Self-reported Household Income Research Articles

Abstract PO2-09-12: The magnitude and temporal variations of socioeconomic inequalities in quality of life after early breast cancer: results from the multicentric French CANTO cohort

Abstract Objective Previous studies showed that various outcomes in patients with early breast cancer (EBC), from incidence to survival, were influenced by social factors. However, there is limited research on the socioeconomic inequalities in quality of life (QoL) after treatment for EBC, and the magnitude and changes over time of these inequalities have not been quantified. This study examines the socioeconomic inequalities in QoL and their time trends among a large cohort of patients with EBC. Methods We conducted a comprehensive longitudinal analysis using data from the prospective multicentric CANTO study (CANcer TOxicity, NCT01993498), which included participants with EBC enrolled between 2012 and 2018. QoL was assessed using the summary score of the EORTC QLQ-C30 questionnaire at the time of diagnosis and 1 and 2 years post-diagnosis. We included patients with complete QoL data at diagnosis and 2 years post-diagnosis. Analyses were conducted for three indicators of socioeconomic status separately: self-reported financial difficulties, household income and educational level. We first analyzed trajectories of QoL by socioeconomic status from diagnosis to Year 1 and Year 2. Then, social inequalities in QoL were estimated using the regression-based slope indexes of inequality (SII) and compared across the follow-up periods. The SII represents the absolute change in the QLQ-C30 summary score along the two extremes of the socioeconomic gradient, taking into account the intermediate groups and their relative sizes. The analyses were adjusted for age at diagnosis, Charlson comorbidity index, disease stage, use and type of endocrine therapy, use and type of chemotherapy, breast surgery, radiotherapy use, and lymph node management. Results In the 5915 analyzed patients, compared to those with higher socioeconomic status, those reporting a high level of financial difficulty, lower income, or lower education were younger, most often premenopausal, with comorbidities, diagnosed with stage III BC, and treated with mastectomy and axillary lymph node dissection. There were no differences between socioeconomically-defined groups concerning BC histology, grade and IHC-defined subtype. Social inequalities in QoL at baseline were statistically significant for all socioeconomic status indicators (SIIfinancial difficulties = -7.6 [-8.9;-6.2], SIIincome= -4.0 [-5.2;-2.8]) and SIIeducation= -1.9 [-3.1;-0.7]). In multivariable analyses, social inequalities significantly increased (interaction p< 0.05) in Year 1 (SIIfinancial difficulties = -11.1 [-12.8;-9.4], SIIincome= -6.5 [-8.0;-5.0] and SIIeducation= -5.0 [-6.6;-3.5]) and Year 2 (SIIfinancial difficulties = -10.7 [-12.2;-9.1], SIIincome= -6.7 [-8.0;-5.3] and SIIeducation= -4.7 [-6.1;-3.3]) suggesting a widening socioeconomic gap in QoL outcomes irrespective of pre-diagnosis health, tumor characteristics and treatment. Similar results were observed in subgroups defined by menopausal status (pre/postmenopausal) and type of systemic treatment (chemotherapy, endocrine therapy). Conclusion Our study highlights and quantifies the association of several individual socioeconomic indicators with the QoL of patients with EBC in France. The magnitude of socioeconomic inequalities in QoL increased over time after EBC diagnosis in a country with a strong welfare system and universal healthcare coverage. In the era of precision medicine, these results underscore the importance of developing interventions to improve precision care, considering the conditions in which people are born, grow, work, live and age and the wider set of forces and systems shaping the conditions of daily life. Citation Format: José Luis Sandoval, Antonio Di Meglio, Arlindo Ferreira, Maria Alice Franzoi, Fabrice André, Barbara Pistilli, Christelle Jouannaud, Marion Fournier, Philippe Rouanet, Asma Dhaini Mermeche, Paul Cottu, Sibille Everhard, Anne-Laure Martin, Silvia Stringhini, Idris Guessous, Ines Vaz Luis, Gwenn Menvielle. The magnitude and temporal variations of socioeconomic inequalities in quality of life after early breast cancer: results from the multicentric French CANTO cohort [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO2-09-12.

Costs incurred by people with co-morbid tuberculosis and diabetes and their households in the Philippines.

