Country-level Income Research Articles

A collaborative effort across Africa to investigate risk factors and outcomes of premature acute coronary syndrome: Protocol for the EAS Lipid Registry of Africa (LIPRA)

Data on acute coronary syndrome (ACS) is lacking in Africa where cases of premature ACS seem to be on the rise. Africa would benefit from an epidemiological assessment of premature ACS to determine its risk factors and management in this demographic to inform guidelines and practice. The European Atherosclerosis Society recognised this urgency and formed a growing network across 11 African countries to create the Lipid Registry of Africa (EAS-LIPRA). This article is based on the EAS-LIPRA protocol and presents the aims, concept and methodological considerations, and the operations and collaborative governance structure of this project. EAS-LIPRA aims to report risk factors and outcomes of premature ACS in Africa to further understand its prevalence and management via collating and pooling multinational prospective data on premature ACS across multiple sites in Africa into a standardised registry. Data will be stratified into subgroups based on country-level income as defined by the World Bank, and within country residence of urban versus rural areas. Valid statistical procedures will be employed to compare and observe trends in the pooled data based on demographics, clinical and laboratory variables, and disparities in its management. Being the first multinational lipid registry in Africa, it is envisaged that the network will expand to other African countries and sites yet to participate, facilitate other epidemiological studies in preventive cardiology, and set a precedent for other developing countries and regions.

Disparities in mortality rates from aortic aneurysm and dissection by country-level income status and sex

ObjectiveTo investigate the impact of national income level and sex on mortality trends from aortic aneurysm and dissection in addition to all aortic disease as a whole. MethodsUsing data from the World Health Organization mortality database, we conducted an analysis of mortality trends from aortic disease between 2000 and 2019, Countries were categorized into middle-income and high-income countries (MICs and HICs) on the basis of income level. Age-standardized and sex-specific age-standardized mortality rates per 100,000 persons, along with male-to-female mortality ratios, were calculated. Trends over the study period were analyzed using joinpoint regression. ResultsOur analysis comprised 29 MICs and 46 HICs, with an average population of 595 million and 1042 million during the observation period. During the observation period, age-standardized mortality rates from aortic disease decreased to 2.21 (2.17-2.25) and 2.28 (2.26-2.30) in MICs and HICs, respectively (average annual percentage change of −0.5% in MICs and −1.8% in HICs, P < .05 for both). However, mortality rates from aortic dissection increased in HICs from 2000 to 2019 (average annual percentage change of 1.3%, P < .001). Mortality from aortic disease, aortic dissection, and aortic aneurysm were male dominant in MICs and HICs but decreasing trends during the observation periods except for aortic dissection in MICs. ConclusionsWe present the contemporary and comprehensive analysis of global socioeconomic status and aortic diseases mortality. Although trends of mortality from aortic diseases are on the decline in both MICs and HICs, there is a striking increase in mortality for aortic dissection, specifically in HICs.

School socioeconomic status and psychological complaints among adolescents in 44 countries: The mediating role of schoolwork pressure and classmate support and the moderating role of family SES and country-level income inequality

Previous research has reported both positive and negative associations between school socioeconomic status (SES) and internalizing problems among adolescents. Little is known about cross-national differences in this association, as well as potential mediators and moderators. Therefore, this study investigated this association using representative cross-national samples of adolescents whilst exploring the mediating role of schoolwork pressure and classmate support, and the moderating role of family SES and country-level income inequality. Using data from adolescents aged 11–15 from 44 countries, participating in the 2017/2018 Health Behaviour in School-aged Children (HBSC) study (N = 202,202), we employed multilevel regression models with cross-level interactions. School SES was operationalized as the average family affluence of adolescents within a school and psychological complaints (e.g., feeling low/depressed) were used as an indication of internalizing problems. On average across countries, adolescents in higher SES schools reported more psychological complaints, with a large effect size. However, differences in this association were observed across countries, with a positive association in 19 out of 44 countries, a negative association in one country, and nonsignificant associations in the remaining countries. Schoolwork pressure partially mediated the average association between school SES and psychological complaints, as school SES was positively associated with schoolwork pressure which was associated with more psychological complaints. Our results did not support the mediating role of classmate support. Also, we found a moderating effect of family SES, indicating a stronger positive association between school SES and psychological complaints for those with a below average family SES compared to those with an average and above average family SES. No moderating effect was observed for country-level income inequality. These findings suggest that adolescents with low family SES attending higher SES schools are especially at risk for psychological complaints, and may therefore require tailored support. A promising strategy to reduce psychological complaints entails addressing schoolwork pressure.

