Patterns and socioeconomic differences in secondhand exposure to cigarettes, e-cigarettes, and heated tobacco products at home in Hong Kong adolescents

INTRODUCTION

Smoke or aerosols from cigarettes, e-cigarettes (ECs), or heated tobacco products (HTPs) are harmful. Yet, there is little knowledge about the specific patterns of secondhand tobacco exposure by source within household settings and the socioeconomic status (SES) differences in adolescents.

METHODS

We used territory-representative student data from a cross-sectional school-based survey in 2020-2021 to calculate the weighted prevalence of secondhand exposure to cigarettes, e-cigarettes, and HTPs in the past seven days. Parental education and perceived family affluence were used as indicators of socioeconomic status. Generalized linear mixed models were used to analyze associations.

RESULTS

Among 22039 participants, 29.8% reported any secondhand tobacco exposure (SH-Any) at home, primarily from cigarettes (27.4%), followed by e-cigarettes (4.0%) and HTPs (0.9%). Tertiary parental education level was associated with lower SH-Any exposure (Adjusted odds ratio, AOR=0.49; 95% CI: 0.45-0.53, p<0.001), fewer exposure days (β= -0.685, p<0.001), lower exposure to cigarettes (SH-CC) (AOR=0.49; 95% CI: 0.45-0.54, p<0.001) and to e-cigarettes or HTPs (SH-EC/HTP) (AOR=0.57; 95% CI: 0.45-0.71, p<0.001). 'Poor' family affluence was associated with higher exposures [AOR(SH-Any) =1.14; 95% CI: 1.06-1.22, p=0.001; β(days)=0.160, p<0.001; AOR(SH-CC) =1.15; 95% CI: 1.07-1.24, p<0.001], except for SH-EC/HTP exposure, which was higher in students in an affluent family (AOR =1.66; 95% CI: 1.25-2.21, p<0.001). Significant SES differences in SH-EC/HTP exposure were found only in groups with low parental education level. Dose-response relationships were found between lower SH-Any and SH-CC and higher SES categories (p for trend<0.001).

CONCLUSIONS

Adolescents experienced a high prevalence of tobacco smoke exposure at home, primarily from cigarettes. Higher SES was associated with lower tobacco exposure, except for SH-EC/HTP, which was higher among adolescents from affluent families. Additionally, high parental education level was protective against exposure to SH-EC/HTP. Comprehensive control measures to reduce the use of these tobacco products are needed to protect adolescents of diverse socioeconomic backgrounds.

Trends in social inequality in breastfeeding duration in Denmark 2002-2019

AIMS

The aim of the present study was to analyse trends in full breastfeeding for at least 4 months across socioeconomic position in Denmark over a 17-year-long period from 2002 to 2019 using parental education as the indicator of socioeconomic position.

METHODS

The study used data on full breastfeeding collected between 2002 and 2019 by community health nurses in the collaboration Child Health Database, n=143,075. Data were linked with five categories of parental education from population registers. Social inequality was calculated as both the relative (odds ratio) and absolute social inequality (slope index of inequality). A trend test was conducted to assess changes in social inequality over time.

RESULTS

A social gradient in full breastfeeding was found for the entire study period. The odds ratio for not being fully breastfed for at least 4 months ranged from 3.30 (95% confidence interval 2.83-3.84) to 5.09 (95% confidence interval 4.28-6.06) during the study period for infants of parents with the lowest level of education (primary school) compared with infants of parents with the highest level of education (5+ years of university education). The slope index of inequality was between -38.86 and -48.81 during the entire study period, P=0.80. This indicated that both the relative and absolute social inequality in full breastfeeding to at least 4 months of age was unchanged in the study period from 2002 to 2019.

CONCLUSIONS

This study showed a persistent relative and absolute social inequality in full breastfeeding for at least 4 months from 2002 to 2019 in Denmark.

Barriers associated with pulse and plant-based meat alternative consumption across sociodemographic groups: a Capability, Opportunity, Motivation, Behaviour model approach

Introduction

To enhance environmental sustainability and food security, there should be a change in dietary protein consumption. It is suggested that meat consumption should be reduced and that the currently low consumption of pulses and other plant-based proteins should increase. We aimed to examine (1) how sociodemographic factors and perceived barriers are associated with self-reported current and perceived future pulse and other plant-based meat alternative (PBMA) consumption and (2) how sociodemographic factors relate to perceived barriers.

Methods

Participants were 18-75 year-old Finnish adults (n = 1,000). Multivariable logistic regression was used as the main analysis technique. The results were interpreted by employing the Capability, Opportunity, Motivation, Behaviour (COM-B) model.

Results

Pulses were consumed more often than PBMAs and lower education level and financial strain were associated with more infrequent pulse and PBMA use. The most common perceived barriers for pulse consumption were unfamiliarity, expensive price, and unpleasant taste, which can be interpreted to represent the capability, opportunity and motivation components of the COM-B model, respectively. Women, the young, and financially strained perceived more barriers limiting their pulse consumption than others.

Discussion

To increase plant-based food consumption, it is important that tasty, easy to use and affordable plant-based foods are available for all. Additionally, we suggest that food services should be encouraged to increase the use of pulses in their dishes and that capabilities, opportunities and motivations are taken into account in intervention measures advancing plant protein consumption.

Intergenerational transmission of parental risky health behaviors in Chinese children: Are there socioeconomic status differences?

Background

Risky health behaviors in childhood, including smoking, alcohol consumption, and having a poor diet, are the major sources of non-communicable diseases in adulthood. This study aimed to examine how parents affect children's risky health behaviors and whether intergenerational transmission differs based on socioeconomic status (SES).