Diabetes is a risk factor for TB mortality and relapse. The Philippines has a high TB incidence with co-morbid diabetes. This study assessed the pre- and post-TB diagnosis costs incurred by people with TB and diabetes (TB-DM) and their households in the Philippines. Longitudinal data was collected for costs, income, and coping mechanisms of TB-affected households in Negros Occidental and Cebu, the Philippines. Data collection was conducted four times during TB treatment. The data collection tools were developed by adapting WHO's cross-sectional questionnaire in the Tuberculosis Patient Cost Surveys: A Handbook into a longitudinal study design. Demographic and clinical characteristics, self-reported household income, number of facility visits, patient costs, the proportion of TB-affected households facing catastrophic costs due to TB (>20% of annual household income before TB), coping mechanisms, and social support received were compared by diabetes status at the time of TB diagnosis. 530 people with TB were enrolled in this study, and 144 (27.2%) had TB-DM based on diabetes testing at the time of TB diagnosis. 75.4% of people with TB-DM were more than 45 years old compared to 50.3% of people with TB-only (p<0.001). People with TB-DM had more frequent visits for TB treatment (120 vs 87 visits, p = 0.054) as well as for total visits for TB-DM treatment (129 vs 88 visits, p = 0.010) compared to those with TB-only. There was no significant difference in the proportion of TB-affected households facing catastrophic costs between those with TB-DM (76.3%) and those with TB-only (68.7%, p = 0.691). People with TB-DM in the Philippines face extensive health service use. However, this does not translate into substantial differences in the incidence of catastrophic cost. Further study is required to understand the incidence of catastrophic costs due to diabetes-only in the Philippines.

Feasibility of the International Wealth Index and the Gapminder tool as instruments to assess household income and estimate catastrophic expenditure: A prospective patient-level cohort study in India.

Patient income assessment is required to assess healthcare catastrophic expenditure (Sustainable Development Goal) but self-reported income has several biases. This study aimed to assess the feasibility of the International Wealth Index (IWI) and the Gapminder tool as indirect instruments to assess household income. Prospective cohort study of colorectal cancer patients in five tertiary care hospitals in India (Dec 2020-August 2021). Patient self-reported household income was compared to income estimated from the IWI (twelve questions about household goods) and the Gapminder tool (five pictures of household assets). Agreement between instruments was explored with Bland-Altman methods. Cancer care expenditure from the same cohort was used to illustrate the impact of these tools in catastrophic expenditure rates. From the 226 patients included, 99.5% completed the IWI and the Gapminder tool. Overall, self-reported incomes were lower than the estimated from the IWI and Gapminder tools (median incomes: 17350₹ for self-reported, 37491₹ for IWI and 51520₹ for Gapminder). The IWI showed better agreement with the self-reported income than the Gapminder tool. For both instruments, the agreement was better for low income earning households. Illustrative catastrophic expenditure rates range from 71% to 56% to 43% when using self-reported, IWI and Gapminder incomes respectively. It is feasible to use the IWI and the Gapminder tools to estimate household income although they might overestimate income, with an impact on catastrophic expenditure rates. Further refinement of these tools could enable global monitoring and modelling of catastrophic expenditure from real-world data, at low burden for patients.

Income level and treatment selection in prostate cancer: analysis of a North Carolina population-based cohort.

Disparities in treatment selection based on socioeconomic status for prostate cancer exist. However, the association between patient-level income with treatment selection priorities and treatment received has not been studied. A population-based cohort of 1382 individuals with newly diagnosed prostate cancer was enrolled throughout North Carolina prior to treatment. Patients self-reported household income and were asked about the importance of 12 factors contributing to their treatment decision-making process. Diagnosis details and primary treatment received were abstracted from medical records and cancer registry data. Patients with lower income were diagnosed with more advanced disease (P < .01). Cure was deemed to be "very important" by more than 90% of patients at all income levels. However, patients with lower vs higher household income were more likely to rate factors beyond cure as "very important" such as cost (P < .01), effect on daily activities (P = .01), duration of treatment (P < .01), recovery time (P < .01), and burden on family and friends (P < .01). On multivariable analysis, high vs low income was associated with increased utilization of radical prostatectomy (odds ratio = 2.01, 95% confidence interval = 1.33 to 3.04; P < .01) and decreased use of radiotherapy (odds ratio = 0.48, 95% confidence interval = 0.31 to 0.75; P < .01). New insights from this study on the association between income and treatment decision-making priorities provide potential avenues for future interventions to reduce disparities in cancer care.

Poverty and relapse risk in children with acute lymphoblastic leukemia: a Children’s Oncology Group study AALL03N1 report

