Higher Socioeconomic Status Counterparts Research Articles

Delayed Prescribing of Non-Vitamin K Antagonist Oral Anticoagulants (NOACs) in Patients with Low Socioeconomic Status

Background/Objective: Atrial fibrillation (AF) and venous thromboembolism (VTE) are conditions with significant morbidity and mortality when left untreated. American Heart Association guidelines changed in 2019 to make non-vitamin K antagonist oral anticoagulants (NOACs) the preferred method for preventing stroke and systemic embolism in patients with AF or history of VTE. NOACs were first introduced to the United States in 2010 and now include dabigatran, apixaban, rivaroxaban, and edoxaban. There is a dearth of research concerning the speed with which new treatments are prescribed to those in different socioeconomic status (SES) groups. We hypothesized that patients with lower SES were prescribed NOACs later than higher SES counterparts following the introduction of NOACs in 2010.
 Methods: The IU Cardiovascular Research Consortium/Sidus Dataset was mined for AF and VTE patients prescribed a NOAC between 2010 and 2022. The SES groups were determined using 2020 U.S. Census income data that correlated to patients’ zip codes. The yearly number ofpatients in each SES group were compared to assess for proportional uptake of NOAC prescribing. The primary outcome was the proportion of low SES to high SES prescribing over each year between 2010 and 2022.
 Results: Low SES patients (n=101,945) were prescribed NOACs at an average of 0.65 times the rate of high SES patients (n= 89,130) from 2010 to 2012, the first three years of NOAC market availability. Prescribing rates equilibrated in 2013 and low SES prescribing has outpaced high SES prescribing since 2021.
 Conclusion/Impact: Low SES patients experienced a three year delay in receiving NOAC prescriptions at the same rate as their high SES counterparts. Systemic changes, like more frequent prescribing guideline updates and improved evidence-based education amongst providers in low-income areas, could prevent a similar delay when introducing similarly transformative treatments in the future.

36 Disparities in General Mental Status Between Lower and Higher SES Ethnically Diverse Older Adults

Objective:To investigate differences in performance on a widely used cognitive screener between community-dwelling older adults from two disparate socioeconomic groups.Participants and Methods:Participants were part of a larger study of cognitive screening in healthy older adults. The total sample (N=79, 69.6% female, 19% White/Caucasian, 12.7% Asian, 43% Latino/a, 25.3% Black/African-American) consisted of community-dwelling adults (Mage=73.1 years [SD=7.2] and Meducation=14.3 years [SD=2.6]) who were initially recruited via social media, flyers, and general community announcements. A lack of ethnic minority participants resulted in a two-year commitment to reach communities of color via visits and provision of health literacy to local religious and community programs. Continuous contact with leaders/gatekeepers helped establish research study credibility and forge a stronger sense of trust among ethnically diverse participants in the greater Houston, TX, area. Testing was initially conducted at the clinical study site. Due to low participation rates among people of color, greater effort was placed on tailored strategies to overcome economic and time constraints (i.e., schedule/time conflicts, lack of transportation, inability to pay for parking). To fit the priorities and needs of the participants, testing was also conducted at their homes (25.3%) and nearby religious and community centers (22.8%). Participants identifying as Latino/a or Black were predominantly recruited and tested at their local community center (as requested by gatekeepers/participants) to increase access to the study, in contrast to Caucasian participants. Median income estimates were used to stratify participants by socioeconomic status (SES) based on zip codes into low SES (L-SES) or high SES (H-SES) groups.Results:Participants from the L-SES group had significantly lower total scores on the MoCA than their H-SES counterparts, t(77J=2.837, p=0.003, g=0.696. The average MoCA total score for participants from the L-SES group was 2.64 points lower. The observed differences in MoCA total score when stratifying by ethnicity may be attributable to differences in education level and SES, which are known risk factors for cognitive impairment and will be further examined upon recruitment completion.Conclusions:Studies have found that ethnically diverse older adults not only encounter more barriers to accessing quality health care but also experience disparities in brain health research. Communities of color comprise a sizeable portion of our older adults but have been traditionally underrepresented in clinical research, limiting the generalizability of research findings to clinical treatment. Socioeconomic deprivation has been identified as one of several barriers to research engagement for people of color, placing ethnic communities at increased risk for under- or misdiagnosis and limited access to medical intervention. Preliminary findings have implications for the recruitment of ethnically diverse groups in clinical research. Given the growing racial and ethnic diversity among the United States population, we must do our due diligence to increase understanding of participation and recruitment barriers for racial/ethnic individuals. Tailored community outreach and engagement strategies may be effective in improving the inclusion of ethnically diverse populations and facilitating recruitment and retention in clinical research studies.

