Impact of socioeconomic status on the clinical outcomes in hospitalised patients with SARS-CoV-2 infection: a retrospective analysis

Background Dutch legislation stimulates active participation of employees in their return-to-work (RTW) process. Earlier research showed that employees, particularly with low levels of education, are not always able to self-direct RTW. Empowering leadership may support this process. This study answers two research questions: (1) What differences and similarities do employers of employees with low versus high levels of education show in their management of RTW? (2) To what degree do the roles of employers in both types of organizations resemble empowering leadership? Methods We performed semi-structured, in-depth interviews with 10 HR professionals and supervisors working at a Dutch university. We also analysed transcripts from a study in which 13 HR professionals and supervisors from multiple Dutch industries (employing workers with low levels of education) were interviewed. We used purposive sampling to recruit participants. For question 1, the transcripts were analysed thematically. For question 2, pattern matching was applied. Results Preliminary results indicate that supervisors of both types of employees, show several similarities in managing RTW, such as the focus on possibilities instead of impossibilities, asking the advice of the occupational physician, and seeking support to increase employability. We also found that supervisors of employees with low levels of education have a stronger tendency to control and steer RTW and feel that possibilities for RTW are limited, while supervisors of high-educated employees tend to engage in dialogue more often and search for possibilities for work adjustments. Empowering leadership seems to be less common among supervisors of employees with low levels of education. Conclusions This study will benefit employers (of workers with both low and high levels of education) who aim to enable employees' self-direction in RTW, and help supervisors to develop more empowering leadership styles. This may lead to more sustainable RTW. Key messages Supervisors of employees with lower levels of education have a strong tendency to control and steer their employees’ return-to-work. Enabling employees’ self-direction in return-to-work requires empowering leadership.

Early impairments in spoken discourse abilities have been identified in Alzheimer's disease (AD). However, the impact of AD on spoken discourse and the associated neuroanatomical correlates have mainly been studied in populations with higher levels of education, although preliminary evidence seems to indicate that socioeconomic status (SES) and level of education have an impact on spoken discourse. The purpose of this study was to analyze microstructural variables in spoken discourse in people with AD with low-to-middle SES and low level of education and to study their association with gray matter (GM) density. Nine women with AD and 10 matched (age, SES, and education) women without brain injury (WWBI) underwent a neuropsychological assessment, which included two spoken discourse tasks, and structural magnetic resonance imaging. Microstructural variables were extracted from the discourse samples using NILC-Metrix software. Brain density, measured by voxel-based morphometry, was compared between groups and then correlated with the differentiating microstructural variables. The AD group produced a lower diversity of verbal time moods and fewer words and sentences than WWBI but a greater diversity of pronouns, prepositions, and lexical richness. At the neural level, the AD group presented a lower GM density bilaterally in the hippocampus, the inferior temporal gyrus, and the anterior cingulate gyrus. Number of words and sentences produced were associated with GM density in the left parahippocampal gyrus, whereas the diversity of verbal moods was associated with the basal ganglia and the anterior cingulate gyrus bilaterally. The present findings are mainly consistent with previous studies conducted in groups with higher levels of SES and education, but they suggest that atrophy in the left inferior temporal gyrus could be critical in AD in populations with lower levels of SES and education. This research provides evidence on the importance of pursuing further studies including people with various SES and education levels. Spoken discourse has been shown to be affected in Alzheimer disease, but most studies have been conducted on individuals with middle-to-high SES and high educational levels. The study reports on microstructural measures of spoken discourse in groups of women in the early stage of AD and healthy women, with low-to-middle SES and lower levels of education. This study highlights the importance of taking into consideration the SES and education level in spoken discourse analysis and in investigating the neural correlates of AD. https://doi.org/10.23641/asha.24905046.