AbstractThe association between individual-level poverty and relapse in children receiving maintenance treatment for acute lymphoblastic leukemia (ALL) remains unclear. In a secondary analysis of COG-AALL03N1, we used data from US Census Bureau to categorize patients living below year-specific federal poverty thresholds, calculated using self-reported annual household income and size of household. Participants with federal poverty thresholds above 120% of their yearly household income were categorized as living in extreme poverty. Hazard of relapse was estimated using multivariable proportional subdistributional hazards regression for patients living in extreme poverty while receiving ALL maintenance therapy after adjusting for relevant predictors. Among 592 patients in this analysis, 12.3% of the patients were living in extreme poverty. After a median follow-up of 7.9 years, the cumulative incidence of relapse at 3 years from study enrollment among those living in extreme poverty was significantly higher (14.3%) than those not living in extreme poverty (7.6%). Multivariable analysis demonstrated that children living in extreme poverty had a 1.95-fold greater hazard of relapse than those not living in extreme poverty; this association was mitigated after the inclusion of race/ethnicity in the model, likely because of collinearity between race/ethnicity and poverty. A greater proportion of children living in extreme poverty were nonadherent to mercaptopurine (57.1% vs 40.9%); however, poor adherence did not completely explain the association between poverty and relapse risk. Future studies need to understand the mechanisms underlying the association between extreme poverty and relapse risk. This trial was registered at www.clinicaltrials.gov as #NCT00268528.

Neighborhood deprivation and residential property values do not affect weight loss at 1 or 3 years after bariatric surgery.

This study examined the association between individual- and neighborhood-level sociodemographic factors and surgical weight loss at 1 year (short term) and 3 years (long term). Data were obtained from the baseline survey of the BELONG (Bariatric Experience Long Term) prospective longitudinal cohort study. Individual-level self-reported data on sex, race and ethnicity, education, and household income were obtained by survey. Data from the 2010 US Census were used to calculate area Neighborhood Deprivation Index score and median value of owner-occupied housing units at the census tract level. Patients (N=1341) had a mean age of 43.4 (SD 11.3) years, were mostly female (86%), were mostly Black or Hispanic (52%), had some college education (83%), and had annual household incomes ≥$51,000 (55%). Percentage total weight loss was 25.8% (SD 9.0%) at year 1 and 22.2% (SD 10.5%) at year 3. Race and ethnicity and age were significant predictors of weight loss at 1 and 3 years with a small effect of self-reported household income at year 1. There were no significant associations between census tract-level Neighborhood Deprivation Index score or value of owner-occupied housing units and weight loss at either time point. Health systems could improve the chances of weight-loss maintenance after surgery by addressing factors related to racial and ethnic disparities and to income disparities.

Racial/Ethnic Disparities in Hemophilia-Related Distress

Introduction: Recently, a Hemophilia-Related Distress Questionnaire (HRDq) was validated (Kempton et al. Haemophilia 2021). Hemophilia-related distress has been shown to be higher among people with less education and those who were unemployed. However, differences in hemophilia-related distress according to race/ethnicity have not been previously described but are important to explore to identify potential health inequities. Objective: To examine Hemophilia-related distress according to race/ethnicity. Methods: This cross-sectional study was a planned secondary analysis of HRDq validation study data. Adults aged ≥18 years with Hemophilia A or B were recruited from one of two hemophilia treatment centers between July 2017 and December 2019 Only patients who spoke English were eligible for the study. The HRDq includes 24-questions across four domains: 1) hemophilia management, 2) financial concerns, 3) perceived self-efficacy, and 4) daily function. There were six responses for each question: (Never, A little bit, Sometimes, Often, Most of the Time, Always) scored from 0 to 5, respectively. Higher scores indicate increased hemophilia-related distress, with a total maximum summary score of 120. Race/ethnicity was self-reported, and patients were grouped as Hispanic, White (non-Hispanic) and Black. Total HRDq and domain-specific scores were compared with independent T and ANOVA tests. Unadjusted and multivariable linear regression models were used to examine potential mediators of race/ethnicity and HRDq scores. Multivariable linear regression models included race/ethnicity and one other variable (eg: severity) for model stability and to accommodate the study's relatively small sample size. Results: Among 149 participants enrolled in the study, 143 completed the HRDq and were included in analyses. Approximately, 17.5% of participants were Black, 9.1% were Hispanic and 72.0% were White. Most were male (82.5%) and had Hemophilia A (89.5%), and the average age was 36.7 years [standard deviation (SD)=14.7 years] (Table 1). Approximately 45.5% of participants had severe disease; these proportions were higher among Black (76.0%) and Hispanic (53.8%) participants than White participants (37.9%). Over a third of Black participants had an inhibitor, compared to none of Hispanic participants and <5% of White participants. Self-reported household income was significantly lower among Black compared to White participants. HRDq scores ranged from 2 to 83, with a mean of 35.1 SD= 16.5 and a median of 31. The average HRDq score was significantly higher among Black (mean=42.6 SD=20.6; p-value=.038) participants compared to White (mean=33.2, SD=14.9) participants (Table 1). There were no differences in Hispanic (mean=33.8, SD=16.7, p-value=.89) participants relative to White participants (Table 1). In domain analyses, financial concerns and daily function distress scores were significantly higher among Black than White participants (Table 1). When accounting for inhibitor status or severity, the significantly higher HRDq scores among Black relative to White participants remained (Table 2). However, after accounting for household income, there was no statistically significant difference in Black v White participants' overall HRDq scores (β=6.0 SD=3.7; p-value=0.10). Conclusions: Black participants reported higher hemophilia-related distress than White participants, with significantly greater daily functioning and financial concerns. Differences in household income mediated higher distress scores in Black compared to White participants, highlighting the critical need to better understand the impact of social determinants of health in persons with hemophilia. Further research on how racial/ethnic differences in hemophilia-related distress influence disease self-management and outcomes are needed. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Sex-Differences in Distress, Quality of Life, and Depression Among People with Hemophilia