Methods

Data were extracted from the 1991-2015 China Health and Nutrition Survey (CHNS). Smoking (n = 5,946), alcohol consumption (n = 7,821), and sugar-sweetened beverages (SSBs) consumption (n = 3,537) were used as proxies for risky health behaviors in children. A binary choice model for panel data with a random-effect specification was employed to examine whether risky health behaviors can be transmitted from parents to their children. Subsequently, we conducted a seemingly unrelated estimation test (SUEST) to explore the differences in parental transmission between the different SES groups.

Results

We found strong intergenerational persistence of smoking, alcohol drinking, and SSBs drinking behaviors, except for the mothers' smoking behavior. Mothers had a greater influence on children's alcohol drinking and SSBs drinking behaviors than fathers both in urban and rural areas and in different SES groups. The intergenerational transmission of SSBs drinking behavior exhibited a decreasing trend with increasing SES for both urban and rural families. In urban areas, mothers' alcohol drinking behavior has a decreasing trend with increasing education level, occupation, and income; however, in rural areas, the influence of mothers' alcohol drinking behavior occurred in the same direction with increasing education level and occupation type. In rural areas, the influence of fathers' drinking and smoking behaviors on children appears to mostly increase with increasing SES. Meanwhile, the influence of such behaviors among urban fathers would decrease with increasing SES.

Conclusion

Parents' behaviors and SES can influence the initiation of risky health behaviors in their offspring. Thus, to promote healthy behaviors, policymakers can introduce health education programs for parents, particularly for those living in rural areas and with a low SES.

Disparities in Nutritional Adequacy of Diets between Different Socioeconomic Groups of Finnish Adults

Information on dietary adequacy is needed to assess food and nutrition security in a modern society, especially in the transition towards climate-friendly food systems. In this study, differences in the nutritional adequacy of diets among Finnish adults were evaluated in population groups of different education, income and urbanisation levels. The study used data from the FinDiet 2017 Survey (n = 1655, 18-74 years). Modelled usual intakes of foods and nutrients were evaluated relative to food-based dietary guidelines issued by the National Nutrition Council of Finland (FNNC) and with respect to nutrient adequacy following the Nordic Nutrition Recommendations and FNNC. For about half of the nutrients studied, intakes were found to be adequate. Intakes of protein, fat, saturated fatty acids and salt were estimated to be high. By contrast, inadequate intakes were seen in folate and vitamins A, D, B1, B2 and C in almost all groups studied. Groups with a higher education and income, groups that lived in urban areas and, in particular, women adhered more closely to recommended food consumption and nutrient intakes than others. However, major challenges posed by the Finnish diet are common to all groups studied, and only certain dietary features evaluated in view of nutritional adequacy are associated with socioeconomic differences.

Socioeconomic differences in food habits among 6- to 9-year-old children from 23 countries-WHO European Childhood Obesity Surveillance Initiative (COSI 2015/2017)

BACKGROUND

Socioeconomic differences in children's food habits are a key public health concern. In order to inform policy makers, cross-country surveillance studies of dietary patterns across socioeconomic groups are required. The purpose of this study was to examine associations between socioeconomic status (SES) and children's food habits.

METHODS

The study was based on nationally representative data from children aged 6-9 years (n = 129,164) in 23 countries in the World Health Organization (WHO) European Region. Multivariate multilevel analyses were used to explore associations between children's food habits (consumption of fruit, vegetables, and sugar-containing soft drinks) and parental education, perceived family wealth and parental employment status.

RESULTS

Overall, the present study suggests that unhealthy food habits are associated with lower SES, particularly as assessed by parental education and family perceived wealth, but not parental employment status. We found cross-national and regional variation in associations between SES and food habits and differences in the extent to which the respective indicators of SES were related to children's diet.

CONCLUSION

Socioeconomic differences in children's food habits exist in the majority of European and Asian countries examined in this study. The results are of relevance when addressing strategies, policy actions, and interventions targeting social inequalities in children's diets.

Manual occupations with high all-cause mortality: The contribution of socioeconomic and occupational characteristics

AIMS

Most high mortality-risk occupations are manual occupations. We examined to what extent high mortality of such occupations could be explained by education, income, unemployment or industry and whether there were differences in these effects among different manual occupations.

METHODS

We used longitudinal individual-level register-based data, the study population consisting of employees aged 30-64 at the end of the year 2000 with the follow-up period 2001-2015. We used Cox proportional hazard regression models in 31 male and 11 female occupations with high mortality.

RESULTS

There were considerable differences between manual occupations in how much adjusting for education, income, unemployment and industry explained the excess mortality. The variation was especially large among men: controlling for these variables explained over 50% of the excess mortality in 23 occupations. However, in some occupations the excess mortality even increased in relation to unadjusted mortality. Among women, these variables explained a varying proportion of the excess mortality in every occupation. After adjustment of all variables, mortality was no more statistically significantly higher than average in 14 occupations among men and 2 occupations among women.

CONCLUSIONS

The high mortality in manual occupations was mainly explained by education, income, unemployment and industry. However, the degree of explanation varied widely between occupations, and considerable variation in mortality existed between manual occupations after controlling for these variables. More research is needed on other determinants of mortality in specific high-risk occupations.

