent in the clerk class increased men and women's cardiovascular mortality risk compared with that in the upper class (HRs=1.59 (1.14 to 2.20) and 2.65 (1.14 to 6.13) for 10 years increase, respectively, for men and women). Men with a high rate of transitions had about a 1.2-fold increased risk of all-cause and external-cause mortality compared with those without transitions during their professional life. This association was also observed for women's all-cause mortality.

CONCLUSIONS

Strong associations between professional trajectories and mortality from different causes of death were found. Long exposure to lower socioeconomic conditions was associated with increased mortality risk from various causes of death. The results also suggest gradual associations between transition rates and mortality.

Internet use, social engagement and health literacy decline during ageing in a longitudinal cohort of older English adults

Background

Health literacy skills tend to decline during ageing, which is often attributed to age-related cognitive decline. Whether health literacy skills may be influenced by technological and social factors during ageing is unknown.

Methods

We investigated whether internet use and social engagement protect against health literacy decline during ageing, independent of cognitive decline. We used prospective data from 4368 men and women aged ≥52 years in the English Longitudinal Study of Ageing from 2004 to 2011. Health literacy was measured at baseline (2004–2005) and at follow-up (2010–2011) using a reading comprehension test of a fictitious medicine label. The influences of consistent internet use and engagement in each of the civic, leisure and cultural activities on health literacy decline over the follow-up were estimated.

Results

After adjusting for cognitive decline and other covariates, consistent internet use (1379/4368; 32%) was protectively associated with health literacy decline (OR=0.77; 95% CI 0.60 to 0.99), as was consistent engagement in cultural activities (1715/4368; 39%; OR=0.73; 95% CI 0.56 to 0.93). As the number of activities engaged in increased, the likelihood of health literacy decline steadily decreased (p_trend<0.0001), with OR=0.51 (95% CI 0.33 to 0.79) for engaging in all four of the internet use and civic, leisure and cultural activities versus none.

Conclusions

Internet use and social engagement, particularly in cultural activities (eg, attending the cinema, art galleries, museums and the theatre), may help older adults to maintain health literacy during ageing. Support for older adults to maintain socially engaged lives and to access the internet should help promote the maintenance of functional literacy skills during ageing.

A glossary of policy frameworks: the many forms of 'universalism' and policy 'targeting'

The recognition that certain characteristics (such as poverty, disadvantage or membership of marginalised social or cultural groups) can make individuals more susceptible to illness has reignited interest in how to combine universal programmes and policies with ones targeted at specific groups. However, 'universalism' and 'targeting' are used in different ways for different purposes. In this glossary, we define different types and approaches to universalism and targeting. We anticipate that greater clarity in relation to what is meant by 'universalism' and 'targeting' will lead to a more nuanced debate and practice in this area.

Amenable mortality by household income and living arrangements: a linked register-based study of Finnish men and women in 2000-2007

BACKGROUND

Mortality amenable to healthcare interventions has increasingly been used as an indirect indicator of the effect of healthcare on health inequalities. Studies have consistently shown socioeconomic differences in amenable mortality, but evidence on the joint effects of multiple socioeconomic and demographic factors is limited. We examined whether income and living arrangements have an independent effect on amenable mortality taking into account other dimensions of social position.

METHODS

The longitudinal and yearly updated individual level data were derived from different administrative registers and obtained from Statistics Finland. The data set includes an 11% random sample of all individuals aged 25-74 years at the end of 1999 and an 80% oversample of deaths in the follow-up period between 2000 and 2007. We used Cox proportional hazard regression with appropriate weights.

RESULTS

We found twofold to threefold differences in amenable mortality between the top and bottom income quintiles. These differences were found to be largely attenuated by economic activity and living arrangements. We also found differences in amenable mortality by living arrangements suggesting that those living alone, as well as lone parents and those cohabiting have higher amenable mortality. These differences were largely independent of our indicators of socioeconomic position and economic activity.

CONCLUSIONS

While our results give indirect support to the hypothesis that income differences in amenable mortality may be at least partially due to barriers in access to care, the large independent effects of living arrangements on amenable mortality suggest that seeking care may also have an impact.

Decomposing social capital inequalities in health

BACKGROUND

Research has shown network social capital associated with a range of health behaviours and conditions. Little is known about what social capital inequalities in health represent, and which social factors contribute to such inequalities.

METHODS

Data come from the Montreal Neighbourhood Networks and Healthy Aging Study (n=2707). A position generator was used to collect network data on social capital. Health outcomes included self-reported health (SRH), physical inactivity, and hypertension. Social capital inequalities in low SRH, physical inactivity, and hypertension were decomposed into demographic, socioeconomic, network and psychosocial determinants. The percentage contributions of each in explaining health disparities were calculated.

RESULTS

Across the three outcomes, higher educational attainment contributed most consistently to explaining social capital inequalities in low SRH (% C=30.8%), physical inactivity (15.9%), and hypertension (51.2%). Social isolation, contributed to physical inactivity (11.7%) and hypertension (18.2%). Sense of control (24.9%) and perceived cohesion (11.5%) contributed to low SRH. Age reduced or increased social capital inequalities in hypertension depending on the age category.

CONCLUSIONS

Interventions that include strategies to reduce socioeconomic inequalities and increase actual and perceived social connectivity may be most successful in reducing social capital inequalities in health.