Introduction: A recently validated hemophilia-distress questionnaire (HRDq) was developed to evaluate patients’ hemophilia-specific concerns. Distress is a multi-factorial and unpleasant experience that is associated with adverse health outcomes, and it can be independent of depression. Potential sex-differences in hemophilia-related distress as well as other aspects of mental and physical well-being have not been well described. Objective: To examine self-reported hemophilia-related distress, general distress, depression, quality of life, pain, and overall health according to sex. Methods: This cross-sectional study was a planned secondary analysis of HRDq validation study data. Adults aged ≥18 years with Hemophilia A or B who were recruited from one of two hemophilia treatment centers between July 2017 and December 2019 and agreed to participate. Those who did not complete HRDq were excluded (n=6) from the study. We used a validated hemophilia-related distress questionnaire (HRDq) that asks participants to rate their level of concern across four domains 1) hemophilia management; 2) financial concerns; 3) perceived self-efficacy; and 4) daily functioning. We also examined hemophilia-related quality of life (Haem-A-QoL) and general measures of QoL (EQ-5D-5L), distress (Kessler 6+; NCCN distress thermometer), mental health (PROMIS-29 and depression with PHQ9), physical health (PROMIS-29), and overall health (EQ-5D-5L VAS). Average scores according to sex were compared with independent T-tests. Unadjusted and multivariable linear regression models were used to examine potential mediators of sex and HRDq and other scores. Results: Among 149 participants enrolled in the study, 143 completed the HRDq and were included in analyses. Approximately 82.0% were male and 18.0% were female. Most participants had Hemophilia A (89.2%), and the average age was 35.1 years [standard deviation (SD)=14.7 years]. A higher proportion of men had Hemophilia A, severe disease, an inhibitor, target joint bleeds, HIV or HCV infection, and were treated with prophylaxis compared to women (Table 1). Self-reported education, household income, health insurance, financial rating, and age were similar. Total HRDq scores and domain specific scores were similar in men and women (Table 2). Haem-A-QoL scores were significantly lower (indicating better QoL), in females than males (B=-6.57, SE=3.28; p-value=.048), but after accounting for severity, these differences were no longer statistically significant. NCCN distress thermometer, PHQ-9 depression, PROMIS-29 anxiety, and fatigue scores were significantly higher in women than men. Approximately 32.0% of woman reported moderate or severe depression compared to 15.2% of men (p-value<.001). After accounting for severity and treatment, the elevated NCCN distress, PHQ-9 depression, PROMIS-29 anxiety, and fatigue scores among females remained. There were no differences between groups in general QoL, self-reported pain intensity, nor overall health. Conclusions: Hemophilia-related distress scores were similar in men and women, despite men having more severe disease and unfavorable clinical characteristics. Men had poorer Haem-A-QoL scores, which was accounted for by disease severity. However, general measures of distress and depression were higher among women with hemophilia compared to men, which is consistent with what is observed in the general population and among people with other chronic diseases. This study highlights the need for mental health services to be integrated into the care of women with hemophilia as well as the need for future research to better understand the impact of mental health on traditional bleeding outcomes. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Poverty during Maintenance and Relapse Risk in Children with Acute Lymphoblastic Leukemia (ALL): A Report from Children's Oncology Group Study (COG-AALL03N1)

