Individual-level Socioeconomic Position Research Articles

Socio-economic position, multimorbidity, and health care utilization among Danish left ventricular assist device patients.

Increasing numbers of patients with advanced heart failure and significant comorbidity and social barriers are considered for left ventricular assist devices (LVADs). We sought to examine health care utilization post-LVAD implantation, including the influence of individual-level socio-economic position and multimorbidity. We conducted a Danish nationwide cohort study linking individual-level data from clinical LVAD databases, the Scandiatransplant Database, and Danish national medical and administrative registries. Socio-economic position included cohabitation status, educational level, and employment status. Multimorbidity was defined as two or more chronic conditions from at least two chronic disease groups. Health care utilization (hospital activity, general practice activity, and redeemed medical prescriptions) within 2years post-discharge after LVAD implantation was evaluated using descriptive statistics at 0.5year intervals. We identified 119 patients discharged alive with first-time LVAD implanted between 2006 and 2018. The median age of the patients was 56.1years, and 88.2% were male. Patients were followed until heart transplantation, LVAD explantation, death, 31 December 2018, or for 2years. The median follow-up was 0.8years. The highest median use of health care services was observed 0-0.5years post-LVAD discharge compared with the subsequent follow-up intervals: 0.5-1, 1-1.5, and 1.5-2years, respectively. The median (interquartile range) number of hospitalizations was 10 (7-14), bed days 14 (9-28), outpatient visits 8 (5-12), telephone contacts with a general practitioner 4 (2-8), and total redeemed medical prescriptions 26 (19-37) within 0-0.5years post-LVAD discharge compared with the median utilization within the consecutive follow-up periods [e.g. within 0.5-1year: hospitalizations 5 (3-8), bed days 8 (4-14), outpatient visits 5 (3-8), telephone contacts 2 (0-5), and redeemed medical prescriptions 24 (18-30)]. The median use of health care services was stable from 0.5years onwards. The median number of hospitalizations and bed days was slightly higher in patients living alone with a low educational level or low employment status within 0-0.5years post-LVAD implantation. Finally, the median number of in-hospital days and redeemed prescriptions was higher among patients with pre-existing multimorbidity. Among patients who underwent LVAD implantation, health care utilization was high in the early post-LVAD discharge phase and was influenced by socio-economic position. Multimorbidity influenced the number of in-hospital days and redeemed prescriptions during the 2year follow-up.

Neighborhood Deprivation and Changes in Oral Health in Older Age: A Longitudinal Population-Based Study

The aim of this study was to examine the extent to which neighborhood-level socioeconomic factors (objective and perceived) are associated with poor oral health in older adults over time, independent of individual socioeconomic position. Data for this cross-sectional and longitudinal observation study came from a socially and geographically representative cohort of men aged 71 to 92 y in 2010–12 (n = 1,622), drawn from British general practices, which was followed up in 2018–19 (aged 78–98 y; N = 667). Dental measures at both times included number of teeth, periodontal pocket depth, self-rated oral health, and dry mouth. Neighborhood deprivation was based on Index of Multiple Deprivation (IMD) and a cumulative index measuring perceptions about local environment. Individual-level socioeconomic position was based on longest-held occupation. Multilevel and multivariate logistic regressions, adjusted for relevant sociodemographic, behavioral, and health-related factors, were performed to examine the relationships of dental measures with IMD and perceived neighborhood quality index, respectively. Cross-sectionally, risks of tooth loss, periodontal pockets, and dry mouth increased from IMD quintiles 1 to 5 (least to most deprived); odds ratios (ORs) for quintile 5 were 2.22 (95% confidence interval [CI], 1.41–3.51), 2.82 (95% CI, 1.72–4.64), and 1.51 (95% CI, 1.08–2.09), respectively, after adjusting for sociodemographic, behavioral, and health-related factors. Risks of increased pocket depth and dry mouth were significantly greater in quintile 5 (highest problems) of perceived neighborhood quality index compared to quintile 1. Over the 8-y follow-up, deterioration of dentition (tooth loss) was significantly higher in the most deprived IMD quintiles after full adjustment (OR for quintile 5 = 2.32; 95% CI, 1.09–4.89). Deterioration of dentition and dry mouth were significantly greater in quintile 5 of perceived neighborhood quality index. Neighborhood-level factors were associated with poor oral health in older age, both cross-sectionally and longitudinally, particularly with tooth loss, and dry mouth, independent of individual-level socioeconomic position.

