Area-level Socioeconomic Status Measures Research Articles

Effect modification of the association between fine particulate air pollution during a wildfire event and respiratory health by area-level measures of socio-economic status, race/ethnicity, and smoking prevalence

Fine particulate air pollution (PM2.5) is decreasing in most areas of the United States, except for areas most affected by wildfires, where increasing trends in PM2.5 can be attributed to wildfire smoke. The frequency and duration of large wildfires and the length of the wildfire season have all increased in recent decades, partially due to climate change, and wildfire risk is projected to increase further in many regions including the western United States. Increasingly, empirical evidence suggests differential health effects from air pollution by class and race; however, few studies have investigated such differential health impacts from air pollution during a wildfire event. We investigated differential risk of respiratory health impacts during the 2008 northern California wildfires by a comprehensive list of socio-economic status (SES), race/ethnicity, and smoking prevalence variables. Regardless of SES level across nine measures of SES, we found significant associations between PM2.5 and asthma hospitalizations and emergency department (ED) visits during these wildfires. Differential respiratory health risk was found by SES for ED visits for chronic obstructive pulmonary disease where the highest risks were in ZIP codes with the lowest SES levels. Findings for differential effects by race/ethnicity were less consistent across health outcomes. We found that ZIP codes with higher prevalence of smokers had greater risk of ED visits for asthma and pneumonia. Our study suggests that public health efforts to decrease exposures to high levels of air pollution during wildfires should focus on lower SES communities.

Socio-economic and ethnocultural influences on geographical disparities in breast cancer screening participation in Victoria, Australia.

To examine the socio-economic and ethnocultural characteristics of geographical areas that may influence variation in breast cancer screening participation. In a cross-sectional analysis breast cancer screening participation for statistical areas in Victoria, Australia (2015-2017) was linked with data from the 2016 Australian Census. We selected four commonly used area-level measures of socio-economic status from the Australian Census (i) income (ii) educational level (iii) occupational status and (iv) employment profile. To assess the ethnocultural characteristics of statistical areas we used the Census measures (i) country of birth (ii) language spoken at home (iii) fluency in English (iv) religion and (v) the proportion of immigrants in an area, together with their recency of migration. All the selected measures were related to screening participation. There was a high degree of association both within and between socio-economic and ethnocultural characteristics of areas as they relate to screening. Ethnocultural characteristics alone accounted for most of the explained geographical disparity in screening participation. Geographical disparities in breast cancer screening participation may be due to ethnocultural factors that are confounded with socio-economic factors.

Socioeconomic Inequalities in COVID-19 Incidence During Different Epidemic Phases in South Korea.

ObjectiveArea-level socioeconomic status (SES) is associated with coronavirus disease 2019 (COVID-19) incidence. However, the underlying mechanism of the association is context-specific, and the choice of measure is still important. We aimed to evaluate the socioeconomic gradient regarding COVID-19 incidence in Korea based on several area-level SES measures.MethodsCOVID-19 incidence and area-level SES measures across 229 Korean municipalities were derived from various administrative regional data collected between 2015 and 2020. The Bayesian negative binomial model with a spatial autocorrelation term was used to estimate the incidence rate ratio (IRR) and relative index of inequality (RII) of each SES factor, with adjustment for covariates. The magnitude of association was compared between two epidemic phases: a low phase (<100 daily cases, from May 6 to August 14, 2020) and a rebound phase (>100 daily cases, from August 15 to December 31, 2020).ResultsArea-level socioeconomic inequalities in COVID-19 incidence between the most disadvantaged region and the least disadvantaged region were observed for nonemployment rates [RII = 1.40, 95% credible interval (Crl) = 1.01–1.95] and basic livelihood security recipients (RII = 2.66, 95% Crl = 1.12–5.97), but were not observed for other measures in the low phase. However, the magnitude of the inequalities of these SES variables diminished in the rebound phase. A higher area-level mobility showed a higher risk of COVID-19 incidence in both the low (IRR = 1.67, 95% Crl = 1.26–2.17) and rebound phases (IRR = 1.28, 95% Crl = 1.14–1.44). When SES and mobility measures were simultaneously adjusted, the association of SES with COVID-19 incidence remained significant but only in the low phase, indicating they were mutually independent in the low phase.ConclusionThe level of basic livelihood benefit recipients and nonemployment rate showed social stratification of COVID-19 incidence in Korea. Explanation of area-level inequalities in COVID-19 incidence may not be derived only from mobility differences in Korea but, instead, from the country's own context.