Race, ethnicity, and socioeconomic differences in incidence of pediatric embryonal tumors in the United States

BACKGROUND

The etiology of childhood cancers and its social patterning remains largely unknown. Accounting for socioeconomic status (SES) when exploring the association between race/ethnicity and cancer incidence is necessary to better understand such etiology. We aimed to investigate differences in the incidence of embryonal tumors (ETs) by SES and race/ethnicity in the United States using population-based registries of the Surveillance, Epidemiology, and End Results (SEER) Program.

PROCEDURE

Children with ETs aged 0-19 years diagnosed between 2000 and 2015 were ascertained from the census tract-level SEER database. SES was measured using a tract-level composite index. Incidence rate ratios (IRRs) with 95% confidence intervals (CIs) by SES quintile and race/ethnicity were estimated using multivariable Poisson regression models.

RESULTS

The majority of tumors had lower incidence among nonwhite children compared with non-Hispanic (NH) white children, after controlling for SES. NH blacks had a higher incidence of Wilms tumor than NH whites (IRR: 1.26; 95% CI, 1.13-1.39). There was an increasing linear trend (P = 0.0001) across increasing SES quintile for embryonal rhabdomyosarcoma after controlling for race/ethnicity. Effect modification by race/ethnicity of the relationship between SES and tumor incidence was observed for several groups. Hispanics had a significant, linear trend (P = 0.0005) in the incidence of Wilms tumor, while Asian/Pacific Islanders experienced a significant inverse trend (P = 0.0002).

CONCLUSIONS

Results from this study suggest differences in the incidence of several ETs by race/ethnicity and that these differences may be modified by SES. Investigation of potential risk factors that are socially patterned is warranted.

Assessing the relationship between multimorbidity and depression in older men and women: the International Mobility in Aging Study (IMIAS)

Objectives: Our study aims to assess whether multimorbidity is an independent risk factor for the development of depression in older adults living in Canada, Brazil, Colombia, and Albania and examines differences in incidence of depression regarding social and psychosocial characteristics.Methods: The longitudinal International Mobility Aging Study (IMIAS) collected information from adults between 65-74 years old. Depression was defined by a 16 or higher score assessed by the Centre for Epidemiological Studies Depression (CES-D) Scale. Multimorbidity was defined as having two or more chronic conditions, which were self-reported by participants using a list of eight physical chronic conditions. Poisson regression was performed to estimate the relative risk of depression in older adults with multimorbidity compared to those living with 0-1 chronic conditions, adjusting for sex, age, education, number of doctor visits, degree of assistance needed, social support, and smoking status. The analysis was stratified by study region (Canada; Latin America; Albania).Results: Crude and adjusted models showed no statistically significant associations between multimorbidity and the incidence of depression in any of the study regions, confirmed by sensitivity analyses. However, the incidence of depression varied across study region, confirmed by the intra-class correlation coefficient which indicated that 13% of variations in depression incidence were due to geographic differences.Conclusion: Multimorbidity does not appear to increase the risk of developing depression in older adults between 65-74. Higher rates of depression in Latin America and Albania (compared to Canada) may be attributed to lifecourse exposures to social and economic adversity in these regions.

Association between socioeconomic position and occupational health service utilisation trajectories among young municipal employees in Finland

OBJECTIVES

To identify groups of municipal employees between the ages of 20 and 34 years with distinct utilisation trajectories of primary care services provided by occupational health service (OHS), measured as the annual number of OHS visits, and to identify demographic and socioeconomic risk factors that distinguish employees in the high utilisation trajectory group(s).

METHODS

The present study is a retrospective register-based cohort study. All municipal employees of the City of Helsinki, Finland, aged 20-34 in the Helsinki Health Study, recruited from 2004 to 2013, with follow-up data for 4 years were included in the study (n=9762). The outcome measure was group-based trajectories of OHS utilisation, identified with a group-based trajectory analysis. The demographic and socioeconomic variables used to predict the outcome were age, first language, educational level and occupational class. The analyses were stratified by gender.

RESULTS

A large proportion of the young employees do not use OHS. Trajectory groups of 'No visits' (50%), 'Low/increasing' (18%), 'Low/decreasing' (22%) and 'High/recurrent' (10%) use were identified. We found occupational class differences in OHS utilisation patterns showing that lower occupational classes had a higher propensity for 'High/recurrent' OHS utilisation for both genders.

CONCLUSIONS

Preventive measures should be targeted particularly to the trajectory groups of 'Low/increasing' and 'High/recurrent' in order to intervene early. In addition, OHS utilisation should be closely monitored among the two lowest occupational classes. More research with longitudinal OHS data is needed.

Economic fluctuations and long-term trends in depression: a repeated cross-sectional study in Estonia 2004-2016

Background

In the 2000s, the Baltic countries experienced unprecedented credit-driven economic growth that was followed by a deep recession. This study examined the impact of profound macroeconomic changes on population mental health in Estonia in 2004–2016.

Methods

Data on 17 794 individuals in the 20–64 age group were obtained from seven nationally representative cross-sectional surveys. The prevalence of past 30-day depression was calculated for men and women further stratified by sociodemographic characteristics. Multivariable regression analysis was used to assess whether these characteristics were associated with the yearly variation in depression.

Results

In 2006, the adjusted prevalence ratio for depression was 0.77 (95% CI 0.64 to 0.93) for men and 0.85 (95% CI 0.74 to 0.97) for women as compared with 2004; in 2010, the prevalence ratio as compared with 2008 for both men and women was 1.22 (95% CIs 1.04 to 1.43 and 1.09 to 1.37, respectively). Among men, the increase in the prevalence of depression in 2008–2010 was statistically significant for 35–64 year olds, ethnic Estonians, those who were married, mid-educated or were employed, whereas among women, a significant increase was observed in 50–64 year olds, Estonians and non-Estonians, those who were not-married, were highly educated or mid-educated, in the mid-income group or were employed.