The relationships between socioeconomic status, dietary knowledge and patterns, and physical activity with adiposity in urban South African women

Background: This cross-sectional study examined the relationship between socioeconomic status (SES), dietary knowledge and patterns, and physical activity level with body mass index of urban South African young women. Methods: Data were collected on 160 black South African women (aged 18–24 years) and included household SES, food frequency and nutritional knowledge questionnaires, self-reported physical activity and anthropometry. To assess household SES index, 1–7 assets were categorised as a lower household SES and those with 8–13 assets as a higher household SES. Structural equation modelling analysis was used to determine the direct, indirect and total effects on adiposity of household SES, age, education, nutrition knowledge score, dietary patterns and physical activity. Results: The prevalence of overweight and obesity was similar among women from high SES households compared with their low SES peers (48.4 vs. 44.8%). More than half (53%) of the women had poor dietary knowledge. Women from low SES households spent more time in moderate to vigorous intensity exercise (MVPA) compared with their high SES counterparts. Two distinct dietary patterns (Western and mixed) were identified. SEM results show that a unit increase in adherence to the ‘Mixed’ dietary pattern compared with ‘Western’ was associated with a 0.81 lower BMI kg/m2 (95% CI −1.54; −0.08), while ≥ 150 minutes’ MVPA per week was associated with a 1.94 lower BMI kg/m2 (95% CI −3.48; −0.41). Conclusion: The associations of SES, diet and physical activity on BMI must be taken into account when developing and designing interventions that target improvement in young women’s health.

The Association of Patient Educational Attainment With Cardiac Rehabilitation Adherence and Health Outcomes.

Participating in cardiac rehabilitation (CR) after a cardiac event provides many clinical benefits. Patients of lower socioeconomic status (SES) are less likely to attend CR. It is unclear whether they attain similar clinical benefits as patients with higher SES. This study examines how educational attainment (one measure of SES) predicts both adherence to and improvements during CR. This was a prospective observational study of 1407 patients enrolled between January 2016 and December 2019 in a CR program located in Burlington, VT. Years of education, smoking status (self-reported and objectively measured), depression symptom level (Patient Health Questionnaire), self-reported physical function (Medical Outcomes Survey), level of fitness (peak metabolic equivalent, peak oxygen uptake, and handgrip strength), and body composition (body mass index and waist circumference) were obtained at entry to, and for a subset (n = 917), at exit from CR. Associations of educational attainment with baseline characteristics were examined using Kruskal-Wallis or Pearson's χ 2 tests as appropriate. Associations of educational attainment with improvements during CR were examined using analysis of covariance or logistic regression as appropriate. Educational attainment was significantly associated with most patient characteristics examined at intake and was a significant predictor of the number of CR sessions completed. Lower educational attainment was associated with less improvement in cardiorespiratory fitness, even when controlling for other variables. Patients with lower SES attend fewer sessions of CR than their higher SES counterparts and may not attain the same level of benefit from attending. Programs need to increase attendance within this population and consider program modifications that further support behavioral changes during CR.