Causal Assessment of Income Inequality on Self-Rated Health and All-Cause Mortality: A Systematic Review and Meta-Analysis.

Whether income inequality has a direct effect on health or is only associated because of the effect of individual income has long been debated. We aimed to understand the association between income inequality and self-rated health (SRH) and all-cause mortality (mortality) and assess if these relationships are likely to be causal. We searched Medline, ISI Web of Science, Embase, and EconLit (PROSPERO: CRD42021252791) for studies considering income inequality and SRH or mortality using multilevel data and adjusting for individual-level socioeconomic position. We calculated pooled odds ratios (ORs) for poor SRH and relative risk ratios (RRs) for mortality from random-effects meta-analyses. We critically appraised included studies using the Risk of Bias in Nonrandomized Studies - of Interventions tool. We assessed certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework and causality using Bradford Hill (BH) viewpoints. The primary meta-analyses included 2,916,576 participants in 38 cross-sectional studies assessing SRH and 10,727,470 participants in 14 cohort studies of mortality. Per 0.05-unit increase in the Gini coefficient, a measure of income inequality, the ORs and RRs (95% confidence intervals) for SRH and mortality were 1.06 (1.03-1.08) and 1.02 (1.00-1.04), respectively. A total of 63.2% of SRH and 50.0% of mortality studies were at serious risk of bias (RoB), resulting in very low and low certainty ratings, respectively. For SRH and mortality, we did not identify relevant evidence to assess the specificity or, for SRH only, the experiment BH viewpoints; evidence for strength of association and dose-response gradient was inconclusive because of the high RoB; we found evidence in support of temporality and plausibility. Increased income inequality is only marginally associated with SRH and mortality, but the current evidence base is too methodologically limited to support a causal relationship. To address the gaps we identified, future research should focus on income inequality measured at the national level and addressing confounding with natural experiment approaches.

Development of geographic inequality in dental caries and its association with socioeconomic factors over an 18-year period in Denmark

BackgroundFew studies have examined the development of geographic and socioeconomic inequalities in caries over time or have simultaneously assessed individual-level socioeconomic position (SEP) and neighborhood-level factors as a multi-layered phenomenon influencing caries inequalities. This study examined (i) the trends in geographic inequalities in caries among adolescents in Denmark and (ii) how the association between SEP and caries has progressed over time, when accounting for individual and neighborhood-level confounding factors.MethodsThis nationwide repeated cross-sectional study included 15-year-olds in Denmark from 1995, 2003, and 2013 (n = 149,808). The outcome was caries experience (measured by the decayed, missing, and filled tooth surfaces [DMFS] index). The exposure of interest was SEP, indicated by the previous year’s parental education, occupational social class, and (equivalized) disposable household income. Covariates included individual-level factors (immigration status, country of origin, number of children and persons in the family, and household type) and neighborhood (residence municipality)-level factors (Gini index; proportion of unemployed, low-educated, and unmarried/non-cohabiting individuals; proportion of single-parent households and households with overcrowding). Data sources included the Danish national dental and administrative social registers and Statistics Denmark’s statistics database (StatBank). Data were analyzed using spatial and spatiotemporal modelling utilizing zero-inflated negative binomial regressions and integrated nested Laplace approximations for Bayesian parametric inference. Observed caries experience geo-maps of the Danish municipalities for 1995, 2003, and 2013 were created.ResultsBetween 1995 and 2013, caries prevalence in the 15-year-olds declined sharply (1995, 71%; 2013, 45%). Caries experience declined in nearly all socioeconomic subgroups and municipalities. However, geographic inequalities persisted with higher caries levels largely concentrated in the relatively deprived areas of Denmark. Increasing relative socioeconomic inequalities in caries over time were observed with significant graded associations between SEP and caries despite adjustment for the various individual and neighborhood-level covariates and the effect of assessment year (e.g., 15-year-olds with parents having basic education had 1.91-fold [95% CI: 1.86–1.95] higher caries experience than those having parents with high education).ConclusionsReducing these enduring inequalities will likely require additional resources and targeted supportive and preventive measures for adolescents from lower SEP backgrounds and those residing in municipalities with higher caries prevalence.