Conclusions

Population mental health is responsive to macroeconomic changes. In less wealthy high-income countries, the greater impact of recession on depression among advantaged groups may relate to a higher debt burden coupled with job insecurity.

Socioeconomic position and alcohol-related harm in Danish adolescents

BACKGROUND

In adults, it has consistently been observed that with equal alcohol consumption levels, alcohol harms individuals with low socioeconomic position (SEP) more than individuals with high SEP. It is unknown if this so-called alcohol harm paradox is also present in adolescents. We aim to test the hypothesis that low SEP is associated with more alcohol-related harm as compared with higher SEP in Danish adolescents.

METHODS

We used survey data from the Danish National Youth Study 2014 including 70 566 students from 119 high schools. Alcohol-related harm was measured by self-report as having been in a fight, involved in an accident, had problems with parents or friends, had sex that was regretted afterwards and done drugs that was regretted afterwards, because of alcohol. Further, a combined measure was constructed defined as having experienced any harm more than once within the last year. SEP was measured as parents' educational level, family income, parents' employment status and experiencing financial strain in the family. Analyses were adjusted by age, sex, perceived ethnicity, class type and binge drinking.

RESULTS

Lower SEP was associated with higher odds of experiencing alcohol-related harm more than once as compared with highest SEP, and lower SEP was associated with higher odds of having been in a fight, problems with parents or friends, sex and regretting afterwards or drugs and regretting afterwards, as compared with highest SEP. These associations were statistically significant. Adjustment for the frequency of binge drinking did not change results.

CONCLUSION

The alcohol harm paradox exists in Danish adolescents, and this should be addressed in future prevention strategies to reduce the risk of alcohol-related harm among adolescents.

Response patterns of young children from two contrasting SES contexts to different numerical tasks with numbers 1-5

This study contributes to a multifaceted picture of young children's emergent number knowledge by focusing on the variety of ways in which children express and use quantitative information. The authors' aims are to (a) explore the extent to which quantifying collections 1-5 and using that information pose different levels of difficulty to children from 33 to 47 months old, (b) identify intra- and intertask response patterns, and (c) analyze the influence of socioeconomic status and age on these response patterns. Sixty-six children from two contrasting socioeconomic status groups (very low and middle) were asked to solve tasks with 1-5 elements in the context of a game. Using quantitative information turned out to be more complex than quantification. Intra- and intertask response patterns showed that children gradually come to understand the first five numerical values according to the numerical sequence in a much less strict way than that proposed by the cardinal-knowers model that posits that children progress in an orderly way in their number knowledge. Children in different ages and socioeconomic status groups were found to be more similar to each other when the whole arc of responses provided was considered than when solely correct performance was measured.

Increased Health and Wellbeing in Preschools (DAGIS) Study-Differences in Children's Energy Balance-Related Behaviors (EBRBs) and in Long-Term Stress by Parental Educational Level

This paper describes the Increased Health and Wellbeing in Preschools (DAGIS) survey process and socioeconomic status (SES) differences in children's energy balance-related behaviors (EBRBs), meaning physical activity, sedentary and dietary behaviors, and long-term stress that serve as the basis for the intervention development. A cross-sectional survey was conducted during 2015⁻2016 in 66 Finnish preschools in eight municipalities involving 864 children (3⁻6 years old). Parents, preschool personnel, and principals assessed environmental factors at home and preschool with questionnaires. Measurement of children's EBRBs involved three-day food records, food frequency questionnaires (FFQ), seven-day accelerometer data, and seven-day sedentary behavior diaries. Children's long-term stress was measured by hair cortisol concentration. Parental educational level (PEL) served as an indicator of SES. Children with low PEL had more screen time, more frequent consumption of sugary beverages and lower consumption of vegetables, fruit, and berries (VFB) than those with high PEL. Children with middle PEL had a higher risk of consuming sugary everyday foods than children with high PEL. No PEL differences were found in children's physical activity, sedentary time, or long-term stress. The DAGIS intervention, aiming to diminish SES differences in preschool children's EBRBs, needs to have a special focus on screen time and consumption of sugary foods and beverages, and VFB.

Quitting activity and use of cessation assistance reported by smokers in eight European countries: Findings from the EUREST-PLUS ITC Europe Surveys

INTRODUCTION

There is clear evidence that the use of cessation aids significantly increases the likelihood of successful smoking cessation. The aim of this study was to examine quitting activity and use of cessation aids among smokers from various European countries. Subgroup differences were also examined for sex, income, education, and age in each country.

METHODS

Cross-sectional data were collected in 2016 from 10,683 smokers in eight European countries participating in the ITC Project: England (n=3,536), Germany (n=1,003), Greece (n=1,000), Hungary (n=1,000), the Netherlands (n=1,136), Poland (n=1,006), Romania (n=1,001), and Spain (n=1,001). We measured quitting activity, including quit attempts in the previous 12 months and intention to quit, use of cessation aids (i.e., medication, quitlines, internet, local services, and e-cigarettes), and whether respondents had received advice about quitting and e-cigarettes from health professionals.

RESULTS

Quit attempts were most common in England (46.3%) and least common in Hungary (10.4%). Quit intention was highest in England and lowest in Greece. Use of e-cigarettes to quit was highest in England (51.6%) and lowest in Spain (5.0%). Use of cessation aids was generally low across all countries; in particular this was true for quitlines, internet-based support, and local services. Receiving health professional advice to quit was highest in Romania (56.5%), and lowest in Poland (20.8%); few smokers received advice about e-cigarettes from health professionals. No clear differences were found for sex and income groups. Across countries, smokers with lower education reported less quitting activity.