Air Pollution and Urban Green Space: Evidence of Environmental Injustice in Adama, Ethiopia

While air pollution data in Ethiopia is limited, existing studies indicate high levels of both ambient and household air pollution; rapid urbanization also threatens the preservation of urban green spaces. In this study, environmental injustice, or the disproportionate burden of environmental exposures on persons of lower socioeconomic status (SES), was explored among women in Ethiopia using a mother and child cohort from the city of Adama. Land-use regression models were previously developed for modeling ambient nitrogen dioxide (NO2) and nitrogen oxides (NOx) throughout Adama, while household air pollution (cooking fuel type) and the presence of green space were assessed through questionnaires and home visits, respectively. The odds of being exposed to these environmental factors were analyzed in association with two SES indicators, education and occupation, using logistic regression. Our results indicate the presence of environmental injustice in Adama, as women with lower SES shouldered a higher burden of air pollution exposure and enjoyed less urban green space than their higher SES counterparts. These findings encourage the prioritization of air quality control and urban planning resources toward policy action within lower SES areas. From a societal perspective, our results also support more upstream interventions, including investment in educational and occupational opportunities. Still, a human rights approach is emphasized, as governments are responsible for protecting the right to a clean environment, especially for those disproportionately exposed. To the best of our knowledge, this is the first study on environmental injustice in Ethiopia, and the first in Sub-Saharan Africa to investigate the inequalities of ambient and household air pollution exposure as well as urban green space access in the same cohort.

Disparities in H1N1 Vaccination Rates: a Systematic Review and Evidence Synthesis to Inform COVID-19 Vaccination Efforts.

BackgroundData suggest that there were disparities in H1N1 vaccine uptake, and these may inform COVID-19 vaccination efforts. We conducted a systematic review to evaluate disparities in H1N1 vaccine uptake, factors contributing to disparities, and interventions to reduce them.MethodsWe searched English-language articles in MEDLINE ALL, PsycINFO, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials from database inception through May 8, 2020. Observational studies examining H1N1 vaccine uptake by race/ethnicity, socioeconomic status, rurality, and disability status in US settings were included. Two reviewers independently assessed study eligibility. Single-reviewer data abstraction was confirmed by a second reviewer. We conducted independent dual quality assessment, and collective strength of evidence assessment.ResultsWe included 21 studies. African American/Black, Latino, and low-socioeconomic status participants had disproportionately lower H1N1 vaccination rates (low- to moderate-strength evidence). However, Latinos were more likely than Whites to intend to be vaccinated, and African American/Blacks and participants with lower-socioeconomic status were just as likely to intend to be vaccinated as their White and higher-socioeconomic status counterparts (low-strength evidence). Vaccine uptake for other groups has been insufficiently studied. Factors potentially contributing to disparities in vaccine uptake included barriers to vaccine access, inadequate information, and concerns about vaccine safety and efficacy. Studies were largely cross-sectional. Many of the studies are a decade old and were conducted in the context of a different pandemic. The categorization of racial and ethnic groups was not consistent across studies and not all groups were well-studied.DiscussionEfforts to avoid disparities in COVID-19 vaccination uptake should prioritize vaccine accessibility and convenience in African American/Black, Latino, and low-SES communities; engage trusted stakeholders to share vaccine information; and address concerns about vaccine safety and efficacy.Primary Funding SourceDepartment of Veterans Affairs, Veterans Health Administration, Health Services Research & Development.Protocol RegistrationPROSPERO CRD42020187078Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-06715-7.

Socioeconomic differences in permanent teeth mineralization of Portuguese girls and boys from Porto, Portugal.

Purpose: Socioeconomic differences in dental maturation can be used to examine the impact of environmental factors on dental maturation. The purpose of this study is to assess socioeconomic differences in dental maturation of the seven permanent mandibular teeth (I1-M2). Methods: A total of 2114 panoramic radiographs of Portuguese children, adolescents and young adults were studied. The sample was divided into a high socioeconomic status (SES) (n = 925), and a low SES group (n = 1189). Ages ranged between 5 and 26 years. Demirjian's stages were used to assess the maturation of the seven mandibular teeth on the left side. Median-age of attainment of each stage and each tooth was calculated and compared between groups using binary logistic regression. Results: Low SES girls showed a consistent advancement in dental maturation across the entire dentition. Low SES boys, however, showed more often a delayed maturation relative to their high SES counterparts, but this pattern was not consistent and a clear socioeconomic difference seems to be absent in boys. Conclusions: While this study was not able to further explore the causes of the dental advancement in girls, it is hypothesized that it might be related to a higher prevalence of overweight/obesity, and possibly caries, in low SES girls, compared to the SES difference in prevalence in boys.