Introduction: There is conflicting evidence regarding the association between poverty and survival in children with cancer. Most studies have relied on surrogate indicators of poverty, such as zip code-based median income for area of residence or on insurance status (Bona, PBC 2016; Kehm, Cancer 2019; Bona, JNCI 2021). We hypothesized that household poverty (measured at the individual level, using self-reported annual household income) during maintenance would be associated with a greater hazard of relapse among children with ALL. Methods: In this secondary analysis of COG-AALL03N1 (primary aim: adherence to oral mercaptopurine during maintenance), we examined the association between household poverty during maintenance and relapse risk in children with ALL. Eligibility for enrollment on AALL03N1 included (1) age <21y at ALL diagnosis; (2) receiving maintenance therapy in first remission. The current analysis was restricted to patients living in US who provided information on annual household income and the number of household members. We used national yearly median poverty thresholds provided by CDC; these take into account the annual household income and the size of family unit (i.e., number of adults and children <18y). For example, the annual income of a three-person household (two parents and one child [patient]) would need to be >$14,480 to be above the poverty threshold in the year 2002 (or >$21,831 in the year 2021). Among those below poverty threshold, we classified families with annual income under 120% federal threshold (median percent below poverty threshold for this cohort) as living in extreme poverty. Hazard of relapse from study enrollment during ALL maintenance therapy was estimated using proportional subdistribution hazard regression models, treating extreme poverty as the primary exposure and adjusting for age at study, sex, NCI risk group, blast cytogenetics, average 6MP and methotrexate dose intensity and time from start of maintenance to study entry. Results: We summarize sociodemographic and disease characteristics of 592 eligible patients in the Table. Median household income of the cohort was $35,000/year (range $10,000->$150,000). Overall, 73 (12.3%) patients met criteria for extreme poverty. Families living in extreme poverty were more likely to self-report their race/ethnicity as Hispanic or African-American and report parental education as high school (HS) or lower. Of note, clinical factors did not differ by poverty level. In a logistic regression, non-white race/ethnicity (odds ratio [OR]=7.9, 95%CI=2.4-26.1, P=0.007; reference: non-Hispanic white) and low parental education (≤HS: OR=4.2, 95%CI=2.4-7.4, P=<0.001; reference: college degree or higher) were associated with greater odds of living in extreme poverty. Cumulative incidence of relapse at 3y (Figure) from study entry among patients living in extreme poverty was higher compared to those without extreme poverty (14.3% [95%CI, 7-24] vs 7.6% [95%CI, 5-10], P=0.04). Patients living in extreme poverty had a 1.97-fold higher hazard of relapse compared to those not living in extreme poverty after adjusting for above mentioned covariates (95%CI=1.03-3.76, P=0.04). The reasons for the association between individual level poverty and relapse risk are likely multifactorial and possibly include poor adherence to oral chemotherapy. We found that patients living in extreme poverty had lower adherence to 6MP compared to those not living in extreme poverty (85.2±19.6% vs 90.6±14.8%, P=0.03). Conclusions: Extreme household poverty is associated with increased hazard of relapse in children receiving maintenance therapy for ALL compared to those living without extreme household poverty. Mechanisms investigating this association need to be explored in future studies. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Socioeconomic inequalities in toothbrushing behaviours in young children: a children's lifestyle survey in a representative population of A city, Okinawa prefecture, Japan.

We have less understanding of which socioeconomic status (SES) indicators may be reflective of latent socioeconomic inequalities in toothbrushing behaviours, especially finishing-toothbrushing by parents in young children. The aim of this study was to reveal the socioeconomic inequalities in children's toothbrushing and finishing-toothbrushing by parents and if it varies by SES indicators. We used data from 'Survey on Children's Life' conducted by A city of Okinawa Prefecture, Japan. The multiple imputed data of 902 (boys, 453) included self-reported children's toothbrushing behaviour and finishing-toothbrushing by parents in three-to six-year-old children. SES was assessed using self-reported household income and parental educational attainment. Absolute and relative inequalities in toothbrushing behaviours were quantified using the slope index of inequality (SII) and relative index of inequality (RII), respectively. There were significant absolute and relative inequalities of children's toothbrushing for household income (SII and RII were 0.241 and 2.73, respectively), of finishing-toothbrushing by parents for household income (SII and RII were 0.133 and 3.28, respectively), and educational attainment (SII and RII were 0.166 and 5.55, respectively). The same inequality trends were observed after adjusting for covariates (child's age and sex, family structure, breakfast and dinner frequency, and sleep duration). Socioeconomic inequalities in children's toothbrushing and finishing-toothbrushing by parents varied according to SES indicators.

Development and Validation of a Model to Predict the Contract Service of Family Doctor: A National Survey in China

BackgroundPrevious studies have reported a relatively low utilization of family doctor contract services (FDCS) in China, while the associated factors are unknown. The current study aimed to explore the factors associated with the utilization of FDCS, and then developed and validated a predictive model based on these identified factors.MethodsWe conducted a nationwide cross-sectional study using an online questionnaire, from March 2019 to April of 2019. Routinely collected variables in daily practice by family doctors were used to develop a derivation model to determine the factors associated with FDCS utilization, and then the external performance of the model was tested.ResultsA total of 115,717 and 49,593 participants were included in the development and validation datasets, respectively. Nearly 6.8% of the participants who signed a contract with FDCS received healthcare services from family doctors in China. Factors associated with the utilization of FDCS included age, male sex, self-reported household income, education attainment, insurance status, self-reported health status, smoking, drinking, self-reported physical activity status, chronic disease, walking distance from the nearest community center, and illness in the last 2 weeks, with an area under the receiver operating characteristic curve (AUC) of 0.660 [95% confidence interval (CI), 0.653–0.667] and good calibration. Application of this nomogram in the validation dataset also showed acceptable diagnostic value with an AUC of 0.659 (95% CI, 0.649–0.669) and good calibration.ConclusionTwelve easily obtainable factors in daily practice of family doctors were used to develop a model to predict the utilization of FDCS, with a moderate performance.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BackgroundSocial determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.MethodsIn this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.ResultsOne thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.ConclusionHigh community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

