Levels Of Socioeconomic Position Research Articles

How Is Human Socioeconomic Position Linked With Dog Ownership Practices? A Study From Denmark

ABSTRACT Connections between dog ownership and socioeconomic position (SEP) are not well understood. This study examined associations between family and neighborhood levels of SEP and dog ownership, dog acquisition factors (purchase price and breed characteristics), and the purposes of owning a dog based on data from a survey carried out in Denmark in 2021. Participants (aged 18–89 years) were recruited using probability sampling (n = 2,112). Stepwise multivariable logistic or multinomial logistic regressions were conducted to identify significant associations with SEP. Approximately 20% of families in Denmark have a dog. Dog ownership was not found to be linked with income, education, or occupation when life course and lifestyle factors were taken into account. Neighborhood SEP was associated with dog ownership, but the association was not ordered. Payment of a high price for the dog was more prevalent both in high-SEP neighborhoods and in high-income families. Dog owners with low income and limited involvement in the labor market were more likely to have mixed-breed dogs. Those with a higher income and the self-employed were more likely to have a pedigree dog. Acquiring a dog to get physical exercise was more common among dog owners living in high-SEP neighborhoods. Owners with higher levels of education were more likely to have a dog because they liked the company of animals, and those with lower levels tended to keep a dog for instrumental reasons and for social support. The reason for keeping a dog for social support was mainly observed among those with lower levels of education who were also frequently (often/sometimes) involuntarily alone. As in many other areas of consumption, the results demonstrate that acquisition of, and reasons for keeping, a dog are linked to socioeconomic status. They also suggest that dogs play different roles in emotional and mental health at different educational levels.

Impact of health literacy, social support, and socioeconomic position on the serum uric acid level in asymptomatic hyperuricaemia patients in China: a structural equation model

BackgroundHyperuricaemia (HUA) poses a significant public health challenge on a global scale. It is mostly asymptomatic hyperuricemia (AHU) with unsatisfactory recognition and control rates. The role of health literacy in influencing health outcomes is of utmost importance, and enhancing health literacy is helpful for patients in managing risk factors. Additionally, social support and socioeconomic position (SEP) have been identified as potential factors influencing health. However, the exact relationships between these factors and AHU remain unclear. This study aimed to investigate the status of health literacy among patients with AHU and explore the relationships between health literacy, social support, SEP, and serum uric acid (SUA) levels.MethodsA cross-sectional study was conducted among 349 participants with AHU in Luzhou, China. The research instruments included a sociodemographic characteristics questionnaire, the Health Literacy Scale for Chronic Patients (HLSCP), and the Social Support Scale (SSRS). The construction of the SEP index was achieved through the application of principal component analysis. Univariate and hierarchical regression analyses were used to evaluate the associations between SEP, social support, health literacy, and SUA levels. Furthermore, structural equation modelling (SEM) was utilized to examine these associations.Results(1) Most patients exhibited low health literacy (90.18 ± 15.11), and only 44.4% possessed basic health literacy. (2) SEP was positively correlated with SUA levels (β = 4.086, P < 0.001), and health literacy was negatively related to SUA levels (β = -0.399, P < 0.001). There was no significant relationship between social support and SUA levels (β = 0.051, t = 1.085). (3) Health literacy mediated the association between SEP and SUA levels (β = -0.490, 95% CI: -0.620 to -0.382). SEP had a direct positive effect on SUA levels (β = 0.723) and health literacy (β = 0.696), and the total effect of SEP on SUA levels was 0.233.ConclusionsThe findings indicate a low level of health literacy among patients with AHU and suggest that health literacy might play a mediating role in the relationship between SEP and SUA levels. Consequently, future initiatives are recommended to prioritize health literacy and devise appropriate intervention strategies to enhance the self-management capabilities of patients with AHU.

Functional limitation in the older Brazilian adults: Association with multimorbidity and socioeconomic conditions.