Unequally Unequal? Contextual-level status inequality and social cohesion moderating the association between individual-level socioeconomic position and systemic chronic inflammation

BackgroundStatus inequality is hypothesised to increase socioeconomic inequalities in health by creating an environment in which social cohesion erodes and social comparisons intensify. Such an environment may cause systemic chronic inflammation. Although these are often-used explanations in social epidemiology, empirical tests remain rare. MethodsWe analysed data from the West of Scotland Twenty-07 Study. Our sample consisted of 1977 participants in 499 small residential areas. Systemic chronic inflammation was measured by high-sensitivity C-reactive protein (hs-CRP; <10 mg/L). An area-level measurement of status inequality was created using census data and contextual-level social cohesion was measured applying ecometrics. We estimated linear multilevel models with cross-level interactions between socioeconomic position (SEP), status inequality, and social cohesion adjusted for age and gender. Our main analysis on postcode sector-level was re-estimated on three smaller spatial levels. ResultsThe difference in hs-CRP between disadvantaged and advantaged SEPs (0.806 mg/L; p = 0.063; [95%CI: −0.044; 1.656]) was highest among participants living in areas where most residents were in advantaged SEPs. In these status distributions, high social cohesion was associated with a shallower socioeconomic gradient in hs-CRP and low social cohesion was associated with a steeper gradient. In areas with an equal mix of SEPs or most residents in disadvantaged SEPs, the estimated difference in hs-CRP between disadvantaged and advantaged SEPs was −0.039 mg/L (p = 0.898; [95%CI: 0.644; 0.566]) and −0.257 mg/L (p = 0.568; [95%CI: 1.139; 0.625]) respectively. In these status distributions, the gradient in hs-CRP appeared steeper when social cohesion was high and potentially reversed when social cohesion was low. Results were broadly consistent when using area-levels smaller than postcode sectors. ConclusionsInequalities in hs-CRP were greatest among participants living in areas wherein a majority of residents were in advantaged SEPs and social cohesion was low. In other combinations of these contextual characteristics, inequalities in systemic chronic inflammation were not detectable or potentially even reversed.

Health inequalities in the geographic distribution of dental practitioners in Costa Rica: An ecological study.

The uneven distribution of dental health services in a territory can cause an imbalance in accessibility, increasing health inequalities. This study aimed to describe the geographical distribution of dental health practitioners according to urbanicity and area-level socio-economic status in Costa Rica. A National Dentist Survey was developed to identify employment status, number of working hours, address and list of the working clinics. Data was completed using information from the national College of Surgeons, including all Costa Rican dentists. The Minimal Geographic Units (MGU) allowed for aggregating the population's individual level socio-economic position. Local Potential Accessibility (LPA) calculated the density of full-time hour's equivalents around each MGU using floating sectors. Clinics were geocoded using Geographic Information Systems, creating 2853 clinical points. Distance between each MGU and the nearest accessible clinics considering full-time working hours equivalents was estimated. MGU were divided into six categories: 'No accessibility', 'Very low accessibility', 'Low accessibility', 'Good accessibility' 'High accessibility' and 'Very high accessibility'. Mean national LPA was 6.5 full-time equivalents per 10 000 inhabitants, 3.4% of the Costa Rican population had no access to dentist; 12.9% had very low accessibility, 22.7% had low accessibility, 35.0% had good accessibility, 16.2% had high accessibility, and 9.8% had very high accessibility. Overall, 39% of the population has a rather low accessibility. LPA was higher in urban districts compared to rural districts and in wealthiest districts compared to most disadvantaged districts. Within districts, after adjustment for district's characteristics, LPA was higher in urban MGU compared to rural MGU and in wealthiest MGU compared to most disadvantaged MGU. This study found that despite having a high number of dentists, their numbers are small in many areas, increasing inequalities in access to health care. The dentist's free establishment, where they can decide to provide private services within a community, creates zones with very high densities, in particular in the wealthiest urban areas, and others with very low densities, in particular the poorest rural areas. The lack of territorial planning has been one of the reasons that has encouraged an imbalance in the availability of dental human resources. To achieve effective universal health coverage, public institutions should focus their efforts on improving access to dental services in underserved areas.

Individual-Level Socioeconomic Position and Long-Term Prognosis in Danish Heart-Transplant Recipients.