The impact of socioeconomic status on mental health and health-seeking behavior across race and ethnicity in a large multiple sclerosis cohort

BackgroundPsychiatric symptoms are common in multiple sclerosis (MS) and may contribute to worse MS outcomes. Previous studies suggest the burden of symptoms may vary by race, ethnicity and socioeconomic status (SES). Our objective was to expand upon this previous work and explore the associations between SES, race, and ethnicity, as predictors of psychiatric symptoms, mental health attitudes, and health-seeking behavior in patients with MS. MethodsPersons with MS answered a national web-based survey including demographic characteristics (including race, ethnicity and measures of SES), mental health attitudes, the Patient Health Questionnaire-9 (PHQ-9), the Generalized Anxiety Disorder 7-item (GAD-7) scale, the Modified Fatigue Impact Scale 5-item version (MFIS-5), and the Alcohol Use Disorders Identification Test (AUDIT). The survey also queried mental health availability and perceptions of care. We measured neighborhood-level SES (nSES) of each participant using the Agency for Healthcare Research and Quality (AHRQ) index that was calculated from 5-digit postal codes. Other indicators of participant-level SES included education level and self-reported household income. We assessed the association between race, ethnicity, and neighborhood/participant-level SES indicators and affective symptom burden using generalized linear models that were adjusted for age, sex, and MS characteristics. Results2095 participants answered the survey (mean AHRQ index 54.6 ± 5.4, age 51.3 ± 12.2 years, 7% Black/African American, 5.4% Hispanic/Latino, and 81.8% female). Those in the lowest quartile of nSES (most disadvantaged) were more likely to be either Black/African American or Hispanic/Latino as compared to those in highest quartile (least disadvantaged). Those in the lowest quartile of nSES had higher mean MFIS-5 (1.02 points; 95% CI: 0.39, 1.43), PHQ-9 (1.24 points; 95% CI: 0.49, 1.98), and GAD-7 (0.69 points; 95% CI: -0.01, 1.38) scores relative to those in the highest quartile. Of those who consumed alcohol (n = 1489), participants in the lowest AHRQ quartile had lower mean AUDIT scores (-0.73 points; 95% CI: -1.18, -0.29) as compared to those in higher quartiles. Race and ethnicity were not associated with self-reported psychiatric symptom burden in this cohort. SES was also associated with self-reported improvement of symptoms after receiving mental health care. A higher proportion of Black/African American (44.1% vs 30.2%, p = 0.003) and Hispanic/Latino (49.1% vs 30.6%, p<0.001) participants were more likely to report they would “definitely go” receive mental health care if services were co-located with their MS care as compared to white and Non-Hispanic/Latino participants, respectively. ConclusionHigher SES was associated with a lower burden of psychiatric symptoms and with a higher likelihood of self-reported symptom recovery after receiving mental health treatment. Attitudes regarding mental health care delivery in MS varied according to racial and ethnic background. Future longitudinal studies in more diverse populations should assess whether co-location of mental health services with MS care helps to reduce the gap between access and need of mental health care in MS.

Essay content and style are strongly related to household income and SAT scores: Evidence from 60,000 undergraduate applications.

There is substantial evidence of the relationship between household income and achievement on the standardized tests often required for college admissions, yet little comparable inquiry considers the essays typically required of applicants to selective U.S. colleges and universities. We used a corpus of 240,000 admission essays submitted by 60,000 applicants to the University of California in November 2016 to measure relationships between the content of admission essays, self-reported household income, and SAT scores. We quantified essay content using correlated topic modeling and essay style using Linguistic Inquiry and Word Count. We found that essay content and style had stronger correlations to self-reported household income than did SAT scores and that essays explained much of the variance in SAT scores. This analysis shows that essays encode similar information as the SAT and suggests that college admission protocols should attend to how social class is encoded in non-numerical components of applications.