Analysis of opioid analgesics consumption in Africa: a longitudinal study from a 20-year continental perspective

Opioid analgesics are essential for managing acute and chronic pain in diseases such as cancer. Inadequate opioid access remains a major public health concern in low-income regions including Africa. This study aimed to provide updated and comprehensive data on changes in opioid consumption, specifically in Africa. This longitudinal study has updated and expanded upon the International Narcotics Control Board data obtained from 1999 to 2021, assessing opioid consumption trends across all African countries. The defined daily doses for statistical purposes (SDDD) was used to determine the changes in opioid consumption in Africa. In addition, we used sub-analyses of the data to delve into individual substances, income levels, cancer incidence, cancer mortality, and sub-regional cluster analysis (based on the language spoken) to identify possible disparities and inform further research and tailored solutions. Our results indicate a persistently low and stagnant trend in opioid consumption between 2001-03 and 2019-21, from 73 SDDD (95% CI 69-77) to 55 SDDD (32-79). In-depth analysis revealed a morphine consumption increase from 735 SDDD in 1999 to 1115 SDDD in 2021. Moreover, opioid consumption was closely related to country-level income levels, with most of the low-income and lower-middle-income African countries reporting low opioid consumption. Notably, the escalating incidence and mortality rates associated with cancer in Africa indicated a misalignment with the trajectory of opioid use. Additionally, French-speaking African countries exhibited lower opioid usage than the rest of the continent, suggesting avenues for research into cultural, political, and social aspects. In the context of global doubling in opioid consumption, Africa has shown insufficient and stagnant opioid consumption during the last 20 years. These findings underscore the need for policy reform to facilitate safe and responsible opioid access in Africa, particularly for legitimate indications such as cancer pain and palliative care. None. For the French translation of the abstract see Supplementary Materials section.

A Cross-Country Study of Cigarette Affordability and Single-Stick Purchases Using Survey Data From African Countries.

Reducing cigarette affordability is paramount for reducing cigarette consumption. Measuring affordability requires data on cigarette prices. Unlike the commonly used retail price of a 20-pack of the most-sold cigarette domestically, survey-derived cigarette prices reflect differences arising from the brand variety and the types of packaging in which cigarettes are purchased. This paper uses self-reported cigarette price data from the eight African countries that have implemented the Global Adult Tobacco Survey (GATS) to construct country-level Relative Income Prices. The relationship between cigarette affordability, cigarette smoking prevalence, and cigarette smoking intensity, is examined using logit models for smoking participation (N = 51122) and generalized linear models for conditional cigarette demand (N = 2443). GATS data are also used to produce nationally representative estimates of the prevalence of single-stick cigarette purchases in the sampled countries. The estimated affordability elasticity of cigarette smoking participation is -0.245 (95% CI = -0.411 to -0.078). The estimated affordability elasticity of smoking intensity is -0.155 (95% CI = -0.286 to -0.023). Single-stick cigarette sales dominate all-markets. The proportion of smokers who reported buying cigarettes in the form of single sticks during their most recent cigarette purchase exceeds 90% in Kenya, Tanzania, and Uganda. The results point to the need for governments in the countries sampled to increase excise taxes in a manner that renders cigarettes less affordable over time, and to enact and enforce legislation that prohibits the sale of single cigarettes. These findings highlight that measures to reduce both the demand and supply of cigarettes will be required to reduce their use in the region. This study is the first to examine the prevalence of single-stick cigarette purchases, and the association between cigarette affordability and smoking outcomes, in the African setting, using data from the GATS. Findings provide local evidence for the countries sampled, which represent over half of sub-Saharan Africa's adult population (aged 15 and older), on the importance of implementing excise tax increases that reduce cigarette affordability over time. They also highlight the need to enact and enforce legislation that prohibits the sale of single cigarettes.