The aim of this study was to assess the association between multimorbidity and the presence of functional limitation in basic (BADL) and instrumental activities of daily living (IADL) among Brazilian older adults and to verify whether this association is moderated by socioeconomic conditions. Cross-sectional study with data from the Brazilian National Health Survey (PNS) (2019) for the Brazilian population aged 60 years and over. The dependent variables were functional limitation, based on self-reported difficulty in performing one or more activities of daily living, including six BADL (feeding, bathing, using the toilet, dressing, crossing a room on the same floor and getting out of bed) and four IADL (shopping, managing money, taking medication and using transportation). The independent variables were multimorbidity (presence of two or more self-reported chronic diseases) and socioeconomic measures (per capita household income, asset score, and education level). The association between multimorbidity and outcomes was assessed using adjusted logistic regression models. The moderating effect of socioeconomic conditions on the association between multimorbidity and functional limitations was assessed by including an interaction term. The final sample consisted of 22,725 individuals. The prevalence of functional limitation was 8.5% (95%CI: 7.9-9.2) and 18.6% (95%CI: 17.8-19.5) in BADL and IADL, respectively. Multimorbidity was associated with BADL [OR: 2.30 (95%CI: 1.93-2.74)] and IADL [OR: 2.26 (95%CI: 1.98-2.57)]. The odds of functional limitation were higher among individuals with lower levels of education and income, but there was no interaction between multimorbidity and socioeconomic position measures. Multimorbidity was associated with functional limitation (BADL and IADL) and socioeconomic conditions, and this association was constant across socioeconomic position levels.

The Role of Socioeconomic Position in the Association Between Mental Disorders and Mortality

Studies are lacking summarizing how the association between mental disorders and mortality varies by socioeconomic position (SEP), particularly considering different aspects of SEP, specific types of mental disorders, and causes of death. To investigate the role of SEP in the association between mental disorders and mortality and the association between SEP and mortality among people with mental disorders. MEDLINE, Embase, PsycINFO, and Web of Science were searched from January 1, 1980, through April 3, 2023, and a snowball search of reference and citation lists was conducted. Inclusion criteria were observational studies estimating the associations between different types of mental disorders and mortality, stratified by SEP and between SEP and mortality in people with mental disorders. Pairs of reviewers independently extracted data using a predefined data extraction form and assessed the risk of bias using the adapted Newcastle-Ottawa scale. Graphical analyses of the dose-response associations and random-effects meta-analyses were performed. Heterogeneity was explored through meta-regressions and sensitivity analyses. All-cause and cause-specific mortality. Of 28 274 articles screened, 71 including more than 4 million people with mental disorders met the inclusion criteria (most of which were conducted in high-income countries). The relative associations between mental disorders and mortality were similar across SEP levels. Among people with mental disorders, belonging to the highest rather than the lowest SEP group was associated with lower all-cause mortality (pooled relative risk [RR], 0.79; 95% CI, 0.73-0.86) and mortality from natural causes (RR, 0.73; 95% CI, 0.62-0.85) and higher mortality from external causes (RR, 1.18; 95% CI, 0.99-1.41). Heterogeneity was high (I2 = 83% to 99%). Results from subgroup, sensitivity, and meta-regression analyses were consistent with those from the main analyses. Evidence on absolute scales, specific diagnoses, and specific causes of death was scarce. This study did not find a sufficient body of evidence that SEP moderated the relative association between mental disorders and mortality, but the underlying mortality rates may differ by SEP group, despite having scarcely been reported. This information gap, together with our findings related to SEP and a possible differential risk between natural and external causes of death in individuals with specific types of mental disorders, warrants further research.

Developing SEP65: A Census-Derived Index of Socio-Economic Position Specifically for the Older Population in Aotearoa New Zealand

BackgroundGlobally, societies are ageing as life expectancy increases and fertility rates decline. Many studies exploring associations between socioeconomic position (SEP) and health outcomes among the older population use conventional working-age measures of SEP (education, occupation, and income) or an area-based deprivation index.MethodsMicrodata from the 2013 New Zealand Census was used to create a new measure of socioeconomic position specifically for the population aged ≥65 years (SEP65), using information about housing tenure, wealth, and receiving government benefits. We dichotomised variables representing income, assets, and housing tenure to apportion 489,264 older people in our analytic sample into low, medium and high levels of SEP. A multivariable logistic regression was used to investigate the relationship between smoking and SEP65, controlling for age, sex, ethnicity and area-level deprivation.ResultsWe report inequities between European, Māori and Pacific populations, which increase with age. We found an inverse relationship between the odds of smoking and levels of SEP65. Moreover, we further validated the SEP65 measure against the New Zealand Index of Deprivation (NZDep2013).At the third SPINE20 summit 2022 which took place in Bali, Indonesia, in August 2022, 17 associations endorsed its recommendations.ConclusionUsing an age-specific measure of SEP for the older population will aid policymakers in the appropriate allocation of resources according to need more effectively than working-age indicators.