Purpose: To evaluate the association of county level characteristics with the incidence of invasive squamous cell carcinoma of the cervix among Hispanic women. Methods: The Surveillance, Epidemiology, and End Results (SEER) Program's 18 registries from 2000-2009 were queried and average annual age-adjusted incidence rates per 100,000 Hispanic women for invasive squamous cell carcinoma of the cervix (SCC) were calculated. Patients were stratified by residence in a county with high versus low percent language isolation, percent of Hispanics with less than a high school education and percent of Hispanic families below the poverty level. Results: Between 2000-2009, 5,534 Hispanic women were diagnosed with SCC in SEER. Incidence rates were highest among those living in counties with high levels of LI (8.9 v 10.7), or low levels of education (8.9 v 10.8) or income (8.7 v 11.0). The incidence of SCC was significantly less in women living in counties with higher levels of education and income and lower levels of LI than among those living in counties with lower levels of education and income and higher levels of LI (8.6 v. 11.3). Counties that have higher levels of income and education are less likely to be LI whereas counties with lower levels of income and education are more likely to be LI. Conclusions: Among Hispanic women, county level characteristics such as LI, education, and income have a complex interaction that appears to be associated with the incidence of SCC. Community level interventions need to be evaluated to decrease the high incidence of SCC in this population. Citation Format: Kristy K. Ward, Angelica M. Roncancio, Steven C. Plaxe. The association of county level characteristics with the incidence of squamous cell carcinoma of the cervix in Hispanic women. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr A54.

This study aims to determine parents' expectations of children's education in the perspective of economic education in Beroanging Village, West Bangkala District, Jeneponto Regency, South Sulawesi Province. This study is a qualitative study with a phenomenological approach. The informants in this study were parents who had school-age children at the elementary, junior high, high school, and university levels which were determined purposively based on the criteria of parents who had a high level of economic status but low education, parents who had a high level of education, and elderly who have a low level of education and social status. The results of this study indicate that parents' expectations of children's education in the perspective of economic education in Beroanging Village are divided into three, namely the expectations of parents who consider education as an investment are parents who have a low level of education but a high level of economic status, expectations of education as an economic good or consumption are parents who have a low level of education and economic status, and the expectation of education as a consumption good as well as an investment is parents with a high level of education. Keywords : Ekspektasi Orang Tua, Pendidikan Anak, Pendidikan Ekonomi Informal

Health status of a population can be evaluated by health expectancy expressed as average lifetime in various states of health. The purpose of the study was to compare health expectancy in population groups at high, medium and low educational levels. Health interview data were combined with life table figures using Sullivan's method. Life expectancy was 4.3 years longer for 30-year-old men with a high educational level than for those with a low level. At age 30, the proportion of expected lifetime in self-rated good health was 67.7%, 76.1% and 82.3% for men with a low, medium and high educational level, respectively. Among women, life expectancy differed by 2.7 years between low and high educational level, and the proportion of expected lifetime in self-rated good health was 62.5% at the low and 80.5% at the high educational level. Educational level and life expectancy are clearly related. The social gradient in terms of health expectancy is even greater than that in terms of life expectancy.

Health expectancy represents the average lifetime in various states of health and differs among social groups. The purpose of the study was to determine trends in social inequality in health expectancy since 1994 between groups with high, medium and low educational levels in Denmark. The study was based on data from nationwide registers on educational level and mortality during the period 1994-2005 and data on health status derived from the Danish Health Interview Surveys carried out in 1994, 2000 and 2005. Expected lifetime in self-rated good and poor health, lifetime without and with longstanding illness and expected lifetime without and with long-lasting difficulties or restrictions were estimated by Sullivan's method. Between 1994 and 2005, life expectancy at age 30 years increased by 1.9 years for men and 1.5 years for women with a low educational level. For people with a high educational level, the increase was 2.7 years for men and 2.2 years for women. The difference between people with low and high educational level in expected lifetime in self-rated good health increased by 2.0 and 1.3 years for 30-year-old men and women, respectively. The social gap also increased for other indicators. During the past 12 years, social inequality in life expectancy and health expectancy has increased in Denmark, but the proportion of the population with a low educational level has decreased.

Alzheimer's disease (AD) is a major cause of disability and mortality in older adults. This study aimed to investigate the association of AD with education and genetic factors. We conducted a prospective cohort study using data from the UK Biobank. Genetic risk was assessed using a polygenic risk score for AD. The educational level was categorized as either low, intermediate, or high. AD was defined using the International Classification of Diseases and Related Health Problems, 10th revision. Logistic regression models were used to investigate the independent and combined effects of genetic factors and educational levels on the risk of AD. We included 318,535 participants in this study (age: 56.53 ± 8.09 years; male: 44.81%). Compared with a low genetic risk, a high genetic risk was associated with a significantly greater risk of AD (OR = 7.09, 95% CI: 6.09-8.26). A high educational level was associated with a 30% lower risk of AD compared with a low educational level (OR = 0.70, 95% CI: 0.60-0.81). Combining genetic risk and education categories, individuals with a low genetic risk and high educational level had a more than 90% (OR = 0.09, 95% CI: 0.05-0.16) lower risk of AD compared to those with a high genetic risk and low educational level. There was no significant interaction between genetic risk and educational level regarding AD risk (p for interaction = 0.359). Education counteracts the genetic risk of AD, without an interaction effect. Increasing education to reduce the incidence of AD is of same importance across individuals with different genetic risk.