CONCLUSIONS

Quitting activity and use of cessation methods were low in most countries. Greater quit attempts and use of cessation aids were found in England, where large investments in tobacco control and smoking cessation have been made. Health professionals are important for motivating smokers to quit and promoting the effectiveness of various methods, but overall, few smokers get advice to quit.

Self-Certified Sickness Absence among Young Municipal Employees-Changes from 2002 to 2016 and Occupational Class Differences

We examined changes in self-certified, one-to-three day sickness absence (SA) among young employees from 2002 to 2016 and the magnitude of occupational class differences during that period. All 18–34-year-old employees of the City of Helsinki, Finland were included (2002–2016, n = ~11,725 per year). Employer’s personnel and SA registers were used. Occupational class was categorized to four groups. Changes in self-certified SA from 2002 to 2016 were analyzed with Joinpoint regression and the magnitudes of occupational class differences were estimated with the relative index of inequality (RII). Most of the trends first increased and turned to decrease in 2007/2010. Managers and professionals had the least amount of SA, but steadily increasing trends were observed among men. Self-certified SA followed only partially the typical socioeconomic gradient, as routine non-manuals had the highest levels of SA. The magnitude of occupational class differences in self-certified SA was stable during the study period only among women. Self-certified SA and occupational class differences have increased in recent years among men in the lower occupational classes. Socioeconomic differences exist in self-certified SA among young employees, but gradient is only partial. Overall, high amounts of self-certified SA especially in the lower occupational classes require further studies and preventive measures.

Educational inequalities in hospital care for mortally ill patients in Norway

AIMS

Health care should be allocated fairly, irrespective of patients' social standing. Previous research suggests that highly educated patients are prioritized in Norwegian hospitals. This study examines this contentious issue by a design which addresses two methodological challenges. Control for differences in medical needs is approximated by analysing patients who died from same causes of death. Area fixed effects are used for avoiding that observed educational inequalities are contaminated by geographical differences.

METHODS

Men and women who died 2009-2011 at age 55-94 were examined ( N=103,000) with register data from Statistics Norway and the Norwegian Patient Registry. Educational differences in quantity of hospital-based medical care during the 12-24 months before death were analysed, separate for main causes of death. Multivariate negative binomial regression models were estimated, with fixed effects for residential areas.

RESULTS

High-educated patients who died from cancers had significantly more outpatient consultations at somatic hospitals than low-educated patients during an average observation period of 18 months prior to death. Similar, but weaker, educational inequalities appeared for outpatient visits for patients whose deaths were due to other causes. Also, educational inequalities in number of hospital admissions were marked for those who died from cancers, but insignificant for patients who died from other causes.

CONCLUSIONS

Even when medical needs are similar for mortally ill patients, those with high education tend to receive more medical services in Norwegian somatic hospitals than patients with low education. The roles played by physicians and patients in generating these patterns should be explored further.

The Magnitude of Occupational Class Differences in Sickness Absence: 15-Year Trends among Young and Middle-Aged Municipal Employees

Background: Our aim was to examine the magnitude of relative occupational class differences in sickness absence (SA) days over a 15-year period among female and male municipal employees in two age-groups. Methods: 18-34 and 35-59-year-old employees of the City of Helsinki from 2002 to 2016 were included in our data (n = ~37,500 per year). Occupational class was classified into four groups. The magnitude of relative occupational class differences in SA was studied using the relative index of inequality (RII). Results: The relative occupational class differences were larger among older than younger employees; the largest differences were among 35-59-year-old men. Among women in both age-groups the relative class differences remained stable during 2002-2016. Among younger and older men, the differences were larger during the beginning of study period than in the end. Among women in both age-groups the RII values were between 2.19 (95% confidence intervals (CI) 1.98, 2.42) and 3.60 (95% CI 3.28, 3.95). The corresponding differences varied from 3.74 (95% CI 3.13, 4.48) to 1.68 (95% CI 1.44, 1.97) among younger and from 6.43 (95% CI 5.85, 7.06) to 3.31 (95% CI 2.98, 3.68) among older men.

CONCLUSIONS

Relative occupational class differences were persistent among employees irrespective of age group and gender. Preventive measures should be started at young age.

Educational differences in responses to breast cancer symptoms: A qualitative comparative study

OBJECTIVE

Advanced stage at diagnosis for breast cancer is associated with lower socio-economic status (SES). We explored what factors in the patient interval (time from noticing a bodily change to first consultation with a health care professional) may contribute to this inequality.

DESIGN

Qualitative comparative study.

METHODS

Semi-structured interviews with a sample of women (≥47 years) from higher (n = 15) and lower (n = 15) educational backgrounds, who had experienced at least one potential breast cancer symptom. Half the participants (n = 15) had sought medical help, half had not (n = 15). Without making breast cancer explicit, we elicited women's sense-making around their symptoms and help-seeking decisions.

RESULTS

Containment of symptoms and confidence in acting upon symptoms emerged as two broad themes that differentiated lower and higher educational groups. Women from lower educational backgrounds tended to attribute their breast symptoms to trivial factors and were reticent in using the word 'cancer'. Despite 'knowing' that symptoms could be related to cancer, women with lower education invoked lack of medical knowledge - 'I am not a doctor' - to express uncertainty about interpreting symptoms and accessing help. Women with higher education were confident about interpreting symptoms, seeking information online, and seeking medical help.