Is the association between alcohol use and sickness absence modified by socioeconomic position? findings from the Stockholm public health cohort

BackgroundThe distribution of sickness absence tends to be socially patterned less is however known about the underlying mechanisms and pathways of the social gradient found in sickness absence. The present study aims to investigate (i) if the risk function between average volume of alcohol consumption and sickness absence is modified by socio-economic position (SEP), and (ii) whether such an effect modification can be attributed to differences in drinking patterns and other risk factors including other lifestyle behaviours, health status, and working conditions.MethodsThe study was based on data from the Stockholm public health cohort 2006, with an analytical sample of 13 855 respondents aged 18–64 years. Self-reported information on occupational class (a measure of SEP), alcohol consumption, other lifestyle behaviour, health and working conditions was collected from the survey. The outcome of long-term (> 14 days) sickness absence between 2006 and 2008 was obtained from national registers. Negative binomial regression was used to estimate the Incidence Rate Ratios (IRR) with 95% confidence intervals (CI).ResultsIn the initial analyses, heavy drinking manual workers had a 5-fold increased risk of long-term sickness absence compared to non-manual employees who were moderate drinkers, and approximately 60% of the excess risk among heavy drinking manual workers was attributable to an interaction between alcohol use and SEP. Adjusting for working conditions was associated with the largest attenuation of the risk estimate, compared to other lifestyle behaviors and health. In the fully adjusted model, the IRR was further attenuated for the manual workers and the joint effect of SEP and heavy drinking remained in the final model with an attributable proportion of 49%.ConclusionsIndividuals in Sweden with lower levels of SEP appear to be more vulnerable to alcohol consumption in relation to sickness absence, where differences in working conditions explained a large part but not all of the differential vulnerability.

Trends in the Prevalence of Chronic Non-Communicable Diseases and Multimorbidity across Socioeconomic Gradients in Rural Southwest China.

This study aimed to determine the changing prevalence of five chronic non-communicable diseases (NCDs)- hypertension, coronary heart disease (CHD), stroke, chronic obstructive pulmonary disease (COPD), and asthma-- and its multimorbidity (refers to the co-existence of two or more chronic diseases in an individual) across socioeconomic spectra in rural southwest China. Two cross-sectional health interviews and examination surveys were conducted among individuals aged ≥35 years in rural China. An individual socioeconomic position (SEP) index was constructed using principal component analysis. Anthropometric measurements, blood pressure, and post-bronchodilator spirometry tests were recorded for each participant. The mean age and proportion of men was 56.1 years and 48.4% in 2011, while was 56.6 years and 49.4% in 2021. From 2011 to 2021, the overall prevalence of hypertension, stroke and COPD increased from 26.1%, 1.1%, and 8.7% to 40.4%, 2.4%, and 12.8%, respectively (P < 0.01), while prevalence of CHD (2.1% vs. 2.2%) and asthma (1.4% vs. 1.5%) did not differ between the two study years (P > 0.05). The prevalence of NCDs multimorbidity increased from 2.3% to 9.7%, and was also observed among subgroups categorized by sex, age, ethnicity, level of education, income, and SEP (P < 0.01). In addition, the relative increases in the prevalence of multimorbidity were greater among men, old individuals, ethnic minorities, and those with low level of education and low SEP. Both in 2011 and 2021, ethnic minorities and individuals with lower level of education and low SEP had a higher prevalence of multimorbidity of the five studied chronic NCDs than their counterparts (P <0.01). The prevalence of NCDs multimorbidity increased substantially across all socioeconomic gradients in rural southwest China. Future interventions to further manage NCDs and their multimorbidity must be tailored to address socioeconomic factors.

Socio-economic inequalities in the use of drugs for the treatment of chronic diseases in Italy