Socioeconomic deprivation can limit access to healthcare. Important gaps persist in the understanding of how individual indicators of socioeconomic disadvantage may affect clinical outcomes after heart transplantation. We sought to examine the impact of individual-level socioeconomic position (SEP) on prognosis of heart-transplant recipients. A population-based study including all Danish first-time heart-transplant recipients (n = 649) was conducted. Data were linked across complete national health registers. Associations were evaluated between SEP and all-cause mortality and first-time major adverse cardiovascular event (MACE) during follow-up periods. The half-time survival was 15.6years (20-year period). In total, 330 (51%) of recipients experienced a first-time cardiovascular event and the most frequent was graft failure (42%). Both acute myocardial infarction and cardiac arrest occurred in ≤5 of recipients. Low educational level was associated with increased all-cause mortality 10-20years post-transplant (adjusted hazard ratio [HR] 1.95, 95% confidence interval [CI] 1.19-3.19). During 1-10 years post-transplant, low educational level (adjusted HR 1.66, 95% CI 1.14-2.43) and low income (adjusted HR 1.81, 95% CI 1.02-3.22) were associated with a first-time MACE. In a country with free access to multidisciplinary team management, low levels of education and income were associated with a poorer prognosis after heart transplantation.

Do socioeconomic inequities arise during school-based physical activity interventions? An exploratory case study of the GoActive trial

ObjectiveTo investigate socioeconomic inequities in the intervention and evaluation process of the GoActive school-based physical activity intervention and demonstrate a novel approach to evaluating intervention-related inequalities.DesignExploratory post-hoc secondary data analysis...

Association between individual-level socioeconomic position and incident dementia using UK Biobank data: a prospective study

BackgroundUnder-education and living in poverty are known risk factors for dementia. However, single-variable makers of socioeconomic position (SEP) are often correlated and cannot reflect the overall SEP. We examined association between composite SEP and incident dementia using UK-wide data. MethodsWe leveraged data from the UK Biobank, a nation-wide cohort of half-a-million participants recruited across 22 assessment centres during 2006–10. Participants with data on SEP and without dementia at baseline were included. A composite individual-level metric of SEP (low, medium, or high) was developed through latent class analysis using Stata's gsem command and identified through item-response probabilities based on participants' single socioeconomic factors (ie, education, employment, and household income). Cox proportional hazard models were developed to examine the association between composite SEP and incident dementia after adjusting for age, ethnicity, lifestyle factors (eg, living alone), social interaction (eg, frequency of visits from acquaintances), urbanicity, clinical variables (eg, central obesity), and stratified by sex. As sensitivity test, we repeated our analysis with single socioeconomic factors. Electronic informed consent was obtained from participants at the UK Biobank assessment centres before participations and UK Biobank acquired ethical approval from the National Health Service National Research Ethics Service. FindingsWe included 340 366 adult participants (17 8195 [52·4%] were women and 32 6753 [96·0%] White) aged 38–73 with 3541 incident dementia cases over a mean follow-up period of 12·0 years (SD 1·7). Relative to participants in the highest SEP, those in the medium (HR 1·53 [95% CI 1·33–1·77]; p<0·0001) and low (2·38 [2·05–2·77]; p<0·0001) SEP were associated with higher risks of incident dementia. Sensitivity analyses consistently found higher risks of incident dementia in participants of low educational attainment (HR 1·14 [95% CI 1·03–1·27]; p=0·0107), low household income (HR 2·33 [95% CI 2·03–2·68]; p<0·0001) and being unemployed (HR 1·27 [95% CI 1·11–1·47]; p=0·0008), relative to those of high education, high household income, and being employed, respectively. Limitations of the study include a response of only 503 325 (5·5%) of 9·2 million participants registered with the National Health Service and residual confounding. InterpretationThis study presented a parsimonious approach to construct a composite metric of SEP by employing three key indicators. We found that participants of low SEP were associated with an elevated risk of incident dementia. Socially deprived populations maybe more likely to be exposed to unfavourable psychosocial and environmental stressors that escalate risk of dementia. Our study further strengthens the evidence base for designing policy interventions for at-risk subgroups of lower SEP strata to reduce burdens of dementia. FundingNone.