Neighborhood-level socioeconomic status and outcomes in patients with localized pancreatic adenocarcinoma treated with first-line FOLFIRINOX

Presenter: Douglas S Swords MD, MS | The University of Texas MD Anderson Cancer Center Background: National data demonstrate that neighborhood-level low socioeconomic status (SES) is associated with shorter overall survival (OS) in patients with localized pancreatic ductal adenocarcinoma (PDAC). No previous studies have focused on the impact of SES in patients initially treated with chemotherapy at high-volume institutions. We aimed to assess the associations between SES and receipt of surgery, pathologic/postoperative outcomes, and OS in this population. Methods: We performed a single-center retrospective cohort study of patients who completed ≥ 1 cycle of FOLFIRINOX for non-metastatic PDAC from 2012-2019. Among 519 eligible patients, we excluded those living outside the US (n = 6), residing in areas with suppressed area deprivation index (ADI) values (n = 5), variant histology (n = 5), and unknown surgical status (n = 4). The exposure was ADI, a SES composite constructed using 17 variables measured at the census block group-level. SES was dichotomized as high (ADI values of 1-40th percentile) and low (41-100th percentile). We assessed the associations of SES with resection, pathologic/postoperative outcomes, and OS. Results: Among 499 patients, median age was 64 years (IQR 58, 69), 42.9% were female, and 80.8% were White. The population was skewed towards high SES patients (median ADI 40, scale 0-100[IQR 23, 64]). The resection rate was 31.2% in low SES vs. 39.3% in high SES patients (p = 0.06). When stratified by stage, low SES was associated with lower resection rates in potentially resectable (PR) patients (48.2% vs. 71.8%, p = 0.002) but not in borderline resectable (BR) (38.9% vs. 36.4%, p = 0.75) and locally advanced (LA) (9.8% vs. 15.5%, p = 0.24) patients. Among low vs. high SES resected patients, rates of R1 margins (10.5% vs. 10.5%, p = 1.0), hospital stay (mean 7.9 vs. 6.9 days, p = 0.14), 90-day readmissions (29.0% vs. 19.0%, p = 0.13), major complications (21.3% vs. 14.1%, p = 0.22), and postoperative chemotherapy (64.9% vs. 72.5%, p = 0.29) did not differ significantly. In the overall cohort, median OS in low SES patients was 19 months (95% CI 17, 22) vs. 29 months (95% CI 23, 34) in high SES patients (Figure A, p<0.001). In a multivariable model in the overall cohort, low SES was independently associated with shorter OS (adjusted HR 1.46, 95% CI 1.14, 1.89). Low SES was associated with shorter OS in PR patients (Figure B) but OS did not differ significantly in BR (not shown, p = 0.09) and LA (not shown, p = 0.12) patients. Low SES was associated with similar OS in resected patients (Figure C) but was associated with a modest survival decrement in unresected patients (Figure D). Conclusion: In this cohort of 499 patients with newly diagnosed non-metastatic PDAC who were selected to receive first-line FOLFIRINOX, low SES patients had similar postoperative outcomes and OS to high SES counterparts, reinforcing the value of multimodal therapy at specialized centers. The finding of shorter OS in low SES patients appears to be partially driven by lower rates of being oncologically and medically appropriate for surgery at the conclusion of neoadjuvant therapy. If these findings are confirmed in multi-center studies then it would be appropriate to view low SES patients as a high-risk group deserving of additional supportive resources during first-line therapy.

Cigarette Prices in Rural and Urban Ohio: Effects of Census Tract Demographics.

The prevalence of smoking among rural Americans and Americans of lower socioeconomic status (SES) remains higher than among their urban and higher SES counterparts. Potential factors contributing to these disparities are area-based differences in the retail environment and tobacco control policies. We describe the association between neighborhood demographics and cigarette prices in rural and urban areas. Prices of one pack of Marlboro Reds, Newport menthols, and the cheapest cigarettes in the store were recorded from a stratified random sample of tobacco retailers in urban (N = 104) and rural (N = 109) Ohio in 2016. Associations between prices and census tract demographics (SES and race) were modeled separately in each region, controlling for store type. In the rural region, as the census tract income increased, the price of Marlboro and Newport cigarettes decreased, and the price of the cheapest pack of cigarettes increased. In the urban region, as the census tract income and percentage of White non-Hispanic people increased, the price of Marlboro decreased; there were no associations between census tract characteristics and the price of Newports or the cheapest cigarettes. Results describe a complex association between cigarette brand, prices, and area characteristics, where the cheapest brands of cigarettes can be obtained for the lowest prices in lower SES rural areas. Tobacco control policies that raise the price of cheap cigarettes, particularly minimum price laws, have the potential to reduce SES-related smoking disparities in both rural and urban populations.