Central gender theoretical concepts in health research: the state of the art

Despite increasing awareness of the importance of gender perspectives in health science, there is conceptual confusion regarding the meaning and the use of central gender theoretical concepts. We argue that it is essential to clarify how central concepts are used within gender theory and how to apply them to health research. We identify six gender theoretical concepts as central and interlinked-but problematic and ambiguous in health science: sex, gender, intersectionality, embodiment, gender equity and gender equality. Our recommendations are that: the concepts sex and gender can benefit from a gender relational theoretical approach (i.e., a focus on social processes and structures) but with additional attention to the interrelations between sex and gender; intersectionality should go beyond additive analyses to study complex intersections between the major factors which potentially influence health and ensure that gendered power relations and social context are included; we need to be aware of the various meanings given to embodiment, which achieve an integration of gender and health and attend to different levels of analyses to varying degrees; and appreciate that gender equality concerns absence of discrimination between women and men while gender equity focuses on women's and men's health needs, whether similar or different. We conclude that there is a constant need to justify and clarify our use of these concepts in order to advance gender theoretical development. Our analysis is an invitation for dialogue but also a call to make more effective use of the knowledge base which has already developed among gender theorists in health sciences in the manner proposed in this paper.

CVD risk among men participating in the National Health and Nutrition Examination Survey (NHANES) from 2001 to 2010: differences by sexual minority status

BACKGROUND

Recent research indicates that sexual minority women are at increased risk for cardiovascular disease (CVD) compared with heterosexual women; however, few studies of CVD risk exist for sexual minority men (SMM). This study aimed to determine whether disparities in CVD risk exist for SMM and if CVD risk is consistent across subgroups of SMM.

METHODS

This study utilised publicly available data from the National Health and Nutrition Examination Survey (NHANES), pooled from 2001 to 2010. CVD risk was calculated using the Framingham General CVD Risk Score and operationalised as the ratio of a participant's vascular and chronological age. Differences in this ratio were examined between heterosexual and SMM as a whole, and within subgroups of SMM.

RESULTS

SMM had vascular systems that were, on average, 4% (95% CI -7.5% to -0.4%) younger than their heterosexual counterparts; however, adjustment for education and history of hard drug use rendered this difference statistically insignificant. Analysis of SMM subgroups revealed increased CVD risk for bisexual men and decreased CVD risk for both gay and homosexually experienced heterosexual men when compared with heterosexual men. Differences in CVD risk persisted for only bisexual and homosexually experienced heterosexual men after adjustment for education and history of hard drug use.

CONCLUSIONS

Subgroups of SMM are at increased risk for CVD compared with heterosexual men, and this increased risk cannot be completely attributed to differences in demographic characteristics or negative health behaviours.

Political and economic characteristics as moderators of the relationship between health services and infant mortality in less-developed countries

BACKGROUND

Few studies have addressed how political and economic contexts shape the effects of health services and environment, such that a politically and economically unstable society, despite having sufficient health professionals and facilities, finds it difficult to transfer health resources into actual population health performance. We examined whether political and economic characteristics moderate the effects of health services on infant mortality rates (IMR) in less-developed countries.

METHODS

This study used a longitudinal ecological study design and focused on 46 less-developed countries during the 30-year period from 1980 to 2009. Data were derived from World Development Indicators, the United Nations Commodity Trade Statistics Database and the Polity IV project. Lagged dependent variable panel regression models were used to increase the causal inferences. Random intercept models were used to accommodate the possible problem of a serial correlation of errors because of the repeated measurements.

RESULTS

After controlling for baseline IMR and other socioeconomic variables, our study showed that democracy had a direct effect on IMR, and a moderating effect on the relationship between health services and IMR. The effects of health services on IMR were stronger for countries with a lower level of democracy than for countries with a higher level of democracy in the 10-year models. Compared with other trade-rated characteristics, democracy is a more robust predictor of long-term IMR in less-developed countries.

CONCLUSIONS

Our study provides additional evidence that democracy has direct effects on IMR and further showed that democracy can modify the effects of health services on IMR.

Health impacts of free bus travel for young people: evaluation of a natural experiment in London

BACKGROUND

We used the introduction of free bus travel for young people in London in 2005 as a natural experiment with which to assess its effects on active travel, car use, road traffic injuries, assaults, and on one measure of social inclusion, total number of trips made.

METHODS

A controlled before-after analysis was conducted. We estimated trips by mode and distances travelled in the preintroduction and postintroduction periods using data from London Travel Demand Surveys. We estimated rates of road traffic injury and assault in each period using STATS19 data and Hospital Episode Statistics, respectively. We estimated the ratio of change in the target age group (12-17 years) to the change in adults (ages 25-59 years), with 95% CIs.

RESULTS

The proportion of short trips travelled by bus by young people increased postintroduction. There was no evidence for an increase in the total number of bus trips or distance travelled by bus by young people attributable to the intervention. The proportion of short trips by walking decreased, but there was no evidence for any change to total distance walked. Car trips declined in both age groups, although distance travelled by car decreased more in young people. Road casualty rates declined, but the pre-post ratio of change was greater in young people than adults (ratio of ratios 0.84; 95% CI 0.82 to 0.87). Assaults increased and the ratio of change was greater in young people (1.20; 1.13 to 1.27). The frequency of all trips by young people was unchanged, both in absolute terms and relative to adults.

CONCLUSIONS

The introduction of free bus travel for young people had little impact on active travel overall and shifted some travel from car to buses that could help broader environmental objectives.