Social Gradient Research Articles

Social determinants of modifiable dementia risk in Māori and Non‐Māori: Results of the New Zealand Health, Work and Retirement study

AbstractBackgroundDementia risk varies along the social gradient, which needs to be considered in risk reduction and prevention strategies. Revealing links of social determinants of health (SDOH) and modifiable health and lifestyle factors for dementia holds clues towards maximizing dementia risk reduction opportunities, especially for vulnerable populations. Therefore, the aim was to investigate associations of SDOH and a dementia risk score in Indigenous Māori and Non‐Māori (mainly European descent) in midlife and early late‐life.MethodA subsample of the New Zealand Health, Work and Retirement study completed standardized face‐to‐face cognitive assessments (adapted ‘Kiwi’ Addenbrooke’s Cognitive Examination/ACE‐R) in 2010. We computed the Lifestyle for Brain Health (LIBRA) dementia risk score, comprising 8 risk factors (low/moderate alcohol consumption, heart disease, physical inactivity, chronic kidney disease, diabetes, smoking, hypertension, depression). Higher scores indicate higher dementia risk/poorer lifestyle (range = ‐1;+9.2). First, we assessed associations of LIBRA and cognition. Second, we performed adjusted regression analysis for area‐based (socioeconomic deprivation, health care access, neighborhood safety) and individual SDOH (education, employment status, net income, social loneliness) with LIBRA stratified for Māori and Non‐Māori.ResultsIn 918 participants (age: M = 62.9 years, SD = 6.7, range = 48‐75; females = 52.8%; Māori = 26.2%), a higher LIBRA score (M = 1.8, SD = 1.6, observed range = ‐1; +7.4) was associated with lower cognitive functioning (b = ‐0.30, 95%CI = [‐0.48;‐0.11], p = .002) and cognitive impairment (OR = 1.41, 95%CI = [1.10;1.81], p = .007), adjusted for age, sex, education, ethnicity and area‐based socio‐economic deprivation. Higher area‐based socio‐economic deprivation was associated with higher LIBRA in Māori (b = .10, 95%CI = [0.02;0.18], p = .020), but not in Non‐Māori (b = 0.01, 95%CI = [‐.03;0.05], p = .677). Employment status and lower neighborhood safety were associated with higher LIBRA in Non‐Māori only. Health care access difficulties and social loneliness were associated with higher LIBRA in both populations, while education and net income were not.ConclusionSODH are differentially associated with dementia risk in midlife and early late‐life New Zealanders. Area‐based socioeconomic deprivation was linked to dementia risk in Indigenous Māori, but not in Non‐Māori. This points to systematic inequities in dementia risk, which require equity‐focused policy‐based public health approaches to risk reduction.

A longitudinal study of perceived social position and health-related quality of life

BackgroundA large body of evidence suggests that there is a social gradient in the association between perceived social position and various health outcomes. Yet only a fraction of this research uses longitudinal data, and these studies usually rely on two data points in time, consider a single health outcome measure, overlook non-linear effects of perceived social position, and come almost exclusively from the Western welfare democracies. MethodsUsing data for 1921 individuals from three waves (2008, 2013, 2018) of the Polish Panel Survey (POLPAN), we fit between- and within-individuals hybrid-effects models with cluster-robust standard errors to investigate the association between one's perceived social position (self-placement on a socioeconomic hierarchy scale varying 1 to 10) and subsequent health-related quality of life (HRQoL) measured using the Nottingham Health Profile (NHP) and its six components. ResultsWe find that the association between perceived social position and health-related quality of life is larger when estimated between individuals than within individuals, yet in fixed- and hybrid-effects models perceived social position remains significantly and negatively linked with both the aggregated NHP measure as well as with its components such as emotional reaction, physical abilities, sleep, and social isolation. We also identify that starting to perceive oneself at the lower end of the social hierarchy is associated with a deteriorating health-related quality of life but a change at the top of the perceived social hierarchy is not linked with an improvement in NHP scores. ConclusionsWe provide new evidence on the significant and non-linear links between perceived social position and health-related quality of life and highlight possible pathways linking these two aspects of individuals’ lives.

Kinship and socio-economic status: Social gradients in frequencies of kin across the life course in Sweden

The influence of kin on various outcomes is heavily debated. However, kinship size itself conditions the probability of potential effects. Socio-economic gradients in the prevalence, variance, and types of kin are, therefore, a vital aspect of the functions of kin. Unfortunately, these parameters are largely unknown. We used Swedish register data to enumerate consanguine and in-law kin across the life course of the 1975 birth cohort. We calculated differences in kinship size between this cohort’s income quartiles and educational groups. We decomposed how specific kin relations, generations, and demographic behaviours contributed to these differences. Among low socio-economic status (SES) groups, higher fertility in earlier generations resulted in more kin compared with high-SES groups. Low-SES groups had more horizontal consanguine kin, while high-SES groups had more in-laws. Lower fertility and higher union instability among low-SES men substantially narrowed SES differences in kinship size. Kinship size varied substantially within SES groups.