CONCLUSIONS

Our findings suggest that knowledge of breast cancer alone may not explain socio-economic differences in how women respond to breast cancer symptoms as women with lower education had 'reasons' not to react. Research is needed on how to overcome a wider spectrum of psycho-social factors to reduce future inequality. Statement of contribution What is already known on this subject? Seven of ten breast cancers in the UK are diagnosed after people contact their doctor with symptoms. Women from lower socio-economic backgrounds are more likely to be diagnosed with advanced disease. There is little evidence related to potential drivers of this SES inequality. What does this study add? We qualitatively explored socio-economic (SES) differences in help-seeking for breast symptoms. Women with higher education were more confident about interpreting symptoms and navigating health care. Women with lower education were more reluctant to seek help due to fear of cancer.

Socioeconomic differences in the use of alcohol and drunkenness in adolescents: Trends in the Health Behaviour in School-aged Children study in Finland 1990-2014

AIMS

The aims of this study were to explore time-based trends of socioeconomic differences in alcohol use and drunkenness in Finnish adolescents from 1990 to 2014 and to investigate the significance of two indicators in detecting socioeconomic differences in alcohol use and drunkenness.

METHODS

Data were retrieved from seven surveys conducted as part of the Health Behaviour in School-aged Children (HBSC) study in Finland from 1990 to 2014. The alcohol use and drunkenness of 15-year-old students, as well as socioeconomic status, including educational aspiration and perceived family wealth, were assessed via a self-report questionnaire. Logistic regression models were used to investigate the relationships between alcohol use, drunkenness and indicators of socioeconomic status.

RESULTS

The study showed that the alcohol use and drunkenness of Finnish 15-year-old adolescents have decreased since the late 1990s. However, the level of decrease is not consistent among different socioeconomic groups and socioeconomic differences in drinking behaviour between two educational aspiration groups have persisted over two decades. Girls from the groups with low perceived family wealth were more likely to be frequently drunk in the time period 2006-2014.

CONCLUSIONS

This study suggests that students with low educational aspiration should be the target population for interventions aiming at reducing the alcohol use and drunkenness of Finnish adolescents. In future interventions aimed at reducing heavier drinking, adolescents (especially girls) from less wealthy families should be the first priority. Further studies on trends in socioeconomic differences in alcohol use and drunkenness in adolescence should be conducted using different indicators of socioeconomic status and other social context factors should also be taken into account.

Sociodemographic differences and time trends of bariatric surgery in Sweden 1990-2010

BACKGROUND

The aim of the present study was to examine demographic and socioeconomic differences and time trends of bariatric surgery in Sweden during 1990-2010.

METHODS

An open cohort of all individuals aged 20-64 years was followed between 1990 and 2010. Socioeconomic differences were examined during two periods: 1990-2005 and 2006-2010 using cumulative rates in a closed cohort. Hazard ratios (HRs) of bariatric surgery were calculated in these two periods using Cox regression models.

RESULTS

A majority of the 22,198 individuals that underwent bariatric surgery were women (76.3 %). Women were more likely to undergo surgery in younger ages (30-39 years), while men were more likely to undergo surgery around 10 years later (40-49 years). The number of surgeries increased substantially during the second period. During the whole period, the dominating surgical method was gastric bypass contributing to 69.4 % of the procedures. HRs for bariatric surgery were highest for individuals with intermediate educational level and intermediate-low income in both periods. For married/cohabiting and/or employed individuals, the HRs were highest during the first period whereas an opposite pattern was seen in the second period.

CONCLUSIONS

Individuals in the lowest socioeconomic groups undergo bariatric surgery less often than those with intermediate income and educational level, although previous research has shown that those with low socioeconomic status have the highest rates of morbid obesity. The failure to identify eligible individuals for surgery may result in negative effects on those individuals with the largest need for weight loss.

How an online intervention to prevent excessive gestational weight gain is used and by whom: a randomized controlled process evaluation

BACKGROUND

Online interventions have emerged as a popular strategy to promote healthy behaviors. Currently, there is little agreement about how to capture online intervention engagement. It is also uncertain who engages with weight-related online interventions and how engagement differs by demographic and weight characteristics.

OBJECTIVE

The objectives of this study were to (1) characterize how pregnant women engaged with features of an online intervention to prevent excessive gestational weight gain, (2) identify demographic and weight status subgroups of women within the sample, and (3) examine differences in use of intervention features across the demographic and weight status subgroups.

METHODS

A sample of racially and socioeconomically diverse pregnant women from a northeastern US city was assigned to the intervention group in a randomized controlled trial to prevent excessive gestational weight gain (n=1014). The intervention website included these features: weight-gain tracker, health-related articles, blogs, physical activity and diet goal-setting tools, and local resources. Engagement variables were created to capture the amount, consistency, and patterns of feature use across pregnancy using latent class analysis. Demographic/weight status subgroups were also created using latent class analysis. Differences in engagement across the demographic/weight status subgroups were examined using chi-square analysis.

RESULTS

Six engagement patterns emerged: "super-users" (13.02%, 132/1014), "medium-users" (14.00%, 142/1014), "consistent weight-tracker users" (14.99%, 152/1014); "almost consistent weight-tracker users" (21.99%, 223/1014), "inconsistent weight-tracker users" (15.98%, 162/1014), and "non-users" (20.02%, 203/1014). Four demographic/weight status subgroups emerged: three minority and one white. There were different engagement patterns by demographic/weight status subgroups. Super-users were more likely to be in the white subgroup, while non-users were more likely to be in the minority subgroups. However, around a third of women in minority subgroups were consistently or almost consistently engaging with the weight-tracker (black, young women, 32.2%, 67/208; black, heavier women, 37.9%, 50/132; Hispanic women, 27.4%, 32/117).