Abstract 5913: Socioeconomic position, race/ethnicity and breast cancer mortality among young women in California

Abstract Background: Research has demonstrated that women with lower individual-level socioeconomic position (SEP) are at higher risk for breast cancer (BC) mortality. Census tract-level household educational attainment has been considered both as a proxy for individual-level SEP and an indicator of neighborhood social environment. Few studies have evaluated the association of census tract-level SEP on BC mortality by race/ethnicity, particularly within stage at diagnosis in young women. Objective: To determine associations between residential SEP, measured by household educational attainment, and BC mortality by race/ethnicity within stage at diagnosis among young women in California, 2006-2015. Methods: Data are from a pilot data product, the California Cancer Registry Data with Synthetic Census Tracts, which is available to external researchers coordinated with confidential data available to qualified internal users. The present study includes 41,886 young (25-49 years of age) California women who were diagnosed with primary invasive BC during 2006-2015. SEP was defined based on % of households completing a bachelor’s degree or higher (categorized as ≤30%, 30-60%, and ≥60% of households). Multivariate analyses were conducted to examine the association between SEP and BC mortality by race/ethnicity within stage at diagnosis by calculating hazard ratios (HR) and 95% confidence interval (CI), adjusting for age at diagnosis, marital status, tumor histology and diagnosis year. Results: For Stage I BC, compared to census tracts with ≤30% bachelor’s degree, the adjusted HR (95% CI) was 0.57 (0.44, 0.74) for tracts with 30-60% and 0.48 (0.32, 0.72) for tracts with ≥60% of households attaining a bachelor’s degree. For Stage II, the corresponding HRs (95% CIs) are 0.75 (0.66-0.84) and 0.54 (0.44-0.67); for Stage III, 0.80 (0.72-0.89) and 0.63 (0.51-0.76); and for Stage IV 0.73 (0.65-0.84) and 0.53 (0.41-0.69). When examined by race/ethnicity and stage at diagnosis, a significantly reduced mortality was associated with residing in census tracts with ≥60% of households having attained a bachelor’s degree compared to ≤30% for Stage I only among Asian (HR=0.30; 95% CI=0.11-0.77); for Stage II for White (HR=0.53; 95% CI=0.41-0.70) and Asian (HR=0.56; 95% CI=0.34-0.91); for Stage III White (HR=0.72; 95% CI=0.55-0.94) and Hispanic (HR=0.49; 95% CI=0.24-0.99); and for Stage IV White (HR=0.58; 95% CI=0.41-0.82) and Asian (HR=0.48; 95% CI=0.26-0.90) populations. Sample size was limited among Black and Asian Pacific Islander subgroups. Conclusion: Higher census tract-level SEP, defined as ≥60% of the population having a bachelor’s degree, is associated with a significantly decreased risk for BC-mortality at all stages of diagnosis. This effect isn't consistent across all stages of diagnosis among Hispanic populations, but is consistent among Non-Hispanic White and Asian populations in California, 2006-2015. Citation Format: Zhenzhen Zhang, Ellen Velie, Shangyuan Ye, Joe Zou, Lydia Marcus, Shiuh-Wen Luoh, Duo Jiang, Mandi Yu. Socioeconomic position, race/ethnicity and breast cancer mortality among young women in California [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 5913.

Parental socio-economic position and the risk of type 1 diabetes in children and young adults in Denmark: A nation-wide register-based study.

Diabetes mellitus type 1 is one of the most common serious chronic diseases in childhood and the incidence is increasing. Insight into risk factors may inform our etiologic understanding of the disease and subsequent prevention. Any socio-economic gradient in disease risk indicates a potential for prevention, since this points towards socially patterned environmental risk factors. The aim of this study was to investigate the association between measures of parental socio-economic position and the onset of type 1 diabetes in offspring based on individual data in the entire Danish population. In a study population of all children born in Denmark between 1 January 1987 and 31 December 2010, we examined the association between parental socio-economic position and the risk of type 1 diabetes up to the age of 25 years. The risk of type 1 diabetes was estimated according to maternal education, paternal education and household income using Cox proportional hazards regression, with adjustments for the a priori selected confounding variables: year of birth, maternal age at birth and parental type 1 diabetes. In the study population of 1,433,584 children, a total of 4610 developed type 1 diabetes. We found no clear pattern in type 1 diabetes risk according to parental educational attainment or parental household income. In this large population covering study of the risk of type 1 diabetes according to individual-level parental socio-economic position, we found no strong indication of a socially patterned disease risk.

P108. Neighborhood Disadvantage Associated With Differential Neural Response to Predictable and Unpredictable Threat in a Community Sample of Youth

Childhood socioeconomic disadvantage is a form of adversity associated with alterations in critical frontolimbic circuits that are involved in the pathophysiology of psychiatric disorders. Most work has focused on individual-level socioeconomic position, yet individuals living in deprived communities typically encounter additional environmental stressors that may have unique effects on the brain and, consequently, health outcomes.