Socioeconomic inequalities in cancer incidence in Europe: a comprehensive review of population-based epidemiological studies

BackgroundSince the end of the previous century, there has not been a comprehensive review of European studies on socioeconomic inequality in cancer incidence. In view of recent advances in data source linkage and analytical methods, we aimed to update the knowledge base on associations between location-specific cancer incidence and individual or area-level measures of socio-economic status (SES) among European adults.Materials and methodsWe systematically searched three databases (PubMed, Scopus and Web of Science) for articles on cancer incidence and SES. Qualitative synthesis was performed on the 91 included English language studies, published between 2000 and 2019 in Europe, which focused on adults, relied on cancer registry data and reported on relative risk (RR) estimates.ResultsAdults with low SES have increased risk of head and neck, oesophagogastric, liver and gallbladder, pancreatic, lung, kidney, bladder, penile and cervical cancers (highest RRs for lung, head and neck, stomach and cervix). Conversely, high SES is linked with increased risk of thyroid, breast, prostate and skin cancers. Central nervous system and haematological cancers are not associated with SES. The positive gap in testicular cancer has narrowed, while colorectal cancer shows a varying pattern in different countries. Negative associations are generally stronger for men compared to women.ConclusionsIn Europe, cancers in almost all common locations are associated with SES and the inequalities can be explained to a varying degree by known life-style related factors, most notably smoking. Independent effects of many individual and area SES measures which capture different aspects of SES can also be observed.

An ecological approach to monitor geographic disparities in cancer outcomes.

BackgroundArea-level indices are widely used to assess the impact of socio-environmental characteristics on cancer outcomes. While area-level measures of socioeconomic status (SES) have been previously used in cancer settings, fewer studies have focused on evaluating the impact of area-level health services supply (HSS) characteristics on cancer outcomes. Moreover, there is significant variation in the methods and constructs used to create area-level indices.MethodsIn this study, we introduced a psychometrically-induced, reproducible approach to develop area-level HSS and SES indices. We assessed the utility of these indices in detecting the effects of area-level characteristics on prostate, breast, and lung cancer incidence and stage at diagnosis in the US. The information on county-level SES and HSS characteristics were extracted from US Census, County Business Patterns data and Area Health Resource Files. The Surveillance, Epidemiology, and End Results database was used to identify individuals diagnosed with cancer from 2010 to 2012. SES and HSS indices were developed and linked to 3-year age-adjusted cancer incidence rates. SES and HSS indices empirically summarized the level of employment, education, poverty and income, and the availability of health care facilities and health professionals within counties.ResultsSES and HSS models demonstrated good fit (TLI = 0.98 and 0.96, respectively) and internal consistency (alpha = 0.85 and 0.95, respectively). Increasing SES and HSS were associated with increasing prostate and breast cancer and decreasing lung cancer incidence rates. The results varied by stage at diagnosis and race.ConclusionComposite county-level measures of SES and HSS were effective in ranking counties and detecting gradients in cancer incidence and stage at diagnosis. Thus, these measures provide valuable tools for monitoring geographic disparities in cancer outcomes.

Validating the use of census data on education as a measure of socioeconomic status in an occupational cohort

Purpose Adjusting for smoking status or a reliable surrogate [such as socioeconomic status (SES)] is critically important in occupational epidemiology studies when any smoking-related cancer or cardiovascular disease is an outcome of interest. Sometimes, however, data on smoking patterns or individual-level smoking surrogates such as job title, education, pay scale or other measures of SES are not readily available in occupational cohorts. Methods and materials To obtain a surrogate measure for missing smoking or individual-level SES data, we demonstrate a method used to obtain and geocode residential address histories which were then linked to area-level SES measures from the United States Census in three test samples and then in a full cohort of workers from the Mound nuclear weapons facility in Dayton, Ohio, USA. The mean educational attainment of the Census Block Group was used to derive a categorical estimate of educational attainment which was compared to self-reported (SR) education available from Mound worker histories using Kappa statistics. Lung cancer mortality patterns between area-derived (AD) and SR education were investigated using Standardized Mortality Ratios (SMR) and Cox Proportional Hazards models with stratification or adjustment by either SR or AD education. Results Home address histories were obtained from linkages of individual worker data to online resources. In the test cohorts, mean educational attainment was the Census Block Group measure found to have the largest magnitude association with individual-level SES measures. Among 7251 Mound workers, 5685 (78.4%) had at least one residential address match (mean 4.9 addresses) identified. The SR and AD educational attainment measures were highly correlated (weighted Kappa coefficient 0.10, p < .0001). SMR patterns by SR and AD educational attainment were similar, with steadily decreasing mortality with increased educational attainment by either measure. Cox models for lung cancer using AD education produced similar results as those using SR education as an adjustment factor. Conclusion When individual-level SES indicators are not available for statistical adjustment, area-level SES measures can serve as a reliable surrogate when investigating outcomes that are affected by lifestyle factors such as smoking.

