Lower Educated Persons Research Articles

Extreme Temperatures and Mortality: Effect, Modification, and Acclimatization in A Continental Study

MAA1-O-01 Session Title: Temperature-related Short Term Health Effects Introduction: During the next century, the frequency of temperature extremes, which have been related to increased mortality, is predicted to change. The impact of those changes on public health will be partly determined by our ability to adapt. We aimed to assess in a large sample of cities the increase in daily mortality associated with temperature extremes and to explore the influence of acclimatization. Methods: We conducted a case-crossover study in 50 U.S. cities during the period of 1989–2000. We used hourly weather data and daily mortality data corresponding to 7,531,120 deaths. We selected control days every 3 days within the same month of the same year. Exposure to extreme temperatures was assessed using city-specific indicator variables for extreme cold (≤1st percentile of daily maximum temperature) and extreme heat (≥99th percentile of daily minimum temperature). As a sensitivity analysis, we also assessed the effect of temperature using a piecewise linear variable. In a meta-analysis based on the city-specific conditional logistic regression models, several city characteristics were evaluated as effect modifiers. Results: We observed significant increases in total mortality associated with extreme cold (2-day cumulative change = 1.58%; 95% confidence interval [95% CI] = 0.61–2.56) and especially to extreme heat (5.68%; 3.47–7.89). The increase in mortality occurred mainly at lag 1 for cold and both at lag 0 and lag 1 for heat. Low-educated persons were particularly susceptible to heat, with an additional increase in mortality (lag 0) of 2.55% (95% CI = 0.69–4.41) when compared with those who were highly educated. The heat effects decreased with increasing percentage of air conditioning and mean summer apparent temperature and increased with population density. Subsequent analyses of cause-specific mortality showed a noticeably large increase in cardiac arrest deaths on extremely cold days (2-day cumulative change 14.85%; 95% CI = 5.15–24.55). Most results were similar when exposure was assessed using a piecewise linear temperature variable. For cardiac arrest mortality, the latter analyses showed some indications of a greater impact of cold temperatures in cities with milder winters. Discussion and Conclusions: The study confirmed, in a larger sample of cities than had been previously examined, that temperature extremes are associated with increases in daily mortality. We also found evidence of population acclimatization, especially to heat, which should be taken into account when assessing the public health impact of global warming.

Educational Inequalities in Initiation, Cessation, and Prevalence of Smoking Among 3 Italian Birth Cohorts

We examined socioeconomic inequalities in initiation and cessation rates of smoking and the resultant inequality in smoking prevalence among 3 consecutive Italian birth cohorts. We used data from the 1999-2000 Italian National Health Interview Survey, which included 28958 men and 29769 women who were born between 1940 and 1969. The association between smoking variables and level of education was assessed with logistic regression and life table analyses. Inequalities in the lifetime prevalence of smoking increased across the 3 birth cohorts in Italy. At age 40, lower-educated persons in the youngest cohort reported on average 1 to 5 years of additional exposure to regular smoking compared with higher-educated persons. Inequalities in smoking prevalence increased among both men and women because of widening inequalities in initiation rates. Among women, growing inequalities in cessation rates also played a role. The relative contribution of initiation and cessation to socioeconomic inequalities in smoking rates varied by both gender and birth cohort. For the youngest birth cohort, policies that address inequalities in smoking should focus on both initiation and cessation.

The contribution of specific diseases to educational disparities in disability-free life expectancy.

We examined the contribution that specific diseases, as causes of both death and disability, make to educational disparities in disability-free life expectancy (DFLE). We used disability data from the Belgian Health Interview Survey (1997) and mortality data from the National Mortality Follow-Up Study (1991-1996) to assess education-related disparities in DFLE and to partition these differences into additive contributions of specific diseases. The DFLE advantage of higher-educated compared with lower-educated persons was 8.0 years for men and 5.9 years for women. Arthritis (men, 1.3 years; women, 2.2 years), back complaints (men, 2.1 years), heart disease/stroke (men, 1.5 years; women, 1.6 years), asthma/chronic obstructive pulmonary disease (COPD) (men, 1.2 years; women, 1.5 years), and "other diseases" (men, 2.4 years) contributed the most to this difference. Disabling diseases, such as arthritis, back complaints, and asthma/COPD, contribute substantially to differences in DFLE by education. Public health policy aiming to reduce existing disparities in the DFLE and to improve population health should not only focus on fatal diseases but also on these nonfatal diseases.

The Changing Family Background of the Low-Educated in the Netherlands: Socio-Economic, Cultural, and Socio-Demographic Resources

This article addresses two questions: (a) to what extent have the effects of family background on leaving school without qualifications changed over time in the Netherlands, and (b) to what extent have the background family characteristics of the unqualified changed. We estimate discrete-time event-history models, using data from the Family Surveys Dutch Population 1992, 1998, and 2000. The results show that the effects of parental socio-economic resources and parental educational attainment on leaving school unqualified have decreased over birth cohorts, whereas the effects of parental cultural and socio-demographic resources have been stable. These developments have been accompanied by decreases in the proportions of younger cohorts who leave school without qualifications. The combination of these two developments has caused the family background characteristics of the low-educated to deteriorate: they increasingly originate from families with unfavorable socio-economic, cultural and demographic resources. We argue that due to statistical discrimination and labeling this compositional change may have negative consequences for the economic and social well-being of low-educated persons in the Netherlands.