Decomposing socioeconomic inequality in child vaccination in the Gambia, the Kyrgyz Republic and Namibia

Extant work suggested pro-rich distribution of vaccination coverage in low- and middle-income countries (LMICs). However, the current literature also suggested pro-poor distribution of vaccination in some countries, including the Gambia, the Kyrgyz Republic and Namibia. This study aimed to explain socioeconomic inequalities in the completion rate of the four-core vaccines (i.e., Bacille Calmette-Guérin [BCG], diphtheria-tetanus-pertussis [DTP, 3 doses], Polio [3 doses] and Measles vaccines) in the three aforementioned countries. We used the most recent available Demographic Health Surveys (DHS) to measure vaccination completion rates among children (aged 0–59 months, n = 16,752) in the three countries. The normalized concentration index (Cn) was used to quantify and decompose socioeconomic inequalities in vaccination coverage in each country. The negative values of the Cn index suggested that children belong to lower socioeconomic status groups were more likely to be immunized than their higher socioeconomic status counterparts in the Gambia (Cn = −0.101, 95% confidence interval [CI]: −0.128 to −0.074), the Kyrgyz Republic (Cn = −0.097, 95% CI: −0.13 to −0.063) and Namibia (Cn = −0.161, 95% CI: −0.199 to −0.124). The decomposition analysis of the Cn suggested that the difference in child vaccination completion rates between rural and urban areas was the main factor contributing to the concentration of child vaccination among the poor in the Gambia and Namibia. The concentration of child vaccination among the poor in the Kyrgyz Republic was chiefly determined by household wealth. These results suggest that there should be strategies to improve child immunization uptake among urban children in the Gambia and Namibia. Since household wealth was the main factor contributing to the observed pro-poor distribution of child vaccination in the Kyrgyz Republic, further studies are required to understand the reasons for lower vaccination rate among the wealthy children in order to implement the most effective strategies to increase child vaccination uptake.

Understanding the Needs of Incoming College Freshmen: The Parent Perspective

In the last few years, there has been an increase in reported difficulties related to adjusting to college. While work has been done to analyze how college students perceive themselves related to several domains, such as mental health and physical fitness, there is little research to examine parental perception of college student functioning during the transition into college. Furthermore, there is reason to believe that students may differ in their perceived readiness for college based on their gender and socioeconomic status (SES). Using an anonymous survey, this study examined the extent to which 714 parents of students at the University of Florida perceived their college student as being prepared for university life on the domains of time management, social and emotional functioning, and general life skills. ANOVA analyses were conducted to determine group differences. Overall, significant differences by gender were found, with female students outscoring their male peers in many areas, as reported by their parents. Surprisingly, very few significant differences were found based on SES. Where there were differences, the low SES group outperformed their high SES counterparts. As universities consider the needs of incoming students, they may wish to be more intentional with how they target specific populations.

Smoking cessation patterns by socioeconomic status in Alaska.

The ongoing disparity in smoking prevalence across levels of socioeconomic status (SES) is a significant concern in the tobacco control field, and surveillance of cessation-related activity is key to understanding progress. Historically, lower SES smokers have had much lower quit ratios but this measure can be insensitive to recent quit-related behavior. It is therefore important to examine recent quit-related behavior to assess progress toward addressing this disparity, especially in states with tobacco control programs that focus on this priority population.We compared recent quit attempts and successes among non-Native lower SES Alaska smokers to those of higher SES using data from the 2012–2013 Alaska Behavioral Risk Factor Surveillance System (BRFSS). We assessed quit ratios, one-year and five-year quit rates, and six-month abstinence between the two groups.Cessation-related measures restricted to those who smoked in the previous one year did not significantly vary by SES. However, five year quit rates were significantly lower for persons of lower SES vs. higher SES (14% vs. 32% respectively, p < .001). Results were consistent after adjustment for age, sex, and other factors.Results showed that in the previous year, smokers of lower SES in Alaska were trying to quit and succeeding at similar rates as their higher SES counterparts. However, the equivalent pattern of quit success was not reflected in the five-year time frame. Tobacco control programs should monitor cessation trends using both recent and longer-term time frames for this population. More research is needed on reasons for fewer long-term quits among lower SES smokers.

