Higher Socioeconomic Position Research Articles

‘That is because we are alone’: A relational qualitative study of socio-spatial inequities in maternal and newborn health programme coverage in rural Uttar Pradesh, India

ABSTRACT This qualitative study was conducted in Uttar Pradesh state, India to explore how interrelated socio-economic position and spatial characteristics of four diverse villages may have influenced equity in coverage of community-based maternal and newborn health (MNH) services. We conducted social mapping and three focus group discussions in each village, among women of lower and higher socio-economic position who recently gave birth, and with community health workers (n = 134). Data were analysed in NVivo 11.0 using thematic framework analysis. The extent of socio-economic hierarchies and spatial disparateness within the village, combined with distance to larger centers, together shaped villages’ level of socio-spatial remoteness. Disadvantaged socio-economic groups expressed being more often spatially isolated, with less access to infrastructure, resources or services, which was heightened if the village was physically distant from larger centers. In more socio-spatially remote villages, inequities in coverage of MNH services that disadvantaged lower socio-economic position groups were compounded as these groups more often experienced ASHA vacancies, as well as greater distance to and poorer perceived quality of health services nearest the village. The results inform a conceptual framework of ‘socio-spatial remoteness’ that can guide public health research and programmes to more comprehensively address health inequities within India and beyond.

Social inequalities in pregnancy metabolic profile: findings from the multi-ethnic Born in Bradford cohort study.

Lower socioeconomic position (SEP) associates with adverse pregnancy and perinatal outcomes and with less favourable metabolic profile in nonpregnant adults. Socioeconomic differences in pregnancy metabolic profile are unknown. We investigated association between a composite measure of SEP and pregnancy metabolic profile in White European (WE) and South Asian (SA) women. We included 3,905 WE and 4,404 SA pregnant women from a population-based UK cohort. Latent class analysis was applied to nineteen individual, household, and area-based SEP indicators (collected by questionnaires or linkage to residential address) to derive a composite SEP latent variable. Targeted nuclear magnetic resonance spectroscopy was used to determine 148 metabolic traits from mid-pregnancy serum samples. Associations between SEP and metabolic traits were examined using linear regressions adjusted for gestational age and weighted by latent class probabilities. Five SEP sub-groups were identified and labelled 'Highest SEP' (48% WE and 52% SA), 'High-Medium SEP' (77% and 23%), 'Medium SEP' (56% and 44%) 'Low-Medium SEP' (21% and 79%), and 'Lowest SEP' (52% and 48%). Lower SEP was associated with more adverse levels of 113 metabolic traits, including lower high-density lipoprotein (HDL) and higher triglycerides and very low-density lipoprotein (VLDL) traits. For example, mean standardized difference (95%CI) in concentration of small VLDL particles (vs. Highest SEP) was 0.12 standard deviation (SD) units (0.05 to 0.20) for 'Medium SEP' and 0.25SD (0.18 to 0.32) for 'Lowest SEP'. There was statistical evidence of ethnic differences in associations of SEP with 31 traits, primarily characterised by stronger associations in WE women e.g., mean difference in HDL cholesterol in WE and SA women respectively (vs. Highest-SEP) was -0.30SD (-0.41 to -0.20) and -0.16SD (-0.27 to -0.05) for 'Medium SEP', and -0.62SD (-0.72 to -0.52) and -0.29SD (-0.40 to -0.20) for 'Lowest SEP'. We found widespread socioeconomic differences in metabolic traits in pregnant WE and SA women residing in the UK. Further research is needed to understand whether the socioeconomic differences we observe here reflect pre-conception differences or differences in the metabolic pregnancy response. If replicated, it would be important to explore if these differences contribute to socioeconomic differences in pregnancy outcomes.

Socioeconomic Position, Pre-Obesity and Obesity in Latin American Cities: A Systematic Review.