BackgroundSince the use of medicines is strongly correlated to population health needs, higher drug consumption is expected in socio-economical deprived areas. However, no systematic study investigated the relationship between medications use in the treatment of chronic diseases and the socioeconomic position of patients. The purpose of the study is to provide a description, both at national level and with geographical detail, of the use of medicines, in terms of consumption, adherence and persistence, for the treatment of major chronic diseases in groups of population with different level of socioeconomic position. MethodsA cross-sectional study design was used to define the “prevalent” users during 2018. A longitudinal cohort study design was performed for each chronic disease in new drug users, in 2018 and the following year. A retrospective population-based study, considering all adult Italian residents (i.e. around 50.7 million people aged ≥ 18 years). Different medications were used as a proxy for underlying chronic diseases: hypertension, dyslipidemia, osteoporosis, diabetes and chronic obstructive pulmonary disease. Only “chronic” patients who had at least 2 prescriptions within the same subgroup of drugs or specific medications during the year were selected for the analysis. A multidimensional measures of socio-economic position, declined in a national deprivation index at the municipality level, was used to identify and estimate the relationship with drug use indicators. The medicine consumption rate for each pharmacological category was estimated for prevalent users while adherence and persistence to pharmacologic therapy at 12 months were evaluated for new users.ResultsThe results highlighted how the socioeconomic deprivation is strongly correlated with the use of medicines: after adjustment by deprivation index, the drug consumption rates decreased, mainly in the most disadvantaged areas, where consumption levels are on average higher than in other areas. On the other hand, the adherence and persistence indicators did not show the same trend.ConclusionsThis study showed that drug consumption is influenced by the level of deprivation consistently with the distribution of diseases. For this reason, the main levers on which it is necessary to act to reduce disparities in health status are mainly related to prevention. Moreover, it is worth pointing out that the use of a municipal deprivation indicator necessarily generates an ecological bias, however, the experience of the present study, which for the first-time deals with the complex and delicate issue of equity in Italian pharmaceutical assistance, sets the stage for new insights that could overcome the limits.

Ethnic and socioeconomic inequalities in relation to air pollution exposure in the Netherlands

Abstract Background Air pollution (AP) contributes to a large disease burden and some populations are disproportionately exposed. It is unclear to what extent AP exposure differs across ethnic groups in the Netherlands and how this intersects with socioeconomic position (SEP). First, we identified differences in AP exposures between ethnic groups in the Netherlands. Second, we examined the interrelationships between ethnicity and SEP in relation to AP exposures. Methods We assessed AP exposures for residents of the Netherlands in 2019 (N = 17,251,511). Home address AP levels were estimated by dispersion models of the National Institute of Public Health and the Environment (RIVM). We linked exposure estimations of particulate matter &amp;lt;10 or &amp;lt; 2.5 μm (PM10, PM2.5), nitrogen dioxide (NO2), and elemental carbon (EC) to demographic data gathered by Statistics Netherlands. Absolute and relative differences in AP levels across ethnic groups were assessed. We conducted multivariable linear regression analyses and estimated marginal mean exposures to evaluate differences by ethnicity, SEP, age and sex within urban and rural areas. We tested for interactions and stratified accordingly. Results For the 40 largest minority ethnic groups (N &amp;gt; 18,314 per group), exposure to all pollutants was higher than for ethnic Dutch, with up to 1.5-fold differences for NO2. After stratification for urbanity and SEP, ethnic exposure inequalities persisted. For ethnic Dutch and some migrant groups, we found the lowest AP exposures in the middle SEP group (i.e. U-shaped trends), while we found linear patterns in other large migrant groups, with higher exposures at lower SEP. Conclusions Exposure to PM10, PM2.5, NO2, and EC was consistently higher in minority ethnic groups compared to ethnic Dutch. The association between SEP and AP levels showed different patterns between the majority ethnic Dutch and some of the largest minority ethnic groups. Further research is needed to define the equity and health implications. Key messages • Minority ethnic groups in the Netherlands are consistently exposed to higher levels of air pollution (PM10, PM2.5, NO2, and EC) than the ethnic Dutch population. • Depending on the ethnic group, the association between SEP and air pollution exposure was either linear (i.e. lower exposures at higher SEP) or U-shaped (i.e. lower exposures in the middle SEP group).

Israeli COVID lockdowns mildly reduced overall use of preventive health services, but exacerbated some disparities