Abstract A42: Association between neighborhood deprivation and lung cancer risk in the Southern Community Cohort Study

Abstract Purpose: Counties with the highest rates of lung cancer mortality in the United States from the 1980s have been located in the South. This finding is related to high regional smoking prevalence, but we hypothesized that area-level socioeconomic deprivation may also contribute. We used data from the Southern Community Cohort Study to examine this exposure in a multilevel nested case-control study of incident lung cancer. Methods: Men and women with incident lung cancer were identified through linkage with state cancer registries and the National Death Index (1,334 cases). Approximately four controls were matched to each case on sex, race, age at diagnosis, and year of recruitment (5,315 controls). Individual-level smoking and socioeconomic status were obtained through baseline surveys, while block group-level neighborhood deprivation was obtained from U.S. Census data. Results: After adjustment for smoking and other confounders, but prior to adjustment for individual-level measures of socioeconomic status, there was an increased risk of lung cancer for persons living in neighborhoods with the greatest quartile of deprivation relative to those in neighborhoods with the least (odds ratio (OR) 1.28, 95% confidence interval (CI) 1.00-1.63). Additional adjustment for individual-level measures of socioeconomic status weakened this effect (OR 1.21, 95% CI 0.94-1.55). There was no evidence of effect modification by race or sex. Conclusions: Area-level measures of socioeconomic status were associated with lung cancer risk in this population after control for smoking. Citation Format: Maureen Sanderson, Melinda C. Aldrich, Robert S. Levine, Barbara Kilbourne, Qiuyin Cai, William J. Blot. Association between neighborhood deprivation and lung cancer risk in the Southern Community Cohort Study [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr A42.

Is there a deprivation and maternal education gradient to child obesity and moderate-to-vigorous physical activity? Findings from the Millennium Cohort Study.

The primary aim was to examine associations between individual-level and area-level measures of socioeconomic status (SES) and different measures of overweight/obesity in 7-year-old English children. A secondary aim was to examine associations between individual-level and area-level measures of SES and moderate-to-vigorous intensity physical activity (MVPA). Data were from wave four of the Millennium Cohort Study. Children were classified as normal weight, overweight/obese and centrally obese. MVPA was accelerometer derived. Individual-level and area-level SES were defined using self-reported maternal education and the 2004 English Indices of Multiple Deprivation, respectively. Adjusted linear and multinomial logistic regressions were conducted. Three thousand seven hundred seventeen children (1890 girls) had complete data. Children in the lowest maternal education group and highest deprivation decile were at greatest risk of overweight and central obesity. MVPA was inversely associated with deprivation, and the most deprived children were most likely to achieve 60min of daily MVPA. Individual-level and area-level SES were independently related to overweight and central obesity. Higher rates of overweight and central obesity among deprived children are not due to physical inactivity. Further research examining the concurrent effect of diet and MVPA on child weight status by deprivation is warranted.

A systematic review of socioeconomic status measurement in 13 years of U.S. injury research

ObjectiveThe purpose of this review was to assess the impact of socioeconomic status (SES) on injury and to evaluate how U.S. injury researchers have measured SES over the past 13years in observational research studies. Design & methodsThis systematic review included 119 US injury studies indexed in PubMed between January 1, 2002 and August 31, 2015 that used one or more individual and/or area-level measures of SES as independent variables. Study findings were compared to the results of a previous review published in 2002. ResultsFindings indicate SES remains an important predictor of injury. SES was inversely related to injury in 78 (66%) of the studies; inverse relationships were more consistently found in studies of fatal injury (77.4%) than in studies of non-fatal injury (58%). Approximately two-thirds of the studies (n=73, 61%) measured SES along a gradient and 59% used more than one measure of SES (n=70). Studies that used a gradient measure of SES and/or more than one measure of SES identified significant relationships more often. These findings were essentially equivalent to those of a similar 2002 review (Cubbin & Smith, 2002). ConclusionsThere remains a need to improve measurement of SES in injury research. Public health training programs should include best practices for measurement of SES, which include: measuring SES along a gradient, selecting SES indicators based on the injury mechanism, using the smallest geographic region possible for area-level measures, using multiple indicators when possible, and using both individual and area-level measures as both contribute independently to injury risk. Area-level indicators of SES are not accurate estimates of individual-level SES. Practical applicationsInjury researchers should measure SES along a gradient and incorporate individual and area-level SES measures that are appropriate to the injury outcome under study.