Currently the socioeconomic gradient of obesity it is not well understood in the urban population in Latin American. This study reviewed the literature assessing associations between pre-obesity, obesity, and socioeconomic position (SEP) in adults living in urban areas in Latin American countries. PubMed and SciELO databases were used. Data extraction was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We extracted data on the association between SEP (e.g., education, income), pre-obesity (body mass index [BMI] ≥ 25 and < 30 kg/m2) and obesity (BMI ≥ 30 kg/m2). Relative differences between low and high SEP groups were assessed and defined a priori as significant at p < 0.05. Thirty-one studies met our inclusion criteria and most were conducted in Brazil and Mexico (22 and 3 studies, respectively). One study presented nonsignificant associations. Forty-seven percent of associations between education or income and pre-obesity were negative. Regarding obesity, 80 percent were negative and 20 percent positive. Most negative associations were found in women while in men they varied depending on the indicator used. Pre-obesity and obesity by SEP did not follow the same pattern, revealing a reversal of the obesity social gradient by SEP, especially for women in Latin America, highlighting the need for articulated policies that target structural and agentic interventions.

Increasing inequalities in longevity among Italian workers

Abstract This article examines the evolution of inequalities in life expectancy at 65 and all-cause mortality by socio-economic position (SEP) among Italian workers. Period life tables and negative binomial regression models are used to estimate longevity inequalities. The empirical assessment is carried out on two administrative datasets, one covering the entire population of private sector workers for the years 1990–2019 and the other covering the entire workforce in Turin for the years 1981–2019. We find that social inequalities in life expectancy and all-cause mortality have increased among Italian workers in recent decades. Several robustness checks confirm this worrying trend, especially for men. Longevity has improved for workers in the middle and high SEPs, while it has hardly changed for workers in the lowest SEP. We show that the estimated life expectancy differentials translate into a loss of pension wealth for the most disadvantaged categories, which also increases over time.

What shapes parental feeding decisions over the first 18 months of parenting: Insights into drivers towards commercial and home-prepared foods among different socioeconomic groups in the UK

Infants born into families experiencing socioeconomic disadvantage follow a high-risk trajectory for obesity and poor health in later life. Differences in early childhood food experiences may be contributing to these inequalities. This study aimed to explore the factors that influence parental decisions on when, how and what food to introduce over the first 18 months of their child's life and identify differences according to families' social position. Particular attention was given to social and environmental determinants within and outside the home. This research utilised a longitudinal qualitative methodology, with interviews and photo-elicitation exercises completed by participants when their children were 4–6; 10–12 and 16–18 months of age. Participants were parents (61 mothers; 1 father), distributed across low, medium and high socioeconomic position (SEP). During analysis, observable differences in factors directing parents to home-prepared or commercial foods were identified. Factors that undermined the provision of home-prepared meals included lack of time after returning to work, insufficient support from partners, uncertainty around infant and young child feeding (defined as the introduction and provision of solids) and an implicit trust in the messaging on branded products. These factors directed parents towards commercial foods and were most persistent among families experiencing socioeconomic disadvantage due to barriers accessing formal childcare, less flexible working conditions and fathers being less involved in infant feeding. To facilitate an enabling environment for healthy infant and young child feeding practices and address dietary inequalities, immediate steps that policy makers and healthcare providers can take include: i) changing the eligibility criteria for shared parental leave, ii) aligning claims on commercial infant food labels with international best practices, and iii) improving access to formal childcare.

Population-Based Study of Alcohol-Related Liver Disease in England in 2001-2018: Influence of Socioeconomic Position.

England has seen an increase in deaths due to alcohol-related liver disease (ALD) since 2001. We studied the influence of socioeconomic position on the incidence of ALD and the mortality after ALD diagnosis in England in 2001-2018. This was an observational cohort study based on health records contained within the UK Clinical Practice Research Datalink covering primary care, secondary care, cause of death registration, and deprivation of neighborhood areas in 18.8 million residents. We estimated incidence rate and incidence rate ratios of ALD and hazard ratios of mortality. ALD was diagnosed in 57,784 individuals with a median age of 54 years and of whom 43% had cirrhosis. The ALD incidence rate increased by 65% between 2001 and 2018 in England to reach 56.1 per 100,000 person-years in 2018. The ALD incidence was 3-fold higher in those from the most deprived quintile vs those from the least deprived quintile (incidence rate ratio 3.30, 95% confidence interval 3.21-3.38), with reducing inequality at older than at younger ages. For 55- to 74-year-olds, there was a notable increase in the incidence rate between 2001 and 2018, from 96.1 to 158 per 100,000 person-years in the most deprived quintile and from 32.5 to 70.0 in the least deprived quintile. After ALD diagnosis, the mortality risk was higher for patients from the most deprived quintile vs those from the least deprived quintile (hazard ratio 1.22, 95% confidence interval 1.18-1.27), and this ratio did not change during 2001-2018. The increasing ALD incidence in England is a greater burden on individuals of low economic position compared with that on those of high socioeconomic position. This finding highlights ALD as a contributor to inequality in health.