BackgroundDuring 2020, Israel experienced two COVID-19-related lockdowns that impacted the provision of primary and secondary preventive care.MethodsWe examined the month-by-month performance of selected preventive care services using data from Israel’s national Quality Indicators in Community Healthcare program. Process of care measures included hemoglobin A1c (HbA1c) testing, cholesterol testing, colon cancer screening and mammography. Intermediate outcome measures included low-density lipoprotein control and HbA1c control. Measures were stratified by sex and by area-level socioeconomic position (SEP). Diabetes and mammography are presented in this abstract due to space limitations.ResultsAnnual HbA1c testing among persons with diabetes decreased from 90.9% in 2019 to 88.0% in 2020. Performance of HbA1c tests during lockdown months was as low as half the usual amount. There were compensatory increases in testing during post-lockdown months that did not quite make up for the missed tests. In 2019, 9.0% of Israelis with diabetes had poor glycemic control (HbA1c ≥ 9.0); in 2020, it was 8.8%. In total, 4.5% fewer mammograms were performed in 2020 compared with 2019. Women in the lowest SEP level performed 10.4% fewer mammograms in 2020 than in 2019, while women in the highest SEP level performed 3.1% more mammograms.ConclusionsProlonged COVID lockdowns in 2020 were associated with marked decreases in the performance of preventive health services during those months. Compensatory spikes following the end of lockdowns partly, but did not completely, make up for the missed care. COVID lockdowns may have exacerbated socioeconomic disparities in some preventive health services.

Trends in survival of epithelial ovarian/tubal cancer by histology and socioeconomic status in Denmark 1996–2017

ObjectivesTo examine time trends in ovarian/tubal cancer relative survival, excess mortality, and all-cause mortality for different histological types and levels of socioeconomic position. MethodsWomen with ovarian/tubal cancer diagnosed 1996–2017 were identified in the Danish Cancer Registry (n = 11,755). Age-standardized 5-year relative survival over time was estimated by histology, socioeconomic status, and stage. Furthermore, 5-year excess mortality rate ratios (EMRR) according to calendar time for all categories of histology and socioeconomic status were calculated using a Poisson regression model. Finally, all-cause mortality by histology and socioeconomic status was estimated in multivariate Cox proportional hazards regression models. ResultsStatistically significant improvements in 5-year relative survival occurred for all histological types over time except mucinous tumors (5-year EMRR, localized: 0.92 (95% CI: 0.71–1.16); advanced: 0.96 (95% CI: 0.85–1.08). Increase in relative survival over time and corresponding decrease in excess mortality was observed for all categories of socioeconomic status except for women with localized disease in the lowest income group (5-year EMRR = 0.91 (95% CI:0.76–1.10)). The impact of histology and socioeconomic status on all-cause mortality depended on time since diagnosis. Among the socioeconomic factors, especially low educational level and living alone were associated with increased all-cause mortality, particularly in the first year after diagnosis. ConclusionsOvarian/tubal cancer survival generally increased over time across histological types and socioeconomic factors. However, the lack of improvement for mucinous tumors needs further research. Additionally, the results for women with low income and education shows that continued focus on social equality in survival is necessary.

Trends and socioeconomic disparities in all-cause mortality among adults with diagnosed diabetes by race/ethnicity: a population-based cohort study - USA, 1997–2015

ObjectivesBy race/ethnicity and socioeconomic position (SEP), to estimate and examine changes over time in (1) mortality rate, (2) mortality disparities and (3) excess mortality risk attributed to diagnosed diabetes (DM).DesignPopulation-based...

Physical and psychosocial work factors as explanations for social inequalities in self-rated health.

We investigated the contribution of physical and psychosocial work factors to social inequalities in self-rated health (SRH) in a sample of Danish 40 and 50 years old occupationally active women and men. In this longitudinal study, the study population consisted of 3338 Danish women and men. Data were collected by postal questionnaires in 2000 (baseline) and 2006 (follow-up). The independent variable, socioeconomic position (SEP), was assessed by the highest achieved educational level at baseline. We conducted gender-stratified parallel multiple mediation analyses. In the mediation analyses, SEP was categorised as SEP I, II, III, VI and V among men. Among women, SEP was dichotomised into SEP I-IV and V. The outcome, SRH, was assessed at baseline and follow-up. A wide range of physical and psychosocial work factors were included as potential mediators. We found a social gradient in SRH across all levels of SEP among men. Among women, we only found a poorer SRH among those with the lowest SEP. Mediation analyses showed that work factors together accounted for 56% of the social inequalities in SRH among men and 44% among women. In both genders, ergonomic exposures and job insecurity seemed to play the major role for social inequalities in SRH. For women only, we also found noise to contribute to the social inequalities in SRH. Physical and psychosocial work factors partially explained social inequalities in SRH among both genders. Improvement of the working environment can potentially contribute to the reduction of social inequalities in health.