Frailty and Cognitive Function in Middle-Aged and Older Adults With Congenital Heart Disease

BackgroundLife expectancy of patients with congenital heart disease (CHD) has increased rapidly, resulting in a growing and aging population. Recent studies have shown that older people with CHD have higher morbidity, health care use, and mortality. To maintain longevity and quality of life, understanding their evolving medical and psychosocial challenges is essential. ObjectivesThe authors describe the frailty and cognitive profile of middle-aged and older adults with CHD to identify predictor variables and to explore the relationship with hospital admissions and outpatient visits. MethodsUsing a cross-sectional, multicentric design, we included 814 patients aged ≥40 years from 11 countries. Frailty phenotype was determined using the Fried method. Cognitive function was assessed by the Montreal Cognitive Assessment. ResultsIn this sample, 52.3% of patients were assessed as robust, 41.9% as prefrail, and 5.8% as frail; 38.8% had cognitive dysfunction. Multinomial regression showed that frailty was associated with older age, female sex, higher physiologic class, and comorbidities. Counterintuitively, patients with mild heart defects were more likely than those with complex lesions to be prefrail. Patients from middle-income countries displayed more prefrailty than those from higher-income countries. Logistic regression demonstrated that cognitive dysfunction was related to older age, comorbidities, and lower country-level income. ConclusionsApproximately one-half of included patients were (pre-)frail, and more than one-third experienced cognitive impairment. Frailty and cognitive dysfunction were identified in patients with mild CHD, indicating that these concerns extend beyond severe CHD. Assessing frailty and cognition routinely could offer valuable insights into this aging population.

Understanding public support for workplace diversity and antidiscrimination policies in Europe.

Societal processes and public opinion can affect whether employers take action and which policy measures they choose to boost diversity, equal opportunities and inclusion, and to reduce discrimination in the workplace. Yet, public opinion regarding workplace diversity initiatives (other than affirmative action) has so far received little scholarly attention, especially in Europe. Consequently, we have very little evidence about how the general public feels about workplace diversity policies - particularly those that are more common or more often discussed in Europe - and about which factors shape public support for these workplace diversity initiatives. Yet, a better understanding of the patterns and antecedents of citizens' attitudes toward workplace diversity policies is of clear scientific and practical importance. Against this background, this study sheds light on public attitudes toward three different, commonly applied types of workplace diversity policies, and examines which individual-level and - innovatively - national-level conditions shape public support. To do so, we bring together insights from various different and so far largely disconnected strands of research and a range of theoretical perspectives. We use large-scale, representative survey data from two pooled waves of the Eurobarometer, covering 38,009 citizens across 26 European countries. We enrich these data with information on national-level income inequality as well as countries' labor market and antidiscrimination legislation and policies, obtained from Eurostat and the Migrant Integration Policy Index (MIPEX). Results show significant differences in public support across the three types of policies, with the strongest support for diversity training, followed closely by monitoring recruitment procedures, whereas support for monitoring workforce composition is clearly lower. This is in line with the idea that support tends to be lower for more preferential and prescriptive workplace policies. Furthermore, we find that, in addition to individual-level factors - particularly gender, ethnic minority group membership, personal experiences with discrimination, prejudice, intergroup contact and political orientation - national-level conditions are important antecedents of public support for workplace diversity policies. That is, differences in public attitudes regarding such policies are also shaped by country-level income inequalities, people's perceptions of how widespread discrimination and unequal opportunities are in society, and national-level laws and policies to fight unequal opportunities.

Socioeconomic inequalities in adolescent mental health in the Nordic countries in the 2000s - A study using cross-sectional data from the Health Behaviour in School-aged Children study

BackgroundAdolescents in Sweden experience more mental health problems and lower mental well-being than adolescents in other Nordic countries. According to the literature, one possible explanation may be differences in income inequality. The at-risk-of-poverty rate varies significantly across the Nordic countries, and the highest rate is found in Sweden. The aims of the study were to examine socioeconomic inequalities in subjective health complaints and life satisfaction among adolescents in the Nordic countries during 2002 − 2018 and to explore whether subjective health complaints and life satisfaction were related to income inequality in terms of the at-risk-of-poverty rate at the country level.MethodsData regarding 15-year-olds from the Health Behaviour in School-aged Children study from five survey rounds (2002 − 2018) were used (n = 41,148). The HBSC Symptoms Checklist and Cantril’s ladder were used as measures of subjective health complaints and life satisfaction, respectively. The Family Affluence Scale, the Perceived Family Wealth item and the at-risk-of-poverty rate in each country were used as measures of individual-level socioeconomic conditions and country-level income inequality. Statistical methods involved ANOVA, multiple linear regressions and multilevel regression analyses.ResultsAbsolute and relative socioeconomic inequalities in both subjective health complaints and life satisfaction were found in all countries. Sweden showed average socioeconomic inequalities, Iceland the largest and Denmark the smallest. Country-level income inequality in terms of the at-risk-of-poverty rate was associated with a higher prevalence of subjective health complaints and lower levels of life satisfaction in all countries.ConclusionSocioeconomic inequalities in adolescent mental health and well-being persisted in Nordic countries in the 2000s. Increasing income inequality may have contributed to higher levels of SHC and lower LS in Sweden compared to the other Nordic countries. Policies improving families’ socioeconomic conditions and reducing income inequality at the country level are needed to improve and reduce inequalities in mental health and well-being among adolescents.