Changes in the human migration patterns in the Maramures region (Romania - Ukraine)

In this paper we discuss the changes in human migration patterns in the Maramures region during the last decade. The term “Maramures region” refers to the historical Maramures County, in the Northern sector of the South-Eastern Carpathians, encompassing the superior basin of the Tisa river. After WWI, the region was divided into two distinct sectors, presently belonging to Romania and Ukraine. However, the unitary natural environment, a common history and their peripheral position justify a unified approach to the issue of human migration patterns. Before 1990, due to specific human and natural factors, the mobility pattern was characterized by seasonal agricultural work migrations. Due to the opening of new opportunities after 1990, internal agricultural migration was transformed into international work migration. Herein, we present statistical data acquired through fieldwork for two villages in the Romanian sector: Barsana and Sapanta. International migration rates in 2001 were, correspondingly, 6.4% and 4.8%. With respect to migration directions, the ease of communication in the destination country for lower educated persons plays a vital role.

Frequent failed early HIV detection in a high prevalence area: implications for prevention.

To identify the frequency of and factors associated with early detection of HIV infection in Los Angeles County, data were evaluated from interviews of a population-based sample of adult persons with AIDS. Early detection was defined as greater than 5 years between the first reported positive HIV test and an AIDS diagnosis. The associations between early detection and sociodemographic and behavioral factors were assessed for the period January 1997 through June 2002. Over the study period, only 20% (253/1268) of persons interviewed met the criterion for early detection. Early HIV detection was less likely for women (adjusted odds ratio [AOR] = 0.6, 95% confidence interval [CI]: 0.4, 0.9), blacks (AOR = 0.5, 95% CI: 0.4, 0.8), foreign-born Latinos (AOR = 0.2, 95% CI: 0.1, 0.3), U.S.-born Latinos (AOR = 0.3, 95% CI: 0.2, 0.6, and heterosexuals (AOR = 0.5, 95% CI: 0.3, 0.7). Trends of increasing early detection with older age groups (p < 0.001) and higher educational levels (p < 0.001) were also observed. Our findings indicate an overall low level of early HIV detection and suggest that major sociodemographic and risk group disparities exist in the likelihood of early detection among HIV-infected persons in Los Angeles. These differences have important implications for reducing the level of community HIV transmission and for improving individual health outcomes among people with HIV. Aggressive efforts are needed to expand HIV testing and early detection for women, minorities, heterosexuals, younger age groups, and persons of lower education. Links to treatment and behavioral intervention programs should accompany such expanded testing efforts.

MEASUREMENT OF POVERTY: POLAND IN THE 1980s

This paper presents results of an examination of poverty in Poland in the 1980s. The individual welfare measure is expenditure on consumption per equivalent adult. Household equivalence scales are estimated using a quasi‐exact scales trans logarithmic model. Four poverty indices are calculated. These are intended to capture the following aspects of poverty: (1) incidence, (2) relative deprivation, acid (3) social ability to eliminate poverty by income transfers. The study revealed significant changes in poverty during the investigated period, from 9 to 30 percent with persistent poverty resulting for pensioners, farmers and low educated persons.

An empirical evaluation of the placebo run-in

A prerandomization placebo run-in period is often used in an attempt to exclude potential clinical trial participants who are likely to be poor adherers. It is assumed that potential participants who are poor adherers during the run-in will be less likely to take medication during the trial. This assumption was tested in the Cholesterol Reduction in Seniors Program (CRISP), by prescribing placebo for a 3-week period, but not using the results of the run-in as an entry criterion. The CRISP study was a pilot study designed to compare the effects on lipids and the safety of two doses of lovastatin and placebo in persons 65 years of age and older. After general entry criteria were satisfied, each participant was prescribed placebo for a 3-week period. At the end of the 3-week period, all participants were randomized to one of the three treatment groups, regardless of their adherence to the placebo. Of the 431 participants in the study, 66 (15%) who took less than 80% of the prescribed placebo or who failed to return their unused placebo pills were classified as poor run-in adherers. Poor run-in adherence was associated with lower educational attainment. At 3 and 6 months of follow-up mean adherence was 89.3% and 83.4% among all participants. Exclusion of poor run-in adherers would have increased these means to 90.9% and 85.5%, respectively. Treatment effect as measured by fall in LDL cholesterol would have increased by 2.9 mg/dl in the 40 mg/day dose group at 3 months of follow-up with the addition of a placebo run-in. We conclude that a placebo run-in would have had little effect on the outcome of the CRISP study and would have substantially increased recruitment difficulties. Lower educated persons were more likely to be excluded by a placebo run-in, but the effect of the run-in on follow-up adherence was stronger in less educated participants. More research about the role of a placebo run-in is needed in order to determine the appropriate role of this method in clinical trials.

"John Henryism" and blood pressure in a Dutch population.

In a stratified, random sample of 100 men and 100 women, aged 20-59 years, residing in Zutphen, the Netherlands, the hypothesis was tested that high scores on "John Henryism," a strong behavioral predisposition to cope actively with psychosocial environmental stressors, would be associated with higher blood pressure, especially among persons of lower education. In univariate analyses higher scores on John Henryism were strongly associated with higher blood pressures in men. Among women there was only an association of John Henryism and systolic blood pressure, but this association was no longer statistically significant after adjustment for potential confounders such as age, alcohol consumption, physical activity, Quetelet Index, and education. Among men, however, the association between John Henryism and systolic blood pressure remained statistically significant after adjustment for potential confounders. The association between John Henryism and blood pressure was more pronounced for men of low educational background.