Trends and socioeconomic disparities in diabetes prevalence and quality of care among Israeli children; 2011-2018

BackgroundDespite Israel’s universal health coverage, disparities in health services provision may still exist. We aimed to assess socioeconomic disparities in diabetes prevalence and quality of care among Israeli children, and to assess whether these changed over time.MethodsWe used repeated cross-sectional analyses in the setting of the National Program for Quality Indicators in Community Healthcare. The data were derived from electronic medical records from Israel’s four health maintenance organizations. The study population included all Israeli children aged 2–17 years in 2011–2018 (2018: N = 2,404,856). Socio-economic position (SEP) was measured using Central Bureau of Statistics data further updated by a private company (Points Business Mapping Ltd), and grouped into 4 categories, ranging from 1 (lowest) to 4 (highest). We used logistic regression to assess the association of SEP with diabetes prevalence, diabetes clinic visits, hemoglobin A1C (HbA1C) testing, and poor glycemic control (HbA1c > 9%), and assessed whether these changed over time.ResultsDiabetes prevalence increased with age and SEP, with a total of 3019 children with diabetes. SEP was positively associated with visiting a specialized diabetes clinic (age and sex adjusted Odds Ratio (aORSEP 4 vs. 1 2.45, 95% Confidence Interval (CI) 1.67–3.69)). Although children in higher SEPs were less likely to undergo HbA1c testing (aORSEP 4 vs. 1 0.54, 95% CI 0.40–0.72), they were also less likely to have poor glycemic control (aORSEP 4 vs. 1 0.25, 95% CI 0.18–0.34). Disparities were especially apparent among children aged 2–9 (6.5% poor glycemic control in SEP 4 vs. 38.2% in SEP 1). Poor glycemic control decreased over time, from 44.0% in 2011 to 34.1% in 2018.ConclusionsWhile poor glycemic control rates among children have improved, they remain high compared to rates in adults. Additionally, substantial socioeconomic gaps remain. It is eminent to study the causes of these disparities and develop policies to improve care provided to children in the lower SEP levels, to promote health equity.

First Permanent Molar Caries and Oral Health Practices in Saudi Male Teenagers: Inequalities by Socioeconomic Position.

Objectives Caries remains a problem in high-risk groups aggravated by socioeconomic inequalities. The study aimed to investigate (1) oral health practices associated with caries in the 1st permanent molars in Saudi male teenagers and (2) the impact of socioeconomic position (SEP) on caries control using these practices. Methods A cross-sectional study targeted 1137 male teenagers in intermediate schools in Khobar and Dammam, Saudi Arabia, in 2016. Caries was examined using the World Health Organization criteria and plaque was assessed using the plaque index of Loe and Silness. A questionnaire assessed SEP (parental education, employment, and home ownership) and oral health practices (using fluoridated toothpaste twice daily, regular dental visits for check-ups, and avoiding daily sugary snacks). Regression models analysed the association of these factors with caries presence and the mean number of decayed 1st permanent molars. Stratification was used to assess differences between SEP levels. Results The response rate was 81.7%. Caries prevalence and mean (SD) number of decayed 1st permanent molars were 50.4% and 1.08 (1.31). The use of fluoride toothpaste was associated with lower odds of caries and fewer decayed molars (OR = 0.50 and regression coefficient = −0.35). Differences in the relationship between caries and toothpaste were observed by SEP levels with stronger associations in less advantaged groups. Conclusions Brushing twice daily using fluoride toothpaste was associated with less caries in Saudi male teenagers with stronger association observed in groups with lower SEP. The use of fluoride toothpaste helps in reducing health inequalities associated with SEP.