CONCLUSIONS

While white and higher income women had higher engagement in general, depending on the measure, there was still considerable engagement by the minority and low-income women.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT01331564; http://clinicaltrials.gov/ct2/show/NCT01331564 (Archived by WebCite at http://www.webcitation.org/6Rw4yKxI5).

Maternal health care utilization in Nairobi and Ouagadougou: evidence from HDSS

Background

Maternal mortality is higher and skilled attendance at delivery is lower in the slums of Nairobi (Kenya) compared to Ouagadougou (Burkina Faso). Lower numbers of public health facilities, greater distance to facilities, and higher costs of maternal health services in Nairobi could explain these differences.

Objective

By comparing the use of maternal health care services among women with similar characteristics in the two cities, we will produce a more nuanced picture of the contextual factors at play.

Design

We use birth statistics collected between 2009 and 2011 in all households living in several poor neighborhoods followed by the Nairobi and the Ouagadougou Health and Demographic Surveillances Systems (n=3,346 and 4,239 births). We compare the socioeconomic characteristics associated with antenatal care (ANC) use and deliveries at health facilities, controlling for demographic variables.

Results

ANC use is greater in Nairobi than in Ouagadougou for every category of women. In Ouagadougou, there are few differentials in having at least one ANC visit and in delivering at a health facility; however, differences are observed for completing all four ANC visits. In Nairobi, less-educated, poorer, non-Kikuyu women, and women living in the neighborhood farther from public health services have poorer ANC and deliver more often outside of a health facility.

Conclusions

These results suggest that women are more aware of the importance of ANC utilization in Nairobi compared to Ouagadougou. The presence of numerous for-profit health facilities within slums in Nairobi may also help women have all four ANC visits, although the services received may be of substandard quality. In Ouagadougou, the lack of socioeconomic differentials in having at least one ANC visit and in delivering at a health facility suggests that these practices stem from the application of well-enforced maternal health regulations; however, these regulations do not cover the entire set of four ANC visits.

Socioeconomic differences in alcohol-attributable mortality compared with all-cause mortality: a systematic review and meta-analysis

BACKGROUND

Factors underlying socioeconomic inequalities in mortality are not well understood. This study contributes to our understanding of potential pathways to result in socioeconomic inequalities, by examining alcohol consumption as one potential explanation via comparing socioeconomic inequalities in alcohol-attributable mortality and all-cause mortality.

METHODS

Web of Science, MEDLINE, PsycINFO and ETOH were searched systematically from their inception to second week of February 2013 for articles reporting alcohol-attributable mortality by socioeconomic status, operationalized by using information on education, occupation, employment status or income. The sex-specific ratios of relative risks (RRRs) of alcohol-attributable mortality to all-cause mortality were pooled for different operationalizations of socioeconomic status using inverse-variance weighted random effects models. These RRRs were then combined to a single estimate.

RESULTS

We identified 15 unique papers suitable for a meta-analysis; capturing about 133 million people, 3 741 334 deaths from all causes and 167 652 alcohol-attributable deaths. The overall RRRs amounted to RRR = 1.78 (95% confidence interval (CI) 1.43 to 2.22) and RRR = 1.66 (95% CI 1.20 to 2.31), for women and men, respectively. In other words: lower socioeconomic status leads to 1.5-2-fold higher mortality for alcohol-attributable causes compared with all causes.

CONCLUSIONS

Alcohol was identified as a factor underlying higher mortality risks in more disadvantaged populations. All alcohol-attributable mortality is in principle avoidable, and future alcohol policies must take into consideration any differential effect on socioeconomic groups.

Psychological distress and its correlates among dental students: a survey of 17 Colombian dental schools

BACKGROUND

Links between the demanding nature of studies in the health sciences, students' personality traits and psychological distress have been well-established. While considerable amount of work has been done in medicine, evidence from the dental education arena is sparse and data from Latin America are lacking. The authors conducted a large-scale investigation of psychological distress among dental students in Colombia and sought to determine its curriculum and student-level correlates.

METHODS

The Spanish version of the Derogatis' Symptoms Checklist Revised (SCL-90-R) was administered to all students officially registered and attending classes or clinics in 17 dental schools in 4 geographic districts of Colombia between January and April 2012. Additional information was collected on participants' socio-demographic information and first career choice, as well as school's characteristics such as class size. The Global Severity Index (GSI) score, a measure of overall psychological distress, served as the primary analytical endpoint. Analyses relied on multilevel mixed-effects linear and log-binomial regression, accounting for study design and sample characteristics.

RESULTS

A total of 5700 dental students completed the survey, a response rate of 67%. Pronounced gradients were noted in the association between socio-economic status and psychological distress, with students in higher strata reporting fewer problems. After adjustment for all important covariates, there was an evident pattern of increasing psychological distress corresponding to the transition from the didactic, to the preclinical and clinical phases of training, with few differences between male and female students. Independent of other factors, reliance on own funds for education and having dentistry as the first career choice were associated with lower psychological distress.

CONCLUSIONS

Levels of psychological distress correlated with students' socio-economic and study-level characteristics. Above and beyond the influence of person-level factors, variations in levels of distress paralleled specific transitional stages of the 5-year dental curriculum, providing opportunities for targeted interventions.