To determine the relationship between patient education and the risk of underdiagnosis and undertreatment of asthma, a cross-sectional study of 500 (250 males and 250 females) adult attendees between 16 and 44 years of age was undertaken at five primary health care (PHC) centers in Al-Ain, United Arab Emirates. We used an Arabic translation of the European Community Respiratory Health Survey Screening Questionnaire. Asthmatics with higher levels of education had a significantly higher risk of underdiagnosis and undertreatment than asthmatics with less education. Doctors at PHC centers failed to diagnose 34.6% of the asthmatics with lower levels of education and 77.6% of the patients with higher levels of education. Eighty-five percent of the asthmatics with lower levels of education and 46.6% of the asthmatics with higher levels of education recognized that they had asthma. Thirty-eight percent of the asthmatics with lower levels of education and 83% of the asthmatics with higher levels of education were undertreated. It was found that 19% of the asthmatics with lower levels of education and 3% of the asthmatics with higher level of education were on prophylactic medication for asthma. We concluded that education level was related to underdiagnosis and undertreatment of asthma among adults between 16 and 44 years of age. People with higher levels of education have a higher risk of underdiagnosis and undertreatment than do those with lower levels of education. The factors that might be associated with these findings need to be explored in further studies.

Dutch legislation encourages active participation of employees in their return-to-work (RTW) process. Empowering leadership may support employees' self-direction in this process (i.e. by allowing and enabling their involvement in decision-making). Building upon a previous study, we aimed to study (1) how representatives of a university, i.e. an employer for employees with high levels of education (EH), manage RTW, (2) the similarities and differences between the RTW management of employers (or representatives thereof) of employees with low (EL) and high levels of education, and (3) the degree to which the employers' roles resemble empowering leadership. Qualitative methodology was applied. A thematic analysis of interview transcripts (rq1) was followed by a comparison of themes (rq2) and pattern matching (rq3). (1) EH tend to engage in dialogue and accommodate their employees as much as possible. (2) EL and EH showed several similarities, such as aiming to meet legal requirements on RTW management. Compared to EL, EH tend to focus more on facilitating employees. (3) Empowering leadership seems to be more common among EH. Compared to employees with low levels of education, those with high levels of education may be granted more opportunity to self-direct their RTW. The study results provide starting points for employers for employees with both low and high levels of education who aim to enable employees' self-direction in RTW, and help them to develop empowering leadership styles.

ObjectiveMultimorbidity (MM) is more prevalent among people of lower socioeconomic status (SES), and both MM and SES are associated with higher mortality rates. However, little is known about the relationship between SES, MM, and mortality. This study investigates the association between educational level and mortality, and to what extent MM modifies this association.MethodsWe followed 239,547 individuals invited to participate in the Danish National Health Survey 2010 (mean follow-up time: 3.8 years). MM was assessed by using information on drug prescriptions and diagnoses for 39 long-term conditions. Data on educational level were provided by Statistics Denmark. Date of death was obtained from the Civil Registration System. Information on lifestyle factors and quality of life was collected from the survey. The main outcomes were overall and premature mortality (death before the age of 75).ResultsOf a total of 12,480 deaths, 6,607 (9.5%) were of people with low educational level (LEL) and 1,272 (2.3%) were of people with high educational level (HEL). The mortality rate was higher among people with LEL compared with HEL in groups of people with 0–1 disease (hazard ratio: 2.26, 95% confidence interval: 2.00–2.55) and ≥4 diseases (hazard ratio: 1.14, 95% confidence interval: 1.04–1.24), respectively (adjusted model). The absolute number of deaths was six times higher among people with LEL than those with HEL in those with ≥4 diseases. The 1-year cumulative mortality proportions for overall death in those with ≥4 diseases was 5.59% for people with HEL versus 7.27% for people with LEL, and 1-year cumulative mortality proportions for premature death was 2.93% for people with HEL versus 4.04% for people with LEL. Adjusting for potential mediating factors such as lifestyle and quality of life eliminated the statistical association between educational level and mortality in people with MM.ConclusionOur study suggests that LEL is associated with higher overall and premature mortality and that the association is affected by MM, lifestyle factors, and quality of life.