The Authors Respond

To the Editor: We thank Finn Diderichsen, Ingelise Andersen, Theis Lange, and Naja Hulvej Rod for their comments on our article.1 To the extent that we understand all the points raised, we attempt to address them here. The authors indicate that they would expect the relative effect of smoking on chronic disease not to vary across levels of socioeconomic position. This runs counter to our thinking and the results from selected extant studies. As we outlined in the original article,2 in analyses of large, population-based surveys, where self-reported cigarette smoking is held constant, cotinine, a biomarker of tobacco smoke exposure, has markedly higher levels in the most disadvantaged folk relative to the affluent.3 This could be because people from lower social groups smoke their cigarettes differently, including inhaling more deeply and more frequently, and/or by choosing higher tar-containing brands. We, as others have before us, therefore hypothesized that the risk to health of smoking in disadvantaged individuals may be elevated in comparison to the more affluent – that is, smoking is most deleterious in lower social groups. While there is some support for this hypothesis – as we describe in our article – and more recently, for health behaviors in aggregate,4 this is not a universal observation; hence, our interest in further testing it is in a well-powered study. Although Diderichsen et al. claim that by computing hazard ratios in this context our work is less comparable to other findings, our reckoning is that the majority of articles in fact report this measure of risk. In the interests of being as comprehensive as possible, we also computed absolute measures of risk in our article – age-standardized mortality rates. Diderichsen and others also raise the issue of biased reporting of cigarette smoking habits, which may be most acute in disadvantaged populations and which may provide a further explanation for any effect modification of the health consequences of smoking across social groups. This is precisely why we used blood and salivary cotinine to corroborate self-reported smoking – to the best of our knowledge, the first study to do so in the context of the present research question. The use of this biomarker also has the value of capturing cigarette dose in smokers, as would the analyses we computed by self-reported numbers of cigarettes that can be found in the appendix of the article. G. David Battya and Carlos de MestralbFrom the aDepartment of Epidemiology and Public Health, University College London, London, United Kingdom andbInstitute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland.

Diabetes in Israel- do all patients receive equal care?

Abstract Background Diabetes Mellitus (DM) is associated with micro- and macro-vascular complications, leading to high burden of morbidity and mortality. Populations of low socioeconomic position (SEP) in various countries were found to have increased prevalence of the disease, worse glycemic control, and increased complications. We aimed to examine whether there are social disparities in diabetes care in Israel, as reflected in a national program for quality indicators. Methods The Israel National Program for Quality Indicators in Community Healthcare obtains data from electronic medical records from all health plans, covering the entire Israeli population. In 2017, 497,397 individuals aged &amp;gt;18 years were identified with DM. DM prevalence, quality of care indicators, including process and intermediate outcomes were explored by SEP categories (1-10), determined according to residential addresses. Results DM prevalence in Israeli adults in 2017 was 9.7%, showing a strong SEP gradient, with higher prevalence in individuals of lower SEP. No SEP disparities were observed in process indicators with overall rates of documentation of hemoglobin A1c (HbA1c) of 90.9%, ophthalmologic examinations of 72.5%, and kidney function examinations of 92.5%. However, strong SEP disparities were observed in the prevalence of uncontrolled diabetes (HbA1c≥9%), with an overall rate of 10.0%, and a 5.4-times higher rate in diabetics of the lowest SES level (23.5%) compared with the highest SEP level (4.3%). A somewhat weaker gradient was seen for the well-control of DM (HbA1c&amp;lt;7-8%, according to duration of disease and age), with an overall rate of 69.7%, and a 1.7 ratio, comparing diabetics of the highest vs the lowest SEP level. Conclusions These findings suggest that access to care does not explain SEP disparities in diabetes control in Israel. There is a need to explore the underlying social, cultural, and possibly the benefits-policy determinants of poor control among individuals of low SEP. Key messages Wide socioeconomic disparities are present among Israeli adults in diabetes mellitus prevalence and control rates, but not in care processes indicators. These findings call for a deeper understanding of the determinants and perhaps a revision of current social benefits policy, which may encourage lack of glycemic control.

Socioeconomic disparities in diabetes prevalence and quality of care among Israeli children

Abstract Background Despite Israel’s universal health coverage, disparities in health services provision may still exist. We aimed to assess socioeconomic disparities in diabetes prevalence and quality of care among Israeli children, and to assess trends in these over time. Methods Repeated cross-sectional analyses in the setting of the National Program for Quality Indicators in Community Healthcare that receives data based on electronic medical records from Israel’s four health maintenance organizations. The study population included all Israeli children aged 2-19 years in 2011-2017 (for 2017: N = 2,364,374, including 2,914 with diabetes). Socio-economic position (SEP) was measured using Central Bureau of Statistics data further updated by a private company (Points Business Mapping Ltd), and grouped into 4 categories, ranging from 1 (lowest) to 4 (highest). Using logistic regression, we assessed the association of SEP with diabetes prevalence, diabetes clinic visits, hemoglobin A1C (HbA1C) testing, and poor glycemic control (HbA1C&amp;gt; 9%), and assessed whether these changed over time. Models were adjusted for age, and sex. Results Diabetes prevalence increased with age and SEP. SEP was positively associated with visiting a specialized diabetes clinic (OR SEP 4 vs. 1 2.53, 95% CI 1.72 - 3.70). Odds of HbA1C testing and odds of poor glycemic control were negatively associated with SEP (OR SEP 4 vs. 1: 0.54, 95% CI 0.40 - 0.72 and OR SEP 4 vs. 1: 0.25, 95% CI 0.18 - 0.34 respectively). Disparities were especially apparent among children aged 2-9 (4.6% poor glycemic control in SEP 4 vs. 40.8% in SEP 1). Poor glycemic control decreased over time, from 44.0% in 2011 to 34.8% in 2017. Conclusions While poor glycemic control rates among children have improved, significant socioeconomic gaps remain. It is eminent to study the causes of these disparities and develop policies to improve care provided to children in the lower SEP levels, to promote health equity. Key messages Major socioeconomic inequalities in the control of diabetes among children in Israel remain despite universal health care coverage. The rate of uncontrolled diabetes among Israeli children has improved over time.