Neighborhood Disadvantage Associated With Blunted Amygdala Reactivity to Predictable and Unpredictable Threat in a Community Sample of Youth

BackgroundChildhood socioeconomic disadvantage is a form of adversity associated with alterations in critical frontolimbic circuits involved in the pathophysiology of psychiatric disorders. Most work has focused on individual-level socioeconomic position, yet individuals living in deprived communities typically encounter additional environmental stressors that have unique effects on the brain and health outcomes. Notably, chronic and unpredictable stressors experienced in the everyday lives of youth living in disadvantaged neighborhoods may impact neural responsivity to uncertain threat. MethodsA community sample of children (N = 254) ages 8 to 15 years (mean = 12.15) completed a picture anticipation task during a functional magnetic resonance imaging scan, during which neutral and negatively valenced photos were presented in a temporally predictable or unpredictable manner. Area Deprivation Index (ADI) scores were derived from participants’ home addresses as an index of relative neighborhood disadvantage. Voxelwise analyses examined interactions of ADI, valence, and predictability on neural response to picture presentation. ResultsThere was a significant ADI × valence interaction in the middle temporal gyrus, anterior cingulate cortex, hippocampus, and amygdala. Higher ADI was associated with less amygdala activation to negatively valenced images. ADI also interacted with predictability. Higher ADI was associated with greater activation of lingual and calcarine gyri for unpredictably presented stimuli. There was no three-way interaction of ADI, valence, and predictability. ConclusionsNeighborhood disadvantage may impact how the brain perceives and responds to potential threats. Future longitudinal work is critical for delineating how such effects may persist across the life span and how health outcomes may be modifiable with community-based interventions and policies.

Individual socioeconomic position, neighbourhood disadvantage and mental well-being: a cross-sectional multilevel analysis of mid-age adults

BackgroundSocioeconomic disadvantage is associated with mental illness, yet its relationship with mental well-being is unclear. Mental well-being is defined as feeling good and functioning well. Benefits of mental well-being include reduced mortality, improved immune functioning and pain tolerance, and increased physical function, pro-social behaviour, and academic and job performance. This study aimed to explore the relationship between individual socioeconomic position (SEP), neighbourhood disadvantage and mental well-being in mid-age adults.MethodsMultilevel modelling was used to analyse data collected from 7866 participants from the second (2009) wave of HABITAT (How Areas in Brisbane Influence healTh and activiTy), a longitudinal study (2007–2016) of adults aged 40–65 years living in Brisbane, Australia. Mental well-being was measured using the Warwick Edinburgh Mental Well-Being Scale (WEMWBS). Exposure measures were education, occupation, household income, and neighbourhood socioeconomic disadvantage.ResultsThe lowest MWB scores were observed for the least educated (β = − 1.22, 95%CI = − 1.74, − 0.71), those permanently unable to work (β = − 5.50, 95%CI = − 6.90, − 4.10), the unemployed (β = − 2.62, 95%CI = − 4.12, − 1.13), and members of low-income households (β = − 3.77, 95%CI = − 4.59, − 2.94). Residents of the most disadvantaged neighbourhoods had lower MWB scores than those living in the least disadvantaged neighbourhoods, after adjustment for individual-level SEP (β = − 0.96, 95%CI = − 1.66, − 0.28).ConclusionsBoth individual-level SEP and neighbourhood disadvantage are associated with mental well-being although the association is stronger for individual-level SEP. This research highlights the need to address individual and neighbourhood-level socioeconomic determinants of mental well-being.