Unequal perspectives? Income inequality as a benchmark for support for European integration

Despite growing attention to income inequality in debates about European integration, our understanding of its effect on European Union support remains limited. Using European Social Survey data from 2002 to 2020, we analyse how income inequality and pro-redistribution attitudes shape diffuse and specific forms of support for the European Union. We find no direct effect of country-level income inequality, while individual support for redistribution has a negative effect on both. In line with benchmarking theory, inequality emerges as a contextual moderator: in unequal national settings, egalitarian citizens are comparatively more supportive of further integration than in more equal countries. This effect persists when we control for income position, suggesting an ideological rather than utilitarian basis for benchmarking European Union attitudes. We discuss implications in light of debates about a social Europe.

A global comparative study of wealth-pain gradients: Investigating individual- and country-level associations.

Pain is a significant yet underappreciated dimension of population health. Its associations with individual- and country-level wealth are not well characterized using global data. We estimate both individual- and country-level wealth inequalities in pain in 51 countries by combining data from the World Health Organization's World Health Survey with country-level contextual data. Our research concentrates on three questions: 1) Are inequalities in pain by individual-level wealth observed in countries worldwide? 2) Does country-level wealth also relate to pain prevalence? 3) Can variations in pain reporting also be explained by country-level contextual factors, such as income inequality? Analytical steps include logistic regressions conducted for separate countries, and multilevel models with random wealth slopes and resultant predicted probabilities using a dataset that pools information across countries. Findings show individual-level wealth negatively predicts pain almost universally, but the association strength differs across countries. Country-level contextual factors do not explain away these associations. Pain is generally less prevalent in wealthier countries, but the exact nature of the association between country-level wealth and pain depends on the moderating influence of country-level income inequality, measured by the Gini index. The lower the income inequality, the more likely it is that poor countries experience the highest and rich countries the lowest prevalence of pain. In contrast, the higher the income inequality, the more nonlinear the association between country-level wealth and pain reporting such that the highest prevalence is seen in highly nonegalitarian middle-income countries. Our findings help to characterize the global distribution of pain and pain inequalities, and to identify national-level factors that shape pain inequalities.

The Relationship Between Inequality and Potential Emigration: Evidence from the Gallup World Poll

The existing literature presents conflicting findings regarding the relationship between inequality and potential emigration. This paper utilizes individual-level data from the Gallup World Poll and country-level income inequality measures for 150 countries to contribute new evidence. The findings indicate that increasing inequality is linked to decreased desires and plans for emigration, a consistent global trend observed across various inequality measures and specifications. Notably, this association is more pronounced for women, individuals without overseas networks, and those lacking financial and human capital. Additionally, the study sheds light on how the level of economic development in countries influences the relationship. In low- and middle-income countries, rising inequality is negatively associated with emigration intentions. Conversely, in affluent nations, heightened inequality stimulates greater desires to emigrate, particularly among high-income and highly educated individuals. These insights provide a deeper understanding of how inequality shapes emigration in diverse world regions and across different cohorts, bridging gaps between previous divergent findings.

Use of hospital services by patients with chronic conditions in sub-Saharan Africa: a systematic review and meta-analysis.