Trends in prevalence of obesity and its association with hypertension across socioeconomic gradients in rural Yunnan Province, China

BackgroundThis study aimed to uncover the changing prevalence of obesity and its association with hypertension across socioeconomic gradients in rural southwest China.MethodsData were collected from two cross-sectional health interviews and surveys from 2011 to 2021 among individuals aged ≥ 35 years in rural China. Each participant’s height, weight, waist circumference, and blood pressure were measured. The overall prevalence of obesity, central obesity, and hypertension was directly standardized by age based on the total population of the two surveys. Multivariate logistic regression was used to analyze the association between obesity and prevalence of hypertension and an individual socioeconomic position (SEP) index was constructed using principal component analysis.ResultsFrom 2011 to 2021, the prevalence of obesity, central obesity, and hypertension increased substantially, from 5.9%, 50.2%, and 26.1–12.1%, 58.0%, and 40.4% (P < 0.01), respectively. These increasing rates existed in all subcategories, including sex, age, ethnicity, education, annual household income, access to medical services, and SEP (P < 0.05). In both 2011 and 2021, lower education level and poor access to medical services correlated with higher prevalence of central obesity, while higher SEP correlated with higher prevalence of obesity and central obesity (P < 0.01). Prevalence of obesity was higher in the Han ethnicity participants and individuals with poor access to medical services than in their counterparts (P < 0.01). Whereas the prevalence of central obesity was lower in Han participants than in ethnic minority participants in 2011 (P < 0.01), this trend reversed in 2021 (P < 0.01). A positive relationship between annual household income and prevalence of obesity and central obesity was only found in 2021 (P < 0.01). Obese and centrally obese participants were more likely to be hypertensive in both survey years (P < 0.01).ConclusionsFuture interventions to prevent and manage obesity in rural China should give increased attention to high income, less educated, poor access to medical services, and high SEP individuals. The implementation of these obesity interventions would also help reduce the prevalence of hypertension.

Can Social Mobility Impact Frailty Trajectories of Chinese Adults in Later Life? A Nationwide Longitudinal Study.

Evidence remains unclear on the impact of life-course socioeconomic position (SEP) mobility on frailty trajectories in later life. We aim to examine the longitudinal effects of social mobility on frailty trajectories among Chinese middle-aged and older populations. A total of 13239 participants aged 45 and older from the 2011-2018 China Health and Retirement Longitudinal Study were analyzed. Based on changes in SEP from childhood to adulthood, 5 patterns of social mobility were established. A 32-item deficit cumulative frailty index (FI) was developed to evaluate frailty trajectories at each follow-up. Linear mixed-effects models were used to examine the longitudinal association of the 5 social mobility patterns with the frailty trajectory. The trajectory of late-life FI increased across all 5 social mobility groups during the follow-up. The FI trajectory had the largest disparity between stable high SEP and stable low SEP, with a faster increase in FI of 0.489 (95% confidence interval [CI]: 0.327-0.650, p < .001) in the stable low versus stable high SEP group. The FI trajectories of individuals in the upward and downward mobility groups fall between those in the stable high SEP and low SEP groups. Specifically, compared to the stable high SEP group, the increase in FI was 0.229 (95% CI: 0.098-0.360, p = .001) faster in the downward mobility group, and 0.145 (95% CI: 0.017-0.273, p = .03) faster in the upward mobility group. The impact of social mobility on frailty trajectories was more pronounced among middle-aged adults and women. These findings emphasize that policies to identify vulnerable populations and reduce frailty inequalities should focus on the socioeconomic environment across the life course, with particular attention paid to those with consistently low SEP and downward mobility.