Sex Differences in the Mediating Effects of Modifiable Risk Factors in Associations Between Socioeconomic Position and Cardiovascular Disease Morbidity and Mortality

Abstract Objectives Socioeconomic inequities in cardiovascular diseases (CVDs) are greater in females than males. However, the mechanisms underpinning the excess CVD risk conferred by low socioeconomic position (SEP) in females remain unclear. This study aimed to quantify the mediating effects of modifiable risk factors to associations between SEP and CVD morbidity and mortality. Methods We combined eight cycles of the nationally-representative cross-sectional Canadian Community Health Survey (2000–2011) to identify a cohort of adults (≥35 years) without CVD at the time of survey administration (n = 289,800). Survey data were linked to administrative health (Hospital Discharge Abstract Database) and mortality (Canadian Mortality Database) records for 2000–2012. SEP was captured by a latent variable consisting of self-reported educational level and household income. Self-reported modifiable risk factors, including smoking, physical inactivity, obesity, diabetes, and hypertension were considered as potential mediators. The outcome was CVD morbidity and mortality as reported in administrative health and mortality databases. Generalized structural equation modeling was used to estimate the mediating effects of modifiable risk factors in associations between SEP and CVD morbidity and mortality in males and females. Results The total effects of SEP on CVD morbidity and mortality were higher in females than in males. The modifiable risk factors mediated the higher proportion of the total effects in females than in males (87.80% vs 687.8%). Smoking was the most important mediator of associations between SEP and CVD morbidity and mortality for both males and females. The pathways linking SEP with obesity, diabetes and hypertension and subsequent CVD morbidity and mortality were significant in females but not among males. Conclusions These findings revealed evidence of some sex-specific patterns in the mediating effects of modifiable risk factors on associations between SEP and CVD morbidity and mortality. The findings suggest that different strategies may be required to reduce inequities in CVD in males and females. Funding Sources This study was funded by a Libin Cardiovascular Research Institute of Alberta Innovation Seed Grant and the Petro-Canada Young Innovator Award in Community Health.

The IDEAL household energy dataset, electricity, gas, contextual sensor data and survey data for 255 UK homes

The IDEAL household energy dataset described here comprises electricity, gas and contextual data from 255 UK homes over a 23-month period ending in June 2018, with a mean participation duration of 286 days. Sensors gathered 1-second electricity data, pulse-level gas data, 12-second temperature, humidity and light data for each room, and 12-second temperature data from boiler pipes for central heating and hot water. 39 homes also included plug-level monitoring of selected electrical appliances, real-power measurement of mains electricity and key sub-circuits, and more detailed temperature monitoring of gas- and heat-using equipment, including radiators and taps. Survey data included occupant demographics, values, attitudes and self-reported energy awareness, household income, energy tariffs, and building, room and appliance characteristics. Linked secondary data comprises weather and level of urbanisation. The data is provided in comma-separated format with a custom-built API to facilitate usage, and has been cleaned and documented. The data has a wide range of applications, including investigating energy demand patterns and drivers, modelling building performance, and undertaking Non-Intrusive Load Monitoring research.

Healthy eating: a privilege for the better-off?

Food subsidies for healthier foods and higher taxes for less healthy alternatives have been increasingly used to promote a healthy diet. Yet, some have argued that the fiscal burden on unhealthy products would fall disproportionately on the worse-off, raising equity concerns. This study estimates the association between income and the consumption of key food groups linked to the Mediterranean diet in the adult Portuguese population. We used data from the Portuguese National Food, Nutrition and Physical Activity Survey (IAN-AF 2015-2016), which observed the daily diet of individuals aged above 18 and below 79 years old (n = 3242). Logistic regression models were used to estimate the magnitude of the association between self-reported household income categories and consumption of foods related to the Mediterranean diet (fish, vegetables, fruits and legumes), and not (sweets, sugar-sweetened beverages, cakes & pastries and processed meats). Stratified analyses were performed by education and age categories. We observed that the intake of fish (35.8 vs 38.8 g p = 0.02), vegetables (146.7 vs 166.2 g p < 0.01), and fruits (119.8 vs 150.1 g p < 0.01) was positively related to income, with a clear gradient for the two latter. Yet, the positive income-consumption link for fish was only observed among low-educated people, and the one for legumes among high educated and youths. Conversely, the consumption of most non-Mediterranean foods was not positively related to income categories, with the exception of sweets (34.8 vs 31.8 g p = 0.01) and cakes (26.4 vs 21.4 g p < 0.01) (more prevalent among the better-off). The consumption of healthy food is mostly consistently related to income, contrary to the intake of unhealthy ones. It may well be, therefore, that subsidies to healthy foods could allow access to the worse-off while taxing unhealthy food will not impose a disproportionate burden on them.