Perceptions and measurement of playtime physical activity in English primary school children: The influence of socioeconomic status

Children in areas of low socioeconomic status might face barriers to physical activity during school playtime in comparison to their high socioeconomic status counterparts. However, limited research within the area currently prevents evidence-based interventions from being targeted appropriately. This exploratory study aimed to assess and compare playtime physical activity levels and perceptions of physical activity in primary school children from two schools of different socioeconomic status. Fifty-three children wore an accelerometer during playtime for three school days while 33 children participated in single-sex focus groups to elicit their experiences of physical activity during playtime. Results revealed that children from the low socioeconomic status school spent more time in sedentary activities ( P = 0.001) and spent less time in moderate and moderate to vigorous physical activity ( P = 0.001) than children from the high socioeconomic status school. Despite some between-school similarities in their perceptions of physical activity, differences resonated in their reasons for taking part in physical activity, perceptions of the play environment and ideas to improve physical activity. These findings contribute to current research and provide in-depth information from active users of the play environment that could be useful to inform new interventions for schools of varying socioeconomic status.

School socio-economic status and student socio-academic achievement goals in upper secondary contexts

In recent years motivational researchers have spent considerable time examining race/ethnicity and gender differences in academic and social achievement goals, but little time examining the influence of socioeconomic status (SES). This lack of attention is surprising given that both student motivation and SES have been shown to predict academic attainment. This study surveyed the academic and social achievement goal orientations of 16–17 year old students (n = 130) attending two schools with markedly different socioeconomic profiles. Analyses showed significant differences between the schools on the academic achievement goal scales, with students at the low SES school less likely to endorse adaptive combinations of mastery and performance goals than their high SES counterparts. Students who did not expect to finish senior high school also endorsed social goals that may manifest as disruptive behaviours in the classroom. The findings suggest that SES may influence the adoption of academic achievement goals but not necessarily social achievement goals. Implications for theory and research are discussed.

Minority Youth, Physical Activity, and Fitness Levels: Targeted Interventions Needed

Background: There is a clear disparity in health in the United States such that African Americans and Hispanics are more likely to suffer from morbidity and mortality related to chronic disease than their Caucasian counterparts. Purpose: We will determine whether fourth- and fifth-grade students' measures of health-related fitness and physical activity–related self-efficacy differed when compared by ethnicity and socioeconomic status (SES). Methods: Fourth- and fifth-grade boys and girls (N = 1432) from schools in a large Midwestern metropolitan area were given the FitnessGram fitness test and the 7-item Perceived Self-efficacy to Perform Physical Activity Scale. Results: Multivariate analyses of variance (MANOVAs) identified that both genders had significant main effects for ethnicity (P < .001) and SES (P < .001) for fitness measures and physical activity related self-efficacy. Additional post hoc analysis was completed for fitness variables and self-efficacy items. Discussion: Minority students of low SES scored lower than their Caucasian, higher SES counterparts on both fitness measures and self-efficacy to perform physical activity. Translation to Health Education Practice: Though chronic disease does not manifest itself until late in life, the health behaviors that contribute to it begin in childhood and have a cumulative effect. Thus, direct intervention strategies aimed at high-risk populations are appropriate.

Micronutrient intakes among children and adults in Greece: the role of age, sex and socio-economic status.