To estimate the prevalence of individual chronic conditions and multimorbidity among adults admitted to hospital in countries in sub-Saharan Africa. We systematically searched MEDLINE®, Embase®, Global Index Medicus, Global Health and SciELO for publications reporting on patient cohorts recruited between 1 January 2010 and 12 May 2023. We included articles reporting prevalence of pre-specified chronic diseases within unselected acute care services (emergency departments or medical inpatient settings). No language restrictions were applied. We generated prevalence estimates using random-effects meta-analysis alongside 95% confidence intervals, 95% prediction intervals and I2 statistics for heterogeneity. To explore associations with age, sex, country-level income status, geographical region and risk of bias, we conducted pre-specified meta-regression, sub-group and sensitivity analyses. Of 6976 identified studies, 61 met the inclusion criteria, comprising data from 20 countries and 376 676 people. None directly reported multimorbidity, but instead reported prevalence for individual conditions. Among medical admissions, the highest prevalence was human immunodeficiency virus infection (36.4%; 95% CI: 31.3-41.8); hypertension (24.4%; 95% CI: 16.7-34.2); diabetes (11.9%; 95% CI: 9.9-14.3); heart failure (8.2%; 95% CI: 5.6-11.9); chronic kidney disease (7.7%; 95% CI: 3.9-14.7); and stroke (6.8%; 95% CI: 4.7-9.6). Among patients seeking hospital care in sub-Saharan Africa, multimorbidity remains poorly described despite high burdens of individual chronic diseases. Prospective public health studies of multimorbidity burden are needed to generate integrated and context-specific health system interventions that act to maximize patient survival and well-being.

Global application of National Comprehensive Cancer Network resource-stratified guidelines for systemic treatment of colon cancer: a population-based, customisable model for cost, demand, and procurement.

Resource-stratified guidelines (RSGs) can inform systemic treatment decisions in the face of limited resources. The objective of this study was to develop a customisable modelling tool to predict the demand, cost, and drug procurement needs of delivering National Comprehensive Cancer Network (NCCN) RSG-based systemic treatment for colon cancer. We developed decision trees for first-course systemic therapy for colon cancer based on the NCCN RSGs. Decision trees were merged with data from the Surveillance, Epidemiology, and End Results programme, the International Agency for Research on Cancer's GLOBOCAN 2020 national estimates for colon cancer incidence, country-level income data, and data on drug costs from Redbook (USA), the Pharmaceutical Benefits Scheme (Australia), and the Management Sciences for Health 2015 International Medical Products price guide to estimate global treatment needs and costs, and forecast drug procurement. Simulations and sensitivity analyses were used to explore the effect of scaling up services globally and the effect of alternative stage distributions on treatment demand and cost. We generated a customisable model, in which estimates can be tailored to local incidence, epidemiological, and costing data. First-course systemic therapy is indicated in 608 314 (53·6%) of 1 135 864 colon cancer diagnoses in 2020. Indications for first-course systemic therapy are projected to rise to 926 653 in 2040; the indications in 2020 might be as high as 826 123 (72·7%), depending on stage distribution assumptions. Adhering to NCCN RSGs, patients with colon cancer in low-income and middle income countries (LMICs) would constitute 329 098 (54·1%) of 608 314 global systemic therapy demands, but only 10% of global expenditure on systemic therapies. The total cost of NCCN RSG-based first-course systemic therapy for colon cancer in 2020 would be between about US$4·2 and about $4·6 billion, depending on stage distribution. If all patients with colon cancer in 2020 were treated according to maximal resources, global expenditure on systemic therapy for colon cancer would rise to around $8·3 billion. We have developed a customisable model that can be applied at global, national, and subnational levels to estimate systemic treatment needs, forecast drug procurement, and calculate expected drug costs on the basis of local data. This tool can be used to plan resource allocation for colon cancer globally. None.

Global disparities in mortality and liver transplantation in hospitalised patients with cirrhosis: a prospective cohort study for the CLEARED Consortium