In the study, the use of coping and emotion regulation (ER) strategies is compared in 194 adults aged between 20 and 65 years, regarding their age (emerging, young or middle adulthood), gender and level of education. There are almost no significant differences in the use of coping and ER strategies in adults regarding age. Women use certain ER strategies (e.g., attentional deployment) more than men, but there is no difference between the two groups in the use of coping strategies. Adults with a low level of education use more confrontive coping and distracting in comparison with adults with a high level of education, while the escape- -avoiding coping strategy is used more by adults with low and middle levels of education than those with a high level of education. Regarding ER, adults with a low level of education use more cognitive reappraisal of importance than both groups with a higher educational level, whereas they use suppression and substances only more than adults with a high level of education. Correlations between coping and ER strategies are mostly non-significant, suggesting that coping and ER are distinct processes in adulthood.

BackgroundDisparities in multiple myeloma (MM) prognosis based on sociodemographic factors may exist. We investigated whether education level at diagnosis influenced Chinese MM patient outcomes.MethodsWe performed a multicenter retrospective analysis of data from 773 MM patients across 9 centers in China from 2006 to 2019. Sociodemographic and clinical factors at diagnosis and treatment regimens were recorded, and univariate and multivariate analyses were performed.ResultsOverall, 69.2% of patients had low education levels. Patients with low education levels differed from those with high education levels in that they were more likely to be older, and a higher proportion lived in rural areas, were unemployed, had lower annual incomes and lacked insurance. Additionally, compared to patients with high education levels, patients with low education levels had a higher proportion of international staging system (ISS) stage III classification and elevated lactate dehydrogenase (LDH) levels and underwent transplantation less often. Patients with high education levels had a median progression-free survival (PFS) of 67.50 (95% confidence interval (CI): 51.66–83.39) months, which was better than that of patients with low education levels (30.60 months, 95% CI: 27.38–33.82, p < 0.001). Similarly, patients with high education levels had a median overall survival (OS) of 122.27 (95% CI: 117.05–127.49) months, which was also better than that of patients with low education levels (58.83 months, 95% CI: 48.87–62.79, p < 0.001). In the multivariable analysis, patients with high education levels had lower relapse rates and higher survival rates than did those with low education level in terms of PFS and OS (hazard ratio (HR) = 0.50 [95% CI: 0.34–0.72], p < 0.001; HR = 0.32 [0.19–0.56], p < 0.001, respectively).ConclusionsLow education levels may independently predict poor survival in MM patients in China.

Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Dutch Heart Foundation and ZonMw Goal setting within cardiac care: the effect of linking life goals to health goals on intention to change lifestyle in patients. Background Initiating and maintaining a healthy lifestyle is difficult and often needs several attempts. Reaching health goals may become easier if linked to life goals (see Fig.1). Life goals, also described as abstract, long-term goals, reflect objectives that matter to people personally. Guidelines recommend goal setting to realise behaviour change in patients with cardiovascular disease (CVD). However, research is inconclusive about whether positive effects of lifestyle interventions can be attributed to linking life goals to health goals or to other intervention elements. Purpose This experimental study examines the effect of linking a life goal to a health goal on intention to change lifestyle in patients with CVD. Methods Research panel members of a CVD patient association were recruited for the online study via advertisement on the association’s website. Patients were randomised and controlled into two groups: setting a health goal (HG) and setting a health goal linked to a life goal (+LG). Based on the Theory of Planned Behavior (see Fig.2) and previous research, main outcome measure ‘intention to change lifestyle’ was assessed using a visual analogue scale ranging 0-10 (low to high). Effect of group (HG vs +LG) on intention to change lifestyle (high vs low) was analysed using logistic regression. Gender, age, education level, and type of CVD were entered as possible effect modifiers. Results Patients (N=628) were mostly male (61%), with a mean age of 69±35 years, and medium (33%) or high (47%) education level. In both groups, HG and +LG, 47% of the patients expressed high intention to change lifestyle. Logistic regression showed no effect of group (HG vs +LG) on intention, OR:0.98 (95%CI: 0.72–1.35, p=0.92). Only education level appeared to be an effect modifier, X²(2):8.2, p=0.02; showing that linking a life goal to a health goal was effective in patients with a high education level. Contrary to this, setting a life goal negatively affected intention in patients with a low education level. Among patients with a high education level, percentage of 'high intention' was higher in the +LG group (57%) than in the HG group (45%). In contrast, among patients with a low education level, percentage of 'high intention' was higher in the HG group (48%) than in the +LG group (36%). Conclusions This study showed no main effect of linking a life goal to a health goal on patients’ intention to change lifestyle. Education level was found to be a significant effect modifier. Patients with a high education level significantly benefitted from linking a life goal to a health goal. Patients with lower education levels benefitted most from setting only a health goal. In conclusion, within practice, health care providers may personalise their approach towards goal setting based on patients’ education level.