Infancy weight gain, parental socioeconomic position, and childhood overweight and obesity: a Danish register-based cohort study

BackgroundRapid infant weight gain (RIWG) is a very strong predictor of childhood overweight and obesity (COO). Socioeconomic position (SEP) is also related to the risk of COO and parents of different SEP may differ in their reaction to accelerated infant weight gain. Together this could lead to differences in how weight gain and COO risk relate across SEP. This study aimed to analyse possible interaction of SEP and RIWG on COO risk.MethodsA register-based longitudinal cohort study followed 19,894 healthy, term infants, born in Denmark between December 2011 and May 2015. Logistic regression models were used to estimate odds ratios (OR) of COO risk at 2 years (22–26 months) of age with 95% confidence intervals (95% CI) for categories of infancy weight gain based on changes in weight-for-age z-scores between 0 and 8–10 months of age (slow (<− 0.67), mean (− 0.67–0.67), rapid (> 0.67–1.34) and very rapid (> 1.34)). Possible multiplicative and additive interaction of SEP (based on household income and maternal education) on the relationship between infancy weight gain and COO were analysed.ResultsIn total, 19.1 and 15.1% experienced rapid or very rapid weight gain, respectively, and 1497 (7.5%) children were classified with COO at follow-up. These prevalences were higher in those with lower levels of SEP. Adjusted OR for COO were 3.09 (95% CI [2.66–3.59]) and 7.58 (95% CI [6.51–8.83]) for rapid and very rapid weight gain, respectively, when household income was included in the model. Results were similar in the model including maternal education. No signs of interactions were detected on a multiplicative scale. Weak signs of additive interaction were present, but these values did not reach significance.ConclusionBoth rapid and very rapid weight gain were associated with substantially higher risks of COO but these associations were not modified by SEP. This indicates that promotion of healthy weight gain should take place in all population groups irrespective of their SEP.

Socioeconomic disparities in prevalence and behaviors of smoking in rural Southwest China

BackgroundThis study examines how prevalence and behaviors of smoking differ by socioeconomic status among rural southwest Chinese adults.MethodsA cross-sectional survey was conducted including 7743 adults aged ≥35 years in rural regions of Yunnan Province, China from 2016 to 2018. Information on individual socioeconomic status (SES), ethnicity, and self-reported smoking behaviors was collected utilizing a standardized questionnaire. The individual socioeconomic position (SEP) index was constructed using principal component analysis. Multivariate logistic regression models were used to analyze the association between individual SES variables and the prevalence and behaviors of smoking.ResultsIn the study population, the overall prevalence rate of current smokers was 33.5%. Males had a markedly higher prevalence of current smokers than females (62.6% vs. 4.8%, P < 0.01). Of these smokers, 74.5% began smoking during adolescence, 88.8% had never attempted to quit smoking, and 81.1% reported smoking in public places. Ethnic minority participants and those with low levels of education and/or low SEP were more likely to use tobacco as well as more likely to start smoking, and regularly smoke, during adolescence (P < 0.01). Participants with poor access to medical services had a higher prevalence of current smoking than their counterparts (P < 0.01). Among current smokers, Han ethnicity, good access to medical services, and high SEP were positively associated with the probability of having attempted to quit smoking at least once, while a high level of education and high SEP were negatively associated with the probability of smoking in public places.ConclusionsDisparities in prevalence and behaviors of smoking exist across a diversity of indicators of individual SES in rural southwest China. Future tobacco cessation interventions should focus on men, ethnic minorities, and those with low education levels, poor access to medical services, and low SEP.