The aim of the present study was to report the usual nutrient intakes of sixteen micronutrients by schoolchildren, adults and the elderly in Greece and to further explore the role of age, sex and socio-economic status (SES) on meeting the recommended nutrient intakes. Dietary intake, demographic and SES data from three existing studies conducted in Greece (in 9–13-year-old children; 40–60-year-old adults; and 50–75-year-old women) were collected. The prevalence of study participants with inadequate micronutrient intakes were assessed using the estimated average requirement (EAR) cut-point method. Regarding sex and age differences, the highest prevalences of inadequate nutrient intakes occurred in post-menopausal women. In both sexes and all age groups, the prevalence of vitamin D intake below EAR reached 100%. Furthermore, nutrient intakes of 75% or more below EAR were found for vitamin E in all age groups, folate in women and for calcium and magnesium in post-menopausal women (p < 0.05). Regarding SES differences, the prevalences of inadequate calcium and vitamin C intakes were higher for children and postmenopausal women of lower SES compared to their higher SES counterparts (p < 0.05). The current study reported the highest prevalences of inadequate intakes for both sexes and all age and SES groups for calcium, folate and vitamins D and E. These findings could provide guidance to public health policy makers in terms of updating current dietary guidelines and fortifying foods to meet the needs of all population subgroups.

Cardiac rehabilitation barriers by rurality and socioeconomic status: a cross-sectional study.

IntroductionDespite greater need, rural inhabitants and individuals of low socioeconomic status (SES) are less likely to undertake cardiac rehabilitation (CR). This study examined barriers to enrollment and participation in CR among these under-represented groups.MethodCardiac inpatients from 11 hospitals across Ontario were approached to participate in a larger study. Rurality was assessed by asking participants whether they lived within a 30-minute drive-time from the nearest hospital, with those >30 minutes considered “rural.” Participants completed a sociodemographic survey, which included the MacArthur Scale of Subjective Social Status. One year later, they were mailed a survey which assessed CR utilization and included the Cardiac Rehabilitation Barriers Scale. In this cross-sectional study, CR utilization and barriers were compared by rurality and SES.ResultsOf the 1809 (80.4%) retained, there were 215 (11.9%) rural participants, and the mean subjective SES was 6.37 ± 1.76. The mean CRBS score was 2.03 ± 0.73. Rural inhabitants reported attending significantly fewer CR sessions (p < .05), and greater CR barriers overall compared to urban inhabitants (p < .01). Patients of lower subjective SES were significantly less likely to be referred, enroll, and participate in CR, and reported significantly greater barriers to CR compared to their high SES counterparts (p < .01). Prominent barriers for both groups included distance, cost, and transportation problems. These relationships sustained adjustment, and a significant relationship between having undergone coronary artery bypass graft surgery and lower barriers was also identified.ConclusionsThe results confirm that rural inhabitants and patients of low SES experience greater barriers to CR utilization when compared to their urban, high SES counterparts. It is time to implement known strategies to overcome these barriers, to achieve equitable and greater use of CR.

Is There an Association Between Gasoline Prices and Physical Activity? Evidence from American Time Use Data

AbstractObesity is epidemic in the United States, and there is an imperative need to identify policy tools that may help fight this epidemic. A recent paper in the economics literature finds an inverse relationship between gasoline prices and obesity risk—suggesting that increased gasoline prices via higher gasoline taxes may have the effect of reducing obesity prevalence. This study builds upon that paper. It utilizes cross‐sectional time series data from the American Time Use Survey (ATUS) over 2003–2008, utilizes the increases that occurred in gasoline prices in this period due to Hurricane Katrina and to the global spike in gasoline prices as a “natural experiment,” and explores how time spent by Americans on different forms of physical activity is associated with gasoline price levels. Economic theory suggests that higher gasoline prices may alter individual behavior both via a “substitution effect” whereby people seek alternatives to motorized transportation, and an “income effect” whereby the effect of higher gasoline prices on the disposable family budget leads people to make various adjustments to what they spend money on. The latter may lead to some increase in physical activity (for example, doing one's own yard work instead of hiring help), but may also lead to decreases in other physical activities that involve expenses, such as team sports or workouts at the gym. Thus, ultimately, the relationship between gasoline prices and physical activity must be empirically determined. Results from multivariate regression models with state and time fixed effects indicate that higher gasoline prices are associated with an overall increase of physical activity that is at least moderately energy intensive. The increases are most pronounced in periods where gasoline prices fluctuate more sharply and unexpectedly. These results appear robust to a number of model specifications. One of the major components of this increase appears to be an increase in housework that is at least moderately energy intensive—such as interior and exterior cleaning, garden, and yard work. This tentatively suggests that there is an income effect of higher gasoline prices, or a possible increase in prices of such services when gasoline prices increase. However, the increases in physical activity associated with increased gasoline prices are weaker among minorities and low socioeconomic status (SES) individuals. Hence, while a policy that increases gasoline prices via raised gasoline taxes may have benefits in terms of increasing overall physical activity levels in the United States, these benefits may not accrue to low SES individuals to the same extent as to their higher SES counterparts. This suggests that if increasing physical activity is the primary goal, then it may be more efficient to use a tax that can exert an income effect on mid‐to‐high SES households, such as a targeted income tax. On the other hand, if gasoline taxes are imposed to address other negative externalities of gasoline use, then these taxes may have the added benefit of increasing physical activity at least among some segments of U.S. society.