The association between socioeconomic status (SES) and alcohol-related diseases has been widely explored. Less is known, however, on whether the association of moderate drinking with all-cause mortality is modified by educational level (EL). Using harmonized data from 16 cohorts in the MORGAM Project (N = 142,066) the association of pattern of alcohol intake with hazard of all-cause mortality across EL (lower = primary-school; middle = secondary-school; higher = university/college degree) was assessed using multivariable Cox-regression and spline curves. A total of 16,695 deaths occurred in 11.8years (median). In comparison with life-long abstainers, participants drinking 0.1-10g/d of ethanol had 13% (HR = 0.87; 95%CI: 0.74-1.02), 11% (HR = 0.89; 0.84-0.95) and 5% (HR = 0.95; 0.89-1.02) lower rate of death in higher, middle and lower EL, respectively. Conversely, drinkers > 20g/d had 1% (HR = 1.01; 0.82-1.25), 10% (HR = 1.10; 1.02-1.19) and 17% (HR = 1.17; 1.09-1.26) higher rate of death. The association of alcohol consumption with all-cause mortality was nonlinear, with a different J-shape by EL levels. It was consistent across both sexes and in various approaches of measuring alcohol consumption, including combining quantity and frequency and it was more evident when the beverage of preference was wine. We observed that drinking in moderation (≤ 10g/d) is associated with lower mortality rate more evidently in individuals with higher EL than in people with lower EL, while heavy drinking is associated with higher mortality rate more evidently in individuals with lower EL than in people with higher EL, suggesting that advice on reducing alcohol intake should especially target individuals of low EL.

Objective To investigate the relationship between the education level of staff members and the risk factors for stroke in a university in China. Methods From January 2014 to May 2014, a total of 659 staff members in a university in China were collected with a cluster sampling method. The basic information and the relevant data of the risk factors for stroke of the subjects were collected and recorded completely. The subjects were divided into 3 groups according to their education levels from low to high. The relationship between their education levels and the risk factors for stroke were analyzed. Results A total of 633 staff members were enrolled, including 426 men (67.3%) and 207 women (32.7%). The low, middle and high education level groups were 188 (29.7%), 193 (30.5%), and 252 (39.8%), respectively. With the increase of the education level, the prevalence of hypertension, dyslipidemia, and stroke decreased, and the awareness rates of hypertension and dyslipidemia and the treatment rate increased. The proportion of drinking increased in the male group and that decreased in the female group. The proportion of regular exercise increased in the female group. Multivariate logistic regression analysis showed that after adjusting for age, per capita income, employment, drinking, smoking, regular exercise and other factors, compared with the high education level group, the risk of hypertension increased 2.55 times in the low education level group in males (odds ratio [OR] 2.55, 95% confidence interval [CI] 1.42-4.58; P=0.002); the prevalence risk of dyslipidemia increased 2.25 (OR 2.25, 95% CI 1.31-3.86; P=0.003) and 2.02 times in the low and middle education level groups (OR 2.02, 95% CI 1.23-3.33; P=0.006) respectively; the risk of smoking decreased 42% in the middle education level group (OR 0.58, 95% CI 0.36-0.93; P=0.024); the risk of hypertension increased 6.27 times in the low level education group in women (OR 6.27, 95% CI 1.59-24.74; P=0.009); the risk of dyslipidemia increased 3.91 times in the middle education level group (OR 3.91, 95% CI 1.70-8.98; P=0.001); the risk of drinking increased 3.49 times in the low level education group (OR 3.49, 95% CI 1.12-10.92; P=0.032), and the weekly regular exercise decreased 65% in the low level education group (OR0.35, 95% CI 0.15-0.82; P=0.016). Conclusion The incidence of the risk factors for stroke in the low education level group was higher than the populations of high or middle education level. Key words: Educational Status; Stroke; Risk Factors