Socio-economic position and burden of ischemic heart disease in Finland in 2017

Abstract Background Ischemic heart disease (IHD) caused every fourth death in the European region in 2017. Furthermore, it accounted for about 12% of total disease burden estimated with disability adjusted life years (DALYs). DALYs summarize premature mortality (years of life lost, YLL) and morbidity (years lived with disease, YLD) in a specific cause. These disease burden estimates are customarily used to examine time trends or differences between countries or regions. However, they have seldom been calculated by socio-economic position (SEP), especially using individual-level SEP indicators. Methods We calculated DALYs for the Finnish 30+ year-old population in 2017. For YLL, we used Statistics Finland database for total population. For YLD, we used individual level data from the cross-sectional health examination FinHealth 2017 survey (n = 6538), which was linked with administrative register data. Population attributable fractions (PAFs) for selected IHD risk factors (smoking, blood pressure, total cholesterol and body mass index, BMI) were also calculated. Methodology published by the Global Burden of Disease study, such as disability weights for YLD and relative risks for PAFs, was applied where applicable. Results DALYs for IHD per 1000 population were 61.1 for men and 31.0 for women. Premature mortality (YLL) caused over 80% of DALYs. Burden of IHD morbidity (YLD) was higher in low education groups. In the total population, PAFs for IHD risk factors for men and women, respectively, were as follows: 17% and 8% for smoking, 56% and 58% for elevated systolic blood pressure, 25% and 28% for high cholesterol, and 27% and 24% for high BMI. Conclusions IHD morbidity was higher among low education groups. A large part of IHD burden was attributable to major cardiovascular risk factors, most markedly to elevated systolic blood pressure. In the future, the burden of disease could be increasingly assessed also by SEP. Key messages The burden of IHD in Finland was especially high among men, and majority of the burden was due to premature mortality. Over 50% of the IHD burden was attributed to elevated systolic blood pressure. Assessing the burden of diseases by socio-economic position provides a new perspective for examining socio-economic differences in health.

A national pilot program for chronic diseases and health inequalities in South Korea

BackgroundTo achieve the health equity, it is important to reduce socioeconomic inequalities when managing chronic diseases. In South Korea, a pilot program for chronic diseases was implemented at the national level. This study aimed to examine its effect on socioeconomic inequalities in chronic disease management at the individual and regional levels.MethodsKorean National Health Insurance data from September 2016 to October 2017 were used. Study subjects in the national pilot program for chronic diseases included 31,765 participants and 5,741,922 non-participants. The dependent variable was continuity of prescription medication. Socioeconomic position indicators were health insurance contribution level and the area deprivation index. Covariates were gender, age, and the Charlson Comorbidity Index (CCI). A multilevel logistic regression model was used to address the effects at both the individual and regional levels. This is a cross-sectional study.ResultsUnlike the group of non-participants, the participants showed no inequality in prescription medication continuity according to individual-level socioeconomic position. However, continuity of prescription medication was higher among those in less deprived areas compared to those in more deprived areas in both the participation and non-participation groups.ConclusionsThis study found that the pilot program for chronic diseases at the least did not contribute to the worsening of health inequalities at the individual level in South Korea. However, there was a trend showing health inequalities based on the socioeconomic level of the area. These findings suggest that additional policy measures are needed to attain equality in the management of chronic diseases regardless of the regional socioeconomic position.

Cortisol activity partially accounts for a relationship between community socioeconomic position and atherosclerosis

Compared to others, individuals living in communities of socioeconomic disadvantage experience more atherosclerotic cardiovascular disease (CVD) and a greater extent of preclinical atherosclerosis. Although the mechanisms underlying these associations remain unclear, it is widely hypothesized that alterations in normative cortisol release from the Hypothalamic Pituitary Adrenal (HPA) axis may play a role in linking lower community socioeconomic position (C-SEP) to CVD risk. The current study examined this hypothesis in relation to a marker of preclinical atherosclerosis among 488 healthy midlife adults (30–54 years, Mean age= 43, 52% Female, 81% White). All participants were employed and without clinical CVD. C-SEP was estimated from census tract data, and atherosclerosis was measured as intima-medial thickness of the carotid arteries (cIMT) by duplex ultrasonography. Four indicators of HPA activity [cortisol at awakening and the cortisol awakening response (CAR), rate of diurnal decline in cortisol (diurnal slope), and total output expressed as area under the curve (AUC)] were derived from salivary cortisol measurements obtained from 5 samples on each of 3 working days. Path analyses were used to examine associations of C-SEP with cIMT and HPA activity and to test whether individual differences in HPA activity could account for any association of C-SEP with cIMT using bootstrapping (5000 iterations). All models were adjusted for age, sex, race, and composite measures of both individual-level socioeconomic position (income, education, occupation), and cardiometabolic risk (systolic and diastolic blood pressure, waist circumference, fasting lipids and glucose). Lower C-SEP was related to both greater cIMT (b = −0.004, p = .021) and a flatter diurnal slope of cortisol (b = −0.001, p = .039). An indirect effect showed attenuated diurnal slope to partially mediate the relationship between C-SEP and cIMT (95% CI = −0.0018 to −0.0001), and a residual direct effect of C-SEP on cIMT remained significant (95% CI = −0.0097 to −0.004). These results suggest that low C-SEP associations with preclinical atherosclerosis may be due in part to correlated variation in adrenocortical activity.