Life-Course Socioeconomic Position and Mild Cognitive Impairment in Midlife: Evidence from the 1958 British Birth Cohort

BackgroundDementia has been the leading cause of death in the UK since 2015. Increasing evidence supports an association between socioeconomic position (SEP) and dementia onset in later life. However, limited studies have examined how life-course SEP influences the development of mild cognitive impairment (MCI), an intermediate state potentially preceding dementia. Therefore, the present study aims to examine the relationship between life-course SEP and MCI amongst adults aged 50 years in Great Britain.MethodsWe employed data from the National Child Development Study (NCDS), also known as the 1958 British Birth Cohort, to determine the associations between SEP and MCI in 6590 participants. We categorised life-course measures of SEP as stable high/low or moving upward/downward over the life course. We assessed MCI at age 50 using one standard deviation below the averaged combined scores from all cognitive tests available. We then used binary logistic regression to estimate the longitudinal associations between life-course SEP and MCI.ResultsRelative to those of a high SEP across the life course, participants who moved upward, downward, or remained at a low SEP were significantly associated with 25% (95% CI 1.02–1.54, p = 0.035), 70% (95% CI 1.27–2.27, p < 0.001), and 85% (95% CI 1.50–2.29, p < 0.001), respectively, higher odds of MCI, independent of all selected covariates.ConclusionsLower life-course SEP was associated with significantly higher odds of MCI onset in middle life within the NCDS cohort. Public health policies targeting cognitive impairment should encompass a life-course approach to reduce socioeconomic inequalities.

Socioeconomic inequalities in health-related functioning among people with type 2 Diabetes: longitudinal analyses in the Maastricht Study

BackgroundType 2 diabetes mellitus (T2DM) is a common chronic disease that disproportionally affects disadvantaged groups. People with a low socioeconomic position (SEP) have increased risk of T2DM and people with a low SEP and T2DM have higher HbA1c-levels compared to people with T2DM and high SEP. The aim of this study is to analyze longitudinal socioeconomic differences in health-related functioning in people with T2DM.MethodsLongitudinal data from 1,537 participants of The Maastricht Study with T2DM were used (32.6% female, mean (SD) age 62.9 (7.7) years). SEP was determined by baseline measures of education, occupation and income. Health-related functioning (physical, mental and social) was measured with the Short-Form Health Survey and the Impact on Participation and Autonomy survey (all scored from 0 to 100). Associations of SEP and health-related functioning were studied annually over a 10-year period (median (IQR) 7.0 (5.0) years, baseline 2010–2018) using linear mixed methods adjusting for demographics, HbA1c-levels and lifestyle factors.ResultsParticipants with a low SEP had significantly worse health-related functioning compared to those with a high SEP. For example, participants with low income had lower scores for physical (-4.49[CI -5.77;-3.21]), mental (-2.61[-3.78,-1.44]) and social functioning (-9.76[-12.30;-7.23]) compared to participants with high income on a scale from 0 to 100. In addition, participants with a low education significantly declined more over time in mental (score for interaction education with time − 0.23[-0.37;-0.09]) and social functioning (-0.44[-0.77;-0.11]) compared to participants with high education. Participants with low and intermediate incomes significantly declined more over time in physical functioning (-0.17 [-0.34, -0.01 and − 0.18 [-0.36, 0.00]) compared to participants with high income.ConclusionsAmong people with T2DM, those with a lower SEP had worse health-related functioning in general than people with a higher SEP. Additionally, people with T2DM and low education developed poorer mental and social functioning over time compared to people with T2DM and high education. People with T2DM and low or intermediate income declined more in physical functioning over time than those with high incomes. In addition to HbA1c-levels and lifestyle patterns, more attention is needed for socioeconomic differences in health-related functioning for people living with T2DM.

Inequalities in adiposity trends between 1979 and 1999 in Guatemalan children.