Cirrhosis, the end result of liver injury, has high mortality globally. The effect of country-level income on mortality from cirrhosis is unclear. We aimed to assess predictors of death in inpatients with cirrhosis using a global consortium focusing on cirrhosis-related and access-related variables. In this prospective observational cohort study, the CLEARED Consortium followed up inpatients with cirrhosis at 90 tertiary care hospitals in 25 countries across six continents. Consecutive patients older than 18 years who were admitted non-electively, without COVID-19 or advanced hepatocellular carcinoma, were enrolled. We ensured equitable participation by limiting enrolment to a maximum of 50 patients per site. Data were collected from patients and their medical records, and included demographic characteristics; country; disease severity (MELD-Na score); cirrhosis cause; medications used; reasons for admission; transplantation listing; cirrhosis-related history in the past 6 months; and clinical course and management while hospitalised and for 30 days post discharge. Primary outcomes were death and receipt of liver transplant during index hospitalisation or within 30 days post discharge. Sites were surveyed regarding availability of and access to diagnostic and treatment services. Outcomes were compared by country income level of participating sites, defined according to World Bank income classifications (high-income countries [HICs], upper-middle-income countries [UMICs], and low-income or lower-middle-income countries [LICs or LMICs]). Multivariable models controlling for demographic variables, disease cause, and disease severity were used to analyse the odds of each outcome associated with variables of interest. Patients were recruited between Nov 5, 2021, and Aug 31, 2022. Complete inpatient data were obtained for 3884 patients (mean age 55·9 years [SD 13·3]; 2493 (64·2%) men and 1391 (35·8%) women; 1413 [36·4%] from HICs, 1757 [45·2%] from UMICs, and 714 [18·4%] from LICs or LMICs), with 410 lost to follow-up within 30 days after hospital discharge. The number of patients who died while hospitalised was 110 (7·8%) of 1413 in HICs, 182 (10·4%) of 1757 in UMICs, and 158 (22·1%) of 714 in LICs and LMICs (p<0·0001), and within 30 days post discharge these values were 179 (14·4%) of 1244 in HICs, 267 (17·2%) of 1556 in UMICs, and 204 (30·3%) of 674 in LICs and LMICs (p<0·0001). Compared with patients from HICs, increased risk of death during hospitalisation was found for patients from UMICs (adjusted odds ratio [aOR] 2·14 [95% CI 1·61-2·84]) and from LICs or LMICs (2·54 [1·82-3·54]), in addition to increased risk of death within 30 days post discharge (1·95 [1·44-2·65] in UMICs and 1·84 [1·24-2·72] in LICs or LMICs). Receipt of a liver transplant was recorded in 59 (4·2%) of 1413 patients from HICs, 28 (1·6%) of 1757 from UMICs (aOR 0·41 [95% CI 0·24-0·69] vs HICs), and 14 (2·0%) of 714 from LICs and LMICs (0·21 [0·10-0·41] vs HICs) during index hospitalisation (p<0·0001), and in 105 (9·2%) of 1137 patients from HICs, 55 (4·0%) of 1372 from UMICs (0·58 [0·39-0·85] vs HICs), and 16 (3·1%) of 509 from LICs or LMICs (0·21 [0·11-0·40] vs HICs) by 30 days post discharge (p<0·0001). Site survey results showed that access to important medications (rifaximin, albumin, and terlipressin) and interventions (emergency endoscopy, liver transplantation, intensive care, and palliative care) varied geographically. Inpatients with cirrhosis in LICs, LMICs, or UMICs have significantly higher mortality than inpatients in HICs independent of medical risk factors, and this might be due to disparities in access to essential diagnostic and treatment services. These results should encourage researchers and policy makers to consider access to services and medications when evaluating cirrhosis-related outcomes. National Institutes of Health and US Department of Veterans Affairs.

Barriers to and enablers of the HIV services continuum among gay and bisexual men worldwide: Findings from the Global Men's Health and Rights Study.

To assess ecological, structural, community and individual level correlates of health services utilization along a continuum of HIV care, and sexual health and support services among gay and bisexual men worldwide. Using a nonprobability internet sample of 6,135 gay and bisexual men, we assessed correlates of utilization of health services. Chi-Square Tests of Independence were performed to assess drop off along a continuum of HIV care. Multivariable logistic regression analyses using generalized estimating equation models were conducted adjusting for geographic region and clustering by country. In multivariable analyses, we determined the association between utilization outcomes, and ecologic, structural, community and individual correlates by fitting separate generalized estimating equation (GEE) logistic regression models for each of the outcomes, fitted with robust SEs, and accounting for clustering by country. Stratified by sexual identity, analyses adjusted for variables that could influence HIV-related health outcomes including racial/ethnic minority status, participant age, insurance, ability to make ends meet, as well as country-level income (income of country of residence defined by the World Bank). Among men living with HIV (n = 1001), being in HIV care (n = 867) was associated with being on ART (X2 = 191.17, p < .001), and viral load suppression (X2 = 14.03, p < .001); and using ART (n = 840) was associated viral load suppression (X2 = 21.66, p < .001). Overall, the pattern of utilization outcomes were similar for both gay and bisexual men. For example, utilization of PrEP, being in HIV care and utilization of most of the sexual health and support services were negatively associated with sexual stigma. Whereas, utilization of most HIV prevention, and sexual health and support services were positively associated with provider discrimination. Utilization of all HIV prevention and all sexual health services were positively associated with greater community engagement, and receiving services from LGBT-led organizations. Bisexual men had higher odds of reporting provider discrimination when utilizing condom services (gay: AOR = 1.14, [0.95-1.36]; bisexual: 1.58, [1.10-2.28]), PrEP (gay: AOR = 1.06, [0.77-1.45]; bisexual: AOR = 2.14, [1.18-3.89], mental health services (gay: AOR = 1.03, [0.86-1.23]; bisexual: AOR = 1.32, [1.07-1.64]), and community-based support (gay: AOR = 1.23, [1.05-1.45]; bisexual: AOR = 1.49, [1.14-1.93]) than gay men. Bisexual men also reported higher odds of accessing services from LGBT-led organizations when utilizing PrEP (gay: AOR = 5.26, [2.50-11.05]; bisexual: AOR = 7.12, [3.16-16.04]), and community-based support/self-help groups/individual counseling (gay: AOR = 2.63, [1.72-4.01]; bisexual: AOR = 3.35, [2.30-4.88]. It is essential that barriers to health services utilization be addressed at structural and community levels. Structural interventions should be designed to reduce sexual stigma, as well as train and sensitize healthcare providers; and strengthen community level interventions that bring gay and bisexual men together to lead comprehensive health services.