An ecological study of the association between area level green space and adult mortality in Hong Kong.

Introduction: There is evidence that urban design characteristics, including greater green space provision, have positive effects on health. Possible mechanisms include more opportunity for exercise, better air quality, smaller urban heat island effects, and lowered stress levels. Only a few previous studies have examined associations between green space and mortality and they have given inconsistent results. We conducted an ecological study relating green space to mortality in Hong Kong from 2006-2011. Methods: Normalized Difference Vegetation Index (NDVI), a measure of green space coverage, was measured for 199 small geographic areas in Hong Kong. Negative Binomial Regression Models were fit for each mortality outcome with NDVI as a covariate, and age, gender, population density, and area-level measures of socioeconomic status controlled as confounders, with Generalized Estimating Equations used to control for within-area correlation. Results: There were 236734, 58854, 21422, 11744, and 2964 deaths from all natural causes, cardiovascular diseases (CVD), lung cancer, chronic respiratory diseases (CRD), and diabetes, respectively. An increase of 0.44 units in NDVI, equivalent to it’s observed interquartile range, was significantly associated with lower CVD (relative risk (RR) = 0.88, 95% confidence interval (CI) = 0.80, 0.98) and diabetes (RR = 0.72, 95% CI = 0.60, 0.92) mortality, and marginally significantly associated with lower CRD mortality (RR = 0.90, 95% CI = 0.79, 1.02). These associations were stronger for males and residents of low-income areas. Lung cancer mortality had no significant association with green space. Conclusions: Better provision of green space in urban areas, particularly in low income areas, seems to have potential to reduce mortality in densely populated Asian cities. Policy makers involved in urban planning should consider these findings when making difficult decisions concerning land use in an era of rapid urban population growth.

Concordance between Individual vs. Area-Level Socioeconomic Measures in an Urban Setting.

Area-level socioeconomic status (SES) measures have been used as a proxy in child health research when individual SES measures are lacking, yet little is known about their validity in an urban setting. We assessed agreement between census block-group and individual-level SES measures obtained from a caregiver telephone survey in Jackson County, Missouri. Associations with prevalence of childhood overweight (OW), low birth weight (LBW), and household smoking exposure were examined using logistic regression models. Seven hundred eighty-one households were surveyed: 49% male, 76% White, mean child age 9.4 years. We found misclassification rates of 20-35% between individual vs. area-level measures of education and income; Kappa indices ranged from 0.26-0.36 indicating poor agreement. Both SES measures showed an inverse association with LBW and smoking exposure. Area-level SES measures may reflect a construct inclusive of neighborhood resources; routine substitution of these measures should be interpreted with caution, despite similar correlations with health outcomes.

Geographic and Racial Disparities in Breast Cancer–Related Outcomes in Georgia

To measure the effects of race/ethnicity, area measures of socioeconomic status (SES) and geographic residency status, and health care supply (HCS) characteristics on breast cancer (BC)-related outcomes. Female patients in Georgia diagnosed with BC in the years 2000-2009. Multilevel regression analysis with adjustment for variables at the county, census tract (CT), and individual level. The county represents the spatial unit of analysis for HCS. SES and geographic residency status were grouped at the CT level. Even after controlling for area-level characteristics, racial and ethnic minority women suffered an unequal BC burden. Despite inferior outcomes for disease stage and receipt of treatment, Hispanics had a marginally significant decreased risk of death compared with non-Hispanics. Higher CT poverty was associated with worse BC-related outcomes. Residing in small, isolated rural areas increased the odds of receiving surgery, decreased the odds of receiving radiotherapy, and decreased the risk of death. A higher per-capita availability of BC care physicians was significantly associated with decreased risk of death. Race/ethnicity and area-level measures of SES, geographic residency status, and HCS contribute to disparities in BC-related outcomes.