Guatemala suffered from civil war and high levels of inequality and childhood stunting in the second half of the 20th century, but little is known about inequalities in secular trends in adiposity. To investigate differences in childhood body mass index (BMI) and skinfold thickness trajectories from 1979 to 1999 between three groups of children: High socioeconomic position (SEP) Ladino, Low SEP Ladino, and Low SEP Indigenous Maya. The sample comprised 19 346 children aged 7-17 years with 54 638 observations. The outcomes were height, BMI, triceps skinfold thickness (TST), and subscapular skinfold thickness (SST) Z-scores according to the Centers for Disease Control and Prevention (CDC) references. Sex-specific multilevel models were used to estimate and compare mean trajectories from 1979 to 1999 between the three groups. Mean Z-scores were always highest for High SEP Ladino children and lowest for Low SEP Maya children. Despite their very short stature, the Low SEP groups had SST trajectories that were above the 50th centile. The BMI trajectories were relatively flat and within one major centile band of the CDC median, with differences between the three groups that were small (0.2-0.3 Z-scores) and did not attenuate over time. Conversely, the TST Z-score trajectories demonstrated larger positive secular trends (e.g., from -1.25 in 1979 to -0.06 in 1999 for Low SEP Maya boys), with differences between the three groups that were large (0.5-1.2 Z-scores) and did attenuate over time (in boys). Secular trends and between-group difference in the SST Z-score trajectories were less pronounced, but again we found stronger evidence in boys that the estimated inequalities attenuated over time. Secular trends and inequalities in skinfolds differ from those for BMI in Guatemalan children. Differences between groups in skinfolds attenuated over time, at least in boys, but whether this is good news is questionable given the very short stature yet relatively large subscapular skinfolds of the Low SEP groups.

THE ASSOCIATIONS OF SOCIOECONOMIC POSITION WITH STRUCTURAL BRAIN DAMAGE AND CONNECTIVITY AND COGNITION

Abstract Socioeconomic inequalities in the risk for cognitive impairment have been reported, which might partly act through structural brain damage and connectivity. This study investigated the extent to which the association of early-life socioeconomic position (SEP) with later-life cognitive performance is mediated by later-life SEP, and whether the association of SEP with later-life cognitive performance can be explained by structural brain damage and connectivity. We used cross-sectional data from the population-based Maastricht study (n=4,839; mean age 59.2±8.7 years, 49.8% women). Early-life SEP was assessed retrospectively by self-reported poverty and parental education. Later-life SEP included education, occupation, and household income. Participants underwent cognitive testing and 3 T magnetic resonance imaging to measure volumes of white matter hyperintensities, gray matter, white matter, cerebrospinal fluid, and structural connectivity. Multiple linear regression analyses tested the associations between SEP, MRI brain markers and cognition. Structural equation modeling tested mediation. Results indicated that higher SEP was associated with higher grey matter volume, lower white matter volume, and higher structural connectivity. Structural brain damage and lower structural connectivity were associated with lower cognition. Both higher early-life and later-life SEP were associated with higher cognition. The association of early-life SEP with later-life cognition was partly mediated by later-life SES (73.8%). However, the extent to which the association of SEP with cognition could be explained by structural brain damage or connectivity was marginal (up to 5.9%). More research is needed to investigate alternative pathways that can explain the associations between SEP with later-life cognition.

Childhood and life‐course socioeconomic position and cognitive function in adult population of the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)