Sex differences in dementia risk and risk factors: Individual-participant data analysis using 21 cohorts across six continents from the COSMIC consortium.

Sex differences in dementia risk, and risk factor (RF) associations with dementia, remain uncertain across diverse ethno-regional groups. A total of 29,850 participants (58% women) from 21 cohorts across six continents were included in an individual participant data meta-analysis. Sex-specific hazard ratios (HRs), and women-to-men ratio of hazard ratios (RHRs) for associations between RFs and all-cause dementia were derived from mixed-effect Cox models. Incident dementia occurred in 2089 (66% women) participants over 4.6 years (median). Women had higher dementia risk (HR, 1.12 [1.02, 1.23]) than men, particularly in low- and lower-middle-income economies. Associations between longer education and former alcohol use with dementia risk (RHR, 1.01 [1.00, 1.03] per year, and 0.55 [0.38, 0.79], respectively) were stronger for men than women; otherwise, there were no discernible sex differences in other RFs. Dementia risk was higher in women than men, with possible variations by country-level income settings, but most RFs appear to work similarly in women and men.

Income inequality and its relationship with loneliness prevalence: A cross-sectional study among older adults in the US and 16 European countries.

The prevalence of loneliness increases among older adults, varies across countries, and is related to within-country socioeconomic, psychosocial, and health factors. The 2000-2019 pooled prevalence of loneliness among adults 60 years and older went from 5.2% in Northern Europe to 24% in Eastern Europe, while in the US was 56% in 2012. The relationship between country-level factors and loneliness, however, has been underexplored. Because income inequality shapes material conditions and relative social deprivation and has been related to loneliness in 11 European countries, we expected a relationship between income inequality and loneliness in the US and 16 European countries. We used secondary cross-sectional data for 75,891 adults age 50+ from HRS (US 2014), ELSA (England, 2014), and SHARE (15 European countries, 2013). Loneliness was measured using the R-UCLA three-item scale. We employed hierarchical logistic regressions to analyse whether income inequality (GINI coefficient) was associated with loneliness prevalence. The prevalence of loneliness was 25.32% in the US (HRS), 17.55% in England (ELSA) and ranged from 5.12% to 20.15% in European countries (SHARE). Older adults living in countries with higher income inequality were more likely to report loneliness, even after adjusting for the sociodemographic composition of the countries and their Gross Domestic Products per capita (OR: 1.52; 95% CI: 1.17-1.97). Greater country-level income inequality was associated with higher prevalence of loneliness over and above individual-level sociodemographics. The present study is the first attempt to explore income inequality as a predictor of loneliness prevalence among older adults in the US and 16 European countries. Addressing income distribution and the underlying experience of relative deprivation might be an opportunity to improve older adults' life expectancy and wellbeing by reducing loneliness prevalence.

Is the mediating effect of psychosocial stress on the income–health relationship moderated by income inequality?