Social support and socioeconomic status interact to predict Epstein-Barr virus latency in women awaiting diagnosis or newly diagnosed with breast cancer.

Both higher socioeconomic status (SES) and supportive personal relationships confer health benefits, including better immune function. This study assessed the joint impact of SES and social support on the expression of a latent herpesvirus, Epstein-Barr virus (EBV), in a group of highly stressed women. Two-hundred and twenty four women either awaiting further evaluation following an abnormal mammogram or newly diagnosed with breast cancer completed questionnaires and provided blood samples to assess EBV viral capsid antigen (VCA) IgG antibody titers. More highly educated women with more support from friends had lower EBV VCA antibody titers, reflecting a stronger cellular immune response to the latent virus; however, among less educated women, friend support was not associated with EBV antibody titers. As revealed in an ancillary analysis, more highly educated women with more friend support had lower systolic blood pressure (SBP); however, friend support was not associated with SBP among less educated women. Neither depression nor perceived stress mediated these associations. Neither cancer status nor cancer stage among those diagnosed with cancer was significantly related to these outcomes. Lower SES women may not reap the same immunological benefits from friend support when experiencing a stressful life event as their higher SES counterparts.

Socio-Economic Variation in Price Minimizing Behaviors: Findings from the International Tobacco Control (ITC) Four Country Survey

This paper examines how socio-economic status (SES) modifies how smokers adjust to changes in the price of tobacco products through utilization of multiple price minimizing techniques. Data come from the International Tobacco Control Policy Evaluation (ITC) Four Country Survey, nationally representative samples of adult smokers and includes respondents from Canada, the United States, the United Kingdom and Australia. Cross-sectional analyses were completed among 8,243 respondents (7,038 current smokers) from the survey wave conducted between October 2006 and February 2007. Analyses examined predictors of purchasing from low/untaxed sources, using discount cigarettes or roll-your-own (RYO) tobacco, purchasing cigarettes in cartons, and engaging in high levels of price and tax avoidance at last purchase. All analyses tested for interactions with SES and were weighted to account for changing and under-represented demographics. Relatively high levels of price and tax avoidance behaviors were present; 8% reported buying from low or untaxed source; 36% used discount or generic brands, 13.5% used RYO tobacco, 29% reported purchasing cartons, and 63% reported using at least one of these high price avoidance behaviors. Respondents categorized as having low SES were approximately 26% less likely to report using low or untaxed sources and 43% less likely to purchase tobacco by the carton. However, respondents with low SES were 85% more likely to report using discount brands/RYO compared to participants with higher SES. Overall, lower SES smokers were 25% more likely to engage in at least one or more tax avoidance behaviors compared to their higher SES counterparts. Price and tax avoidance behaviors are relatively common among smokers of all SES strata, but strategies differed with higher SES groups more likely to report traveling to a low-tax location to avoid paying higher prices, purchase duty free tobacco, and purchase by cartons instead of packs all of which were less commonly reported by low SES smokers. Because of the strategies lower SES respondents are more likely to use, reducing price differentials between discount and premium brands may have a greater impact on them, potentially increasing the likelihood of quitting.