AbstractBackgroundThe Hispanic/Latino population experiences extensive socioeconomic adversity across the lifespan and is at greater risk of cognitive decline. Yet little is known about the role of life‐course socioeconomic position (SEP) and cognitive function in this population. We assessed the association between childhood SEP and cognitive function in Hispanic/Latino adults, whether this association is mediated by midlife SEP, and whether socioeconomic mobility is associated with cognitive function.MethodWe used baseline data (2008‐2011) from 9556 adults aged 45‐74 years of the Hispanic Community Health Study/Study of Latino (HCHS/SOL), a multi‐center cohort study conducted in four major U.S cities. We determined childhood SEP using parental educational attainment. Midlife SEP was determined through an index combining participants’ education and household income. We classified participants into socioeconomic mobility categories from childhood to adulthood (e.g., persisting low, upward mobility). Cognitive function was ascertained using neurocognitive tests, including the Six‐Item Screener; Brief‐Spanish English Verbal Learning Test Sum and Recall, Controlled Oral Word Association (or Word Frequency), and the Digit Symbol Substitution Test. Using confirmatory factor analysis and these tests we created a global cognition score. We also standardized z‐score of these neurocognitive measures. Survey linear regression models were performed adjusting for age, sex, Hispanic background, U.S born, smoking, depression, and cardiovascular factors. We also conducted mediation analysis to decompose the direct effect of childhood SEP on cognition and the indirect effect through midlife SEP.ResultChildhood SEP showed a graded association with cognitive function in adulthood with a dose‐response relationship across levels of parental education (β and [95% Confidence Interval (CI)]): Elementary/middle school vs. No schooling 0.34 [0.25‐0.43]; High school (HS) vs. No schooling: 0.53 [0.42‐0.64]; and &gt;HS vs. No schooling: 0.68 [0.57‐0.79]). High midlife SEP was also associated with greater cognitive function relative to low midlife SEP. 37% (95% CI 32%‐44%) of the association between childhood SEP and cognition was mediated through midlife SEP. Holding a high SEP over the life‐course was associated with greater cognitive performance (β: 0.90, 95% CI: 0.79‐1.00) as compared with a persisting low SEP.ConclusionThis study provides evidence that childhood and life‐course SEP influence cognitive performance in adulthood

The Joint Effect of Education and Alcohol Use on 100% Alcohol-attributable Hospitalization or Death in Canada.

Individuals with low socioeconomic position (SEP) experience disproportionately greater alcohol-attributable harm than individuals with high SEP despite similar or less alcohol use (i.e., the alcohol harm paradox). We examined the sex/gender- specific independent and joint effects of education and heavy drinking or volume of alcohol use on 100% alcohol-attributable hospitalization or death. We conducted a cohort study among 199,125 current and former alcohol users aged 15-64 years from population-representative Canadian Community Health Surveys (2000-2008) linked to hospitalization and mortality records through 2017. We estimated the sex/gender-specific associations between education and heavy drinking or volume of alcohol use and incident 100% alcohol-attributable hospitalization or death using multivariable Fine and Gray subdistribution hazard models with competing risk (non-100% alcohol-attributable deaths), assessing additive interactions using the Synergy Index (S). Overall, heavy drinking prevalence and volume of alcohol use were similar or lower in individuals with lower education compared with higher education. Lower education levels compared with a bachelor's degree or above were associated with increased 100% alcohol-attributable hospitalization or death [e.g., less than high school, men: hazard ratio (HR) = 2.78; 95% CI = 2.17, 3.56; women: HR = 2.98; 95% CI = 2.00, 4.44]. We found superadditive joint effects between low education and heavy drinking (men: S = 1.22; 95% CI = 1.14, 1.30; women: S = 1.34; 95% CI = 0.88, 2.04) and low education and higher volume of alcohol use (e.g., excess volume, men: S = 1.30; 95% CI = 1.05, 1.62; women: S = 1.41; 95% CI = 0.77, 2.58), with larger inequities in women than men with similar alcohol use. Our study is consistent with the hypothesis that increased vulnerability to alcohol use among individuals with lower education partially explains the alcohol harm paradox in Canada.

Trajectories of primary health care utilization: a 10-year follow-up after the Swedish Patient Choice Reform of primary health care

BackgroundIn January 2010, the choice reform was instituted in Swedish primary health care establishing free entry for private primary health care providers and enabling patients to choose freely among primary health care centers. The motivation behind the reform was to improve access to primary care and responsiveness to patient expectations. Reform effects on health care utilization have previously been investigated by using subgroup analyses assuming a pattern of homogeneous subgroups of the population. By using a different methodological approach, the aim of this study was to, from an equity perspective, investigate long term trends of primary health care utilization following the choice reform.MethodA closed cohort was created based on register data from Region Skåne, the third most populated region in Sweden, describing individuals’ health care utilization between 2007–2017. Using a novel approach, utilization data, measured as primary health care visits, was matched with socioeconomic and geographic determinants, and analyzed using logistic regression models.ResultsA total of 659,298 individuals were included in the cohort. Sex differences in utilization were recorded to decrease in the older age group and to increase in the younger age group. Multivariable logistic regression showed increasing utilization in older men to be associated with higher socioeconomic position, while in women it was associated with lower socioeconomic position. Furthermore, groups of becoming high utilizers were all associated with lower socioeconomic position and with residence in urban areas.ConclusionThe impact of demographic, socioeconomic and geographic determinants on primary health care utilization varies in magnitude and direction between groups of the population. As a result, the increase in utilization as observed in the general population following the choice reform is unevenly distributed between different population groups.