Prevalence of and Factors Associated With Nurse Burnout in the US

Clinician burnout is a major risk to the health of the US. Nurses make up most of the health care workforce, and estimating nursing burnout and associated factors is vital for addressing the causes of burnout. To measure rates of nurse burnout and examine factors associated with leaving or considering leaving employment owing to burnout. This secondary analysis used cross-sectional survey data collected from April 30 to October 12, 2018, in the National Sample Survey of Registered Nurses in the US. All nurses who responded were included (N = 50 273). Data were analyzed from June 5 to October 1, 2020. Age, sex, race and ethnicity categorized by self-reported survey question, household income, and geographic region. Data were stratified by workplace setting, hours worked, and dominant function (direct patient care, other function, no dominant function) at work. The primary outcomes were the likelihood of leaving employment in the last year owing to burnout or considering leaving employment owing to burnout. The weighted sample of 50 273 respondents (representing 3 957 661 nurses nationally) was predominantly female (90.4%) and White (80.7%); the mean (SD) age was 48.7 (0.04) years. Among nurses who reported leaving their job in 2017 (n = 418 769), 31.5% reported burnout as a reason, with lower proportions of nurses reporting burnout in the West (16.6%) and higher proportions in the Southeast (30.0%). Compared with working less than 20 h/wk, nurses who worked more than 40 h/wk had a higher likelihood identifying burnout as a reason they left their job (odds ratio, 3.28; 95% CI, 1.61-6.67). Respondents who reported leaving or considering leaving their job owing to burnout reported a stressful work environment (68.6% and 59.5%, respectively) and inadequate staffing (63.0% and 60.9%, respectively). These findings suggest that burnout is a significant problem among US nurses who leave their job or consider leaving their job. Health systems should focus on implementing known strategies to alleviate burnout, including adequate nurse staffing and limiting the number of hours worked per shift.

Association Between Vulvar Squamous Intraepithelial Lesions and Psychiatric Illness.

The aims of the study were to describe and to compare demographics and the prevalence of psychiatric disorders among patients with low- and high-grade vulvar squamous intraepithelial lesions. A retrospective chart review was performed for patients presenting to a vulvar diseases clinic between 1996 and 2019 (N = 2,462). Intake questionnaire data were entered into a deidentified database. Results were compared between 80 patients with biopsy-confirmed high-grade squamous intraepithelial lesions (HSILs) and 48 patients with biopsy-confirmed low-grade squamous intraepithelial lesions (LSILs). Bivariate analysis was performed to compare demographics and psychiatric treatment and outcomes across HSIL and LSIL groups. Among 128 patients with vulvar disease, 80 (62.5%) had HSILs and 48 (37.5%) had LSILs. Patients with HSILs were significantly older (HSIL median [interquartile range] = 49.0 (39.0-61.0) vs LSIL = 36.0 [29.0-53.0], p = .006). There were no significant differences between groups across race/ethnicity, education, marital status, or self-reported household income categories. Forty percent of HSIL patients reported depression compared with 20.8% of LSIL patients (p = .03), whereas 31.3% of HSIL patients and 8.3% of LSIL patients reported anxiety (p = .002). Bipolar disorder was reported in 3.8% of HSIL patients and no LSIL patients (p = .29). There were no differences in the proportion of patients receiving psychiatric counseling, medications, or hospitalizations between groups. Squamous intraepithelial lesions of the vulva are associated with psychiatric disorders above age-matched national averages; these disorders are more prominent in the HSIL group. Combining mental health services with ongoing disease treatment seem to be part of a comprehensive approach to caring for this patient population.

Direct and indirect pathways between low income status and becoming a high-cost health care user in Ontario, Canada: a mediation analysis of health risk behaviors

PurposeWe investigated natural direct and indirect pathways between low-income status and high-cost user (HCU) transitions considering health risk behaviors as potential mediators. MethodsWe analyzed data from respondents (aged 18+) from four pooled cycles of the Canadian Community Health Survey (2005–2010/2011) linked to administrative data in Ontario, Canada. HCUs were defined as the top 5% of the population, ranked by cost consumption in any of the five years after survey interview. Low-income status was defined from the provincial distribution of self-reported household income, with missing values imputed from neighborhood-level data. In mediation analyses based on marginal structural models, we quantified the contributions of smoking, physical inactivity, alcohol consumption, and body mass index to income-HCU associations. Results115,091 respondents (representative of 9,661,764 Ontarians) were included in the study, of which 7.2% became HCUs. The odds of becoming HCUs were 1.36 times (95% CI: 1.25–1.48) greater for low (vs. high) income status respondents. Smoking, physical activity, alcohol consumption, and body mass index contributed 9.4%, 6.5%, 10.6%, and 4.4% to this association, respectively. Tests for exposure-mediator interactions were not statistically significant. ConclusionsHealth risk behaviors only partially explain income inequalities in future HCU transitions.