How much of the deprivation gap in cancer survival can be explained by variation in stage at diagnosis: an example from breast cancer in the East of England

Socioeconomic differences in cancer patient survival exist in many countries and across cancer sites. In our article, we estimated the number of deaths in women with breast cancer that could be avoided within 5 years from diagnosis if it were possible to eliminate socioeconomic differences in stage at diagnosis. We analysed data on East of England women with breast cancer (2006-2010). We estimated survival for different stage-age-deprivation strata using both the observed and a hypothetical stage distribution (assuming all women acquired the stage distribution of the most affluent women). Data were analysed on 20,738 women with complete stage information (92%). Affluent women were less likely to be diagnosed in advanced stage. Relative survival decreased with increasing level of deprivation. Eliminating differences in stage at diagnosis could be expected to nearly eliminate differences in relative survival for women in deprivation groups 3 and 4, but would only approximately halve the difference in relative survival for women in the most deprived group (5). This means, for a typical cohort of women diagnosed in a calendar year with breast cancer, eliminating deprivation differences in stage at diagnosis would prevent ∼40 deaths in the East of England from occurring within 5 years from diagnosis. Using appropriate weighting we estimated the respective number of avoidable deaths for the whole of England to be ∼450. The findings suggest that policies aimed at reducing inequalities in stage at diagnosis between women with breast cancer are important to reduce inequalities in breast cancer survival.

Socioeconomic differences in adolescent health-related behavior differ by gender

BACKGROUND

Many studies of adolescent health-related behaviors have assessed the effects of gender and parental socioeconomic position (SEP) but not their mutual modification. We investigated socioeconomic differences in health-related behaviors among Slovak adolescents and the potential modification of those differences by gender.

METHODS

Data were collected in 2006 (n = 3547; 49.4% boys; mean [SD] age, 14.3 [0.6] years; response rate, 93.5%). The sample comprised students in the eighth and ninth grades of randomly selected elementary schools in Slovakia. Gender-specific prevalence rates for 9 types of health-related behaviors, including nutritional behavior, physical activity and substance use, were calculated for 3 socioeconomic groups, which were defined by the highest educational level attained by both parents. Gender differences in socioeconomic gradients for health-related behaviors were tested.

RESULTS

Socioeconomic differences were found in nutritional behavior, physical activity, and smoking. Adolescents with lower parental education behaved less healthily. The largest relative socioeconomic difference was no daily vegetable consumption among girls (90.3% of those with high SEP vs 95.2% of those with middle SEP; odds ratio, 2.33). Regarding no daily fruit consumption, differences among girls were 1.51 times and 1.92 times as large as those among boys for children with medium and low SEP, respectively, as compared with those with high SEP.

CONCLUSIONS

Socioeconomic differences in health-related behavior were small, especially for nutritional behavior and physical activity. Interventions that aim to improve health-related behaviors among adolescents with lower SEP should focus on these 2 behaviors, particularly on healthy nutrition in girls with low SEP.

Socioeconomic differences in disability retirement in Finland: the contribution of ill-health, health behaviours and working conditions

AIMS

Socioeconomic differences in disability retirement are large. In this study, the main interest was to find out the contribution of diseases, self-rated health, health behaviours and working conditions to socioeconomic differences in disability retirement.

METHODS

The data are from the nationally-representative Health 2000 Survey to which register-based retirement data have been linked. These data include 3674 persons aged 30-62 years who were employed at baseline. Of the participants, 363 ended up in disability retirement during the follow-up period 2000-2009. Cox regression analysis was used to calculate hazard ratios and their 95% confidence intervals.

RESULTS

The risk of all-cause disability retirement was higher among manual workers (HR for men 2.44, 95% CI 1.64-3.63, women 2.33, 1.57-3.44) than upper-grade non-manual employees. Ill-health and physical working conditions contributed to the socioeconomic differences in disability retirement. The importance of physical working conditions was seen in particular among those aged 50 years or over and those in disability retirement due to musculoskeletal diseases. The contribution of self-rated health was stronger in older than younger disability retirees.

CONCLUSIONS

Our findings suggest that preventing ill-health and improving working conditions, especially among the lower socioeconomic classes, would help reduce socioeconomic differences in disability retirement.

The effectiveness of tobacco marketing regulations on reducing smokers' exposure to advertising and promotion: findings from the International Tobacco Control (ITC) Four Country Survey

Exposure to tobacco product marketing promotes the initiation, continuation, and reuptake of cigarette smoking and as a result the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) has called upon member Parties to enact comprehensive bans on tobacco advertising and promotion. This study examines the immediate and long term effectiveness of advertising restrictions enacted in different countries on exposure to different forms of product marketing, and examines differences in exposure across different socioeconomic status (SES) groups. Nationally representative data from the United Kingdom, Canada, Australia, and the United States, collected from adult smokers between 2002 and 2008 using the International Tobacco Control Four Country Survey (ITC-4), were used in this study (N = 21,615). In light of the specific marketing regulation changes that occurred during the course of this study period, changes in awareness of tobacco marketing via various channels were assessed for each country, and for different SES groups within countries. Tobacco marketing regulations, once implemented, were associated with significant reductions in smokers' reported awareness of pro-smoking cues, and the observed reductions were greatest immediately following the enactment of regulations. Changes in reported awareness were generally the same across different SES groups, although some exceptions were noted. While tobacco marketing regulations have been effective in reducing exposure to certain types of product marketing there still remain gaps, especially with regard to in-store marketing and price promotions.