Just Because It’s Low Cost Doesn’t Mean It’s Accessible

Just Because It’s Low Cost Doesn’t Mean It’s Accessible

Area-level socioeconomic status in relation to outcomes in γ-hydroxybutyrate intoxication

Background. Area-level socioeconomic status (SES) may play an important role in drug abuse patterns, including related health outcomes. This may be particularly relevant for γ-hydroxybutyrate (GHB), which is prototypical of “party” drug abuse. Methods. We retrospectively reviewed GHB-related cases reported to the California Poison Control System (CPCS; January 1, 1999 through June 30, 2007). We limited analysis to CPCS calls containing a residential zip code (ZC). The CPCS data were extracted for key case characteristics, including the residential ZC. We linked cases to corresponding 2000 U.S. Census data for area-level measures of SES and demographics. We used multiple logistic regression analysis to test the associations between area-level SES and GHB case severity, taking into account area-level demographics and individual-level GHB high-risk behaviors. Results. We analyzed 210 cases. Taking into account area-level demographics (age and racial mix; urbanicity) and GHB-related high-risk behaviors (use of GHB congeners; GHB-dependence; co-ingestion of other agents), we associated higher area-level SES with greater GHB case severity. There was 40% increased likelihood of major GHB adverse health outcomes for every $100,000 incremental increase in median home values (OR 1.41; 95% CI 1.1–1.8). For median annual household income (per $10,000), the association was similar (OR 1.39; 95% CI 1.0–1.9). Conclusion. Higher area-level SES is associated with greater GHB-related case severity. This study may serve as a model using a geographic information system (GIS) approach to study the population-based correlates of drugs of abuse reported through poison control surveillance.

Density and type of food retailers surrounding Canadian schools: Variations across socioeconomic status

Lower socioeconomic status (SES) neighbourhoods may have differential access to food retailers, potentially explaining the varying area-level obesity rates. The food retail environment around 188 schools across Canada was examined, including full-service restaurants, fast food restaurants, sub/sandwich retailers, donut/coffee shops, convenience stores, and grocery stores. School addresses were linked to census data to obtain area-level SES measures. Access to food retailers was generally not associated with the neighbourhood SES in the immediate proximity. Within the broader neighbourhood, lower SES neighbourhoods had access to fewer food retailers of all types. This effect was diminished after taking population density into account.

Influence of individual- and area-level measures of socioeconomic status on obesity, unhealthy eating, and physical inactivity in Canadian adolescents

Low socioeconomic status (SES) is a risk factor for obesity. However, few studies have used a multilevel analysis to determine the influence of both individual- and area-level determinants of SES on obesity, and these studies have been limited to adults. The primary objective was to examine associations between individual- and area-level measures of SES and obesity among adolescents by using a multilevel analytic approach. A secondary objective was to examine associations between individual- and area-level measures of SES with unhealthy eating and physical inactivity. The study sample consisted of 6684 youth in grades 6-10 from 169 schools across Canada. Individual-level SES exposures included material wealth and perceived family wealth. Area-level SES exposures included unemployment rate, percentage of adult residents with less than a high school education, and average employment income from head of household. Associations between SES and the outcome measures were examined by using multilevel logistic regression procedures that modeled students (individual level) nested within schools (area level). Both individual-level and all 3 area-level SES measures were inversely associated with obesity. The odds for unhealthy eating were increased for those living in an area with a low percentage of residents with a high school education. The odds of being physically inactive increased with decreasing levels of material wealth and perception of family wealth. Individual- and area-level SES measures were independently related to obesity, which suggests that both individual and environmental approaches may be required to curtail adolescent obesity.

Chronic kidney disease and life course socioeconomic status: A review

Socioeconomic status (SES) may modify the effect of well-established risk factors on the development of kidney disease. Yet, recently, a paradigm shift has occurred with an emphasis on the direct effect of SES on the development of disease. This article covers the role SES may play in initiating and promoting chronic kidney disease (CKD) in the United States, with an emphasis on life-course SES. The literature on SES and kidney disease is discussed. Life-course and social epidemiology approaches are described. Salient risk factors and markers that are associated with both SES and kidney disease early in life include diet, birth weight, and infant mortality. Risk factors associated with individual SES later in life include diabetes mellitus, hypertension, diet, smoking, alcohol, drug use, occupational and environmental exposures, infection, and access to health care. An argument is made for incorporating area-level SES measures. Future research should incorporate both individual and area-level SES and be placed in the context of the life course.