Socioeconomic inequalities in health-related functioning among people with Type 2 Diabetes

Abstract Background Type 2 Diabetes mellitus (T2DM) is a common chronic disease which disproportionally affects disadvantaged groups. People with a low socioeconomic position (SEP) have increased risk of T2DM and people with a low SEP and T2DM have higher HbA1c levels and a higher risk to develop T2DM complications compared to their high SEP counterparts. The aim of this study is to analyze longitudinal socioeconomic differences in health-related functioning in people living with T2DM. Methods Cross-sectional and longitudinal data from 2,004 participants of The Maastricht Study with T2DM were used. SEP was determined by baseline measures of education, occupation and income. Health-related functioning (physical, mental and social) was measured with the SF-36 and the Impact on Participation and Autonomy survey (scores 0-100). Associations of SEP and health-related functioning were studied over a 10-year period (baseline 2010-2018) using linear mixed methods adjusting for demographics, disease characteristics and lifestyle factors. Results Low SEP participants had significantly worse health-related functioning compared to those with a high SEP. For example, participants with low income had lower scores for physical (-4.00[CI 2.62;-5.38]), mental (-2.81[-1.52;-4.10]) and social functioning (-9.10[-6.35;-11.85]) compared to high-income participants. In addition, participants with a low education significantly declined more in mental (interaction estimate time -0.21[-0.05;-0.37]) and social functioning (-0.39[-0.02;-0.76]) compared to participants with high education. Conclusions In individuals with T2DM, socioeconomic health differences are apparent in health-related functioning. Moreover, differences in mental and social functioning widened even more between different levels of education. Beyond disease characteristics and lifestyle, more attention is needed for socioeconomic differences in health-related functioning for people living with T2DM, both in research and practice. Key messages • Among people with T2DM, those with a lower SEP have worse health-related function then individuals with a higher SEP, even with similar demographics, disease characteristics and lifestyle patterns. • Additionally, people with T2DM and low education decline more over time in mental and social functioning than people with T2DM and high education.

Socioecological correlates of parental lifestyle patterns during the prenatal period

Abstract Background There is growing evidence that family lifestyle patterns in early life are associated with the risk of child obesity. However, beyond the influence of socio-economic position, scarce are studies on the social determinants of such lifestyle patterns. The aim was therefore to investigate the socio-ecological correlates of parental lifestyle patterns in pregnancy. Methods We selected 1,110 families from the EDEN birth cohort, recruited in two maternity hospitals in France between 2003 and 2006. In a previous work, we identified two parental lifestyle patterns characterized by 1) “high parental smoking, low maternal diet quality, and low leisure physical activity 2) “low parental body mass index and high gestational weight gain”. Within the framework of both socio-ecological and hierarchical approaches, we conducted multivariable linear regression analyses, with socio-ecological factors added progressively from the most distal to the most proximal, i.e. urban environment variables (block 1); socio-economics, geographic origin, parents’ age, parity (block 2); and psychological factors or access to health care (block 3). Results Parents with a higher socio-economic position (education level, household income), first-time or older mothers and those having attended antenatal sessions had lower scores on the first pattern. Multiparous women, with an intermediate level of education, and older fathers had lower scores on the second pattern. No major associations were reported with urban environment or psychological factors. Conclusions Beyond the expected socio-economic gradient of family lifestyle patterns, we report novel insights into potential levers specific to the prenatal period, such as the opportunity of parenting preparation to engage in healthy behaviours. Analyses will be replicated in three other European cohorts, if confirmed, these findings will be valuable to increase the effectiveness of future childhood obesity prevention strategies in early life. Key messages • Higher socio-economic conditions and attendance of parenting preparation classes are associated with healthier family lifestyle in pregnancy. • The identification of potential facilitators and barriers for family lifestyle in early life will help for further translation to effective childhood obesity prevention and implementation strategies.