Individual and neighbourhood socioeconomic measures and the risk of non-central nervous system solid tumours in children: A nationwide register-based case-control study in Denmark

BackgroundThe aetiology for most solid tumours in childhood is largely unknown. The lack of evidence concerns also the relationship between socioeconomic position (SEP) and risk of childhood solid tumours other than in the central nervous system (CNS). We sought to access the association between individual and neighbourhood SEP measures and risk of childhood non-CNS solid tumours in Denmark and to evaluate whether associations varied by measure of SEP, time point of SEP assessment (during pregnancy versus before diagnosis) and tumour type. MethodsWe conducted a nationwide case-control study based on Danish registry data. We identified all children born in 1980–2013 and diagnosed with a non-CNS solid tumour at ages 0–19 years (N = 1961) from the Danish Cancer Registry and sampled four individually matched controls per case using the Population Registry. We fitted conditional logistic regression models to estimate associations with register-based individual-level and neighbourhood-level SEP measures. ResultsWe observed a tendency of increased odd ratios (OR) in association with medium and high maternal income for most tumour types (e.g. OR for the highest income quintile and malignant bone tumours = 2.11; 95 % CI: 1.01, 4.38) and for parental education in association with higher education for some tumour types. For malignant epithelial neoplasms, higher parental education and income level were overall associated with an increased risk, e.g. OR = 1.63 (95 % CI: 1.00, 2.65) for the fourth group of maternal income during pregnancy. We found no risk pattern for neighbourhood SEP. ConclusionThis large register-study with minimal risk of bias found a tendency of slightly to moderately increased risks for most childhood non-CNS solid tumours in association with higher maternal income and parental education. Future research examining the underlying mechanisms of these socioeconomic differences in non-CNS solid tumours as well as other childhood cancer types are warranted.

Regional inequalities in adiposity in England: distributional analysis of the contribution of individual-level characteristics and the small area obesogenic environment

We use nationally representative English data to examine regional variations in body mass index (BMI) and waist circumference (WC), and to explore their underlying sources. Beyond our “at the mean” analysis, Shapley decomposition combined with unconditional quantile regression analysis allow us to explore the relative contribution of small-area level proxies of the obesogenic environment as opposed to our set of individual-level characteristics, across the whole adiposity distribution. We find that the regional BMI differences, that are more evident towards the right tails of its distribution, are fully accounted for by the neighbourhood obesogenic environment. The latter exerts an independent contribution to excess adiposity over and above the potential mediating role of individual-level lifestyle and socio-economic position (SEP). Overall, the relative contribution of demographics (age and gender) becomes less evident moving to higher quantiles of the BMI distribution, while that of obesogenic environment, individual-level lifestyle and SEP measures becoming more relevant. The neighbourhood obesogenic environment is also much more relevant in the tails of the WC distribution. The role of the obesogenic environment on excess adiposity is more pronounced for women than men. Overall, our results highlight that policies that aim to tackle excess adiposity should address both people and places.

Using ecological socioeconomic position (SEP) measures to deal with sample bias introduced by incomplete individual-level measures: inequalities in breast cancer stage at diagnosis as an example

BackgroundWhen studying the influence of socioeconomic position (SEP) on health from data where individual-level SEP measures may be missing, ecological measures of SEP may prove helpful. In this paper, we illustrate the best use of ecological-level measures of SEP to deal with incomplete individual level data. To do this we have taken the example of a study examining the relationship between SEP and breast cancer (BC) stage at diagnosis.MethodsUsing population based-registry data, all women over 18 years newly diagnosed with a primary BC in 2007 were included. We compared the association between advanced stage at diagnosis and individual SEP containing missing data with an ecological level SEP measure without missing data. We used three modelling strategies, 1/ based on patients with complete data for individual-SEP (n = 1218), or 2/ on all patients (n = 1644) using an ecological-level SEP as proxy for individual SEP and 3/ individual-SEP after imputation of missing data using an ecological-level SEP.ResultsThe results obtained from these models demonstrate that selection bias was introduced in the sample where only patients with complete individual SEP were included. This bias is redressed by using ecological-level SEP to impute missing data for individual SEP on all patients. Such a strategy helps to avoid an ecological bias due to the use of aggregated data to infer to individual level.ConclusionWhen individual data are incomplete, we demonstrate the usefulness of an ecological index to assess and redress potential selection bias by using it to impute missing individual SEP.