BackgroundThere now exists a rich body of literature on the relationship between income, income inequality, and health. The discussion about the impact of income and income inequality on health includes psychosocial mechanisms, such as long-term perceptions of inferiority and social positioning, material advantage from income, and the structural conditions that define what people can do with their material resources. AimsThis study investigated the extent to which income's effects on health are mediated by psychosocial stress, and to what extent those effects are moderated by country-level income inequality and economic development. MethodsData were collected from The European Social Survey, round 7. Multilevel moderated mediation analysis was applied to estimate the extent of psychosocial stress mediation of the effects of income on self-rated health. Moderated parameters were estimated over country-level income inequality and economic development. ResultsSignificant full or partial meditation by psychosocial stress was found in all 20 countries studied. Effects moderated by income inequality and GDP per capita showed expected relationships but failed to reach conventional levels of statistical significance. ConclusionsIndividual-level income remains important for explaining the income–health gradient in self-rated health in Europe. The income–health relationship and the extent to which it is mediated by psychosocial stress varies among countries but is not significantly moderated by contextual income or income inequality. Policies should be aimed at allowing a greater proportion of people to live in material comfort and reduced sense of financial precarity, and protecting individuals from harmful consequences of low income.

Unemployment and expenditure on health and education as mediators of the association between toothbrushing and global income inequalities

ObjectiveThe study assessed the association of country-level income inequalities with the percentage of schoolchildren toothbrushing-at-least-twice-daily; and the mediating effect of country-level unemployment rate and governmental expenditure on health and education (EH&E).MethodsThis was an ecological study. The dependent variable was country-level toothbrushing-at-least-twice-daily among 11-15-year-old schoolchildren. Data for the period 2009 to 2019 were extracted from two global surveys about schoolchildren’s health and from manuscripts identified through a systematic search of three databases. The independent variable was country-level income inequalities measured by the Gini coefficient (GC) extracted from the Sustainable Development Report 2021. The mediators were the unemployment rate and EH&E. We stratified the sample by the level of GC and assessed the correlation between the dependent and independent variables in each stratum. Linear regression was used to assess the relations between the dependent and independent variables, and mediation path analysis was used to quantify the direct, indirect, and total effects.ResultsData were available for 127 countries. The mean (SD) percentage of children who brushed-at-least-twice-daily was 67.3 (16.1), the mean (SD) GC = 41.4 (8.2), unemployment rate = 7.5 (4.7) and EH&E = 8.4 (3.3). The percentage of children brushing at-least-twice-daily had weak and non-significant correlation with GC that was positive in countries with the least inequality and negative for countries with higher levels of inequality. A greater percentage of schoolchildren brushing-at-least-twice-daily was significantly associated with higher GC (B = 0.76, 95%CI: 0.33, 1.18), greater EH&E (B = 1.67, 95%CI: 0.69, 2.64) and lower unemployment rate (B=-1.03, 95%CI: -1.71, -0.35). GC had a significant direct positive effect (B = 0.76, 95%CI: 0.33, 1.18), a significant indirect negative effect through unemployment and EH&E (B=-0.47, 95%CI: -0.79, -0.24) and a non-significant total positive effect (B = 0.29, 95%CI: -0.09, 0.67) on the percentage of schoolchildren brushing-at-least-twice-daily.ConclusionUnemployment and EH&E mediated the association between income inequality and toothbrushing. Country-level factors may indirectly impact toothbrushing.

Trust in science, medicine and medical providers and its relations to vaccine beliefs: A latent class analysis.

People may differ in their vaccine-related beliefs (i.e. efficacy, safety, purpose), with a host of factors influencing these differences. This can produce homogeneous groups of individuals who share certain beliefs, attitudes and opinions not only towards vaccines but science and medicine in general. This study aims to characterise distinct subgroups and identify ideal targets for tailored public health interventions to reinforce favourable vaccine beliefs. Latent class analysis was used to derive unique profiles using the 2019 Gallup survey of 140 countries. We modelled a composite of vaccine beliefs and regressed this on class membership and relevant covariates. Patterns of item endorsement indicated a well-fitting five-class model, with classes distinguished based on whether individuals sought personal knowledge about science, medicine and health; trusted science and scientists; and reported confidence in the health care system. The lowest levels of vaccine beliefs were reported by a class lacking trust and confidence and the highest levels were reported by a class endorsing trust, confidence and desiring medical and scientific knowledge. Country-level income was moderately related to class membership, and vaccine beliefs were higher in lower-income countries. Findings suggest that public health campaigns can focus on improving trust in science and medical providers. Efforts to improve vaccination rates can only be achieved when individuals trust science, view the work of scientists as beneficial and hold favourable views towards health care providers. Individuals will then accrue the necessary wisdom to make good health care decisions that affect not only themselves but also their fellow citizens.