Early life social and health determinants of higher education across three generations

Abstract Background Associations of social and health disadvantages at birth with educational attainment are well-documented. Less is known about the magnitude of the associations across different historical contexts. We investigated associations between a range of early life disadvantages and higher educational attainment across three successive generations. Methods The data were from the register-based Uppsala Birth Cohort Multigenerational Study in Sweden. The study samples include three generations born in 1915-1929 (G1, n = 10 587), 1933-1972 (G2, n = 6566), and 1973-1978 (G3, n = 6684). The outcome was attainment of higher education (more than senior high school) assessed at age 30+ years. Exposures were parental socioeconomic position (SEP), mother's marital status, parity, gestational age and birth weight for gestational age. Multiple logistic regression models were fitted to evaluate the associations across three generations. Results are presented as Average Marginal Effects (AME). Results Low parental SEP was associated with lower probability of higher educational attainment in all three generations. The difference between low versus high parental SEP among men declined by 32 percentage points in G2 (AME: 0.32; 95% CI: 0.27, 0.38) and 27 percentage points in G3 (AME: 0.27; 95% CI: 0.21, 0.33) compared to G1. Among women, the corresponding declines in G2 and G3 were 35 and 28 percentage points. Mothers’ unmarried marital status and high parity were associated with lower probability of education, with no evidence of decline across generations. The association between small for gestational age and education among men persisted across generations while showing a decline in G3 women. Conclusions Associations between early life factors and education persisted across three generations. The influence of parental socioeconomic background on educational attainment appeared to level off in the youngest generation after becoming attenuated in the preceding generation. Key messages • Association between small for gestational age and educational attainment persisted across generations, with an attenuation among the youngest cohort of women. • High parity was associated with lower chance of educational attainment, with no evidence of effect attenuation across generations.

Using repeated measures to study the contribution of alcohol consumption and smoking to the social gradient in all-cause mortality: Results from the Stockholm Public Health Cohort.

The social gradient in consumption behaviours has been suggested to partly explain health inequalities. The majority of previous studies have only included baseline measurements and not considered potential changes in behaviours over time. The study aimed to investigate the contribution of alcohol consumption and smoking to the social gradient in mortality and to assess whether the use of repeated measurements results in larger attenuations of the main association compared to using single baseline assessments. Longitudinal survey data from the population-based Stockholm Public Health Cohort from 2006 to 2014 was linked to register data on mortality until 2018 for 13,688 individuals and analysed through Cox regression. Low socioeconomic position (SEP) was associated with increased mortality compared with high SEP; hazard ratios 1.56 (95% CI 1.30-1.88) for occupational status and 1.77 (95% CI 1.49-2.11) for education, after adjustment for demographic characteristics. Using repeated measurements, alcohol consumption and smoking explained 44% of the association between occupational status and all-cause mortality. Comparing repeated and baseline measures, the percentage attenuation due to alcohol consumption increased from 11% to 18%, whereas it remained similar for smoking (25-23%). Smoking and alcohol consumption explained a large part of the association between SEP and mortality. Comparing results from time-fixed and time-varying models, there was an increase in overall percentage attenuation that was mainly due to the increased proportion explained by alcohol consumption. Repeated measurements provide a better estimation of the contribution of alcohol consumption, but not smoking, for the association between SEP and mortality.

Mapping the connections between education and the risk of dementia

Many studies have shown a connection between education and late-life cognition, with the risk of dementia being inversely associated with educational attainment. This brief article proposes pathways through which cognitive ability in early life, subsequently reinforced by education and then by higher socioeconomic position in midlife, could confer a protective effect on cognitive decline many decades later, in late life. Taking a systems perspective, the article describes mutually reinforcing processes that operate to maintain the stability of cognitive abilities across the life course. The conclusion is that population-level interventions could be designed to enhance cognitive resiliency in our aging populations.