Environmental inequality in industrial brownfields: Evidence from French municipalities

Recent research on environmental inequality has extended its focus from ongoing pollution to legacy pollution by examining the geography of industrial brownfields, defined as non-productive, contaminated land. This article is the first extensive brownfield analysis for a European country from an environmental inequality perspective, exploiting the political momentum in France where brownfield restoration has become a national priority. We combine data on over 7200 industrial brownfields from the 2022 geodatabase ‘Cartofriches’ with socio-economic variables at the municipality level. We demonstrate that communities with higher percentages of foreign-born and unemployed persons are disproportionately more likely to be located in proximity to brownfields. The social gradient increases significantly in communities that host more than two brownfields. There is an inverted U-shaped relationship with income, with a turning point at approximately 25,600 annually. These findings are robust across urban and rural areas, though with regional differences. Our analysis provides entry points for restorative environmental justice considerations and has important implications for Europe's just transition and cohesion policies.

Strong social disparities in access to IVF/ICSI despite free cost of treatment: a French population-based nationwide cohort study

BackgroundAccess to IVF/ICSI is facilitated when the financial barrier is removed. In a national context where in vitro fertilisation (IVF)/intracytoplasmic sperm Injection (ICSI) treatment is cost-free, how many women do not access IVF/ICSI and what are the factors associated with non-access?MethodsUsing French national health insurance databases, the cohort included 20,240 women aged 18–43 years living in France who underwent unsuccessful treatment (no pregnancy) with clomiphene citrate (CC) and/or gonadotropins with treatment started between January and August 2016. The outcome measure was non-access to IVF/ICSI during the 24-month following start of infertility care. Factors associated with non-access to IVF/ICSI were explored using mixed effects logistic regression.ResultsIn the cohort, 65.4% of women did not access IVF/ICSI. In multivariable analysis, non-access to IVF/ICSI was higher in younger women (18–25 years: (OR 2.17, 95% CI: 1.85–2.54) and in older women (40–43 years: (OR=3.60, 95% CI: 3.25–3.98)). Non-access was higher among women below the poverty line (OR=3.76, 95% CI: 3.34–4.23) and showed a significant upward trend with increasing deprivation of place of residence. Distance to the nearest fertility centre was not significantly associated with non-access to IVF/ICSI.ConclusionsIn a national context of cost-free ART treatment, a large proportion of women did not access treatment, with a strong social gradient that raises important issues. We need to understand the underlying social mechanisms to develop an efficient and equitable health policy regarding infertility care.

Social Gradient in Maternal Healthcare Utilization in Malawi: Analysis of Trends

Despite the tremendous efforts to achieve universal health coverage in Malawi, progress has been trivial hitherto. This study uses logistic regression analysis in the context of Andersen’s behavioral model of healthcare utilization to investigate the determinants of antenatal care (ANC), skilled provider-assisted delivery, and facility-based delivery services among women aged 15–49 years in a resource-constrained country—Malawi. Our primary novelty lies in the construction of concentration indices and concentration curves to explore the drivers of socioeconomic inequalities in the context of Andersen’s model. Data from the Malawi Demographic and Health Survey 2004, 2010, and 2015 were used. Our results indicate that predisposing, enabling, and need factors have heterogeneous effects on the utilization of these services. While analysis of the inequalities generally reveals a downward trend, the poor–rich gap in ANC utilization remains exceptionally high. Moreover, decomposition analysis shows that the socioeconomic inequalities are almost exclusively driven by enabling factors, characterizing the observed inequalities as “inequities.”

Non-participation in a health examination survey in a rural-provincial area of Denmark – results from the Lolland-Falster Health Study (LOFUS)

Background: Lolland-Falster Health Study (LOFUS) was a health examination survey that included self-administered questionnaires, clinical examinations, and the collection of biological samples, undertaken in 2016–2020 in a rural, socioeconomically deprived area with the lowest life expectancy in Denmark. The aim of this study was to examine the determinants of non-participation in LOFUS to evaluate the extent to which LOFUS data reflected the general population of the area. Methods: LOFUS invited randomly selected subjects together with their entire household. As determinants of non-participation, we analyzed age, sex, municipality of residency, citizenship, residency status, socioeconomic status, invitation type, and year of invitation. Relative risk regression was used to estimate the association between determinants and non-participation rate, mutually adjusted for other determinants. Results: In total, 53,313 subjects were invited of whom 18,949 (36%) participated. In the multivariable analysis, men had a 3% higher non-participation rate than women; subjects with citizenship other than Danish had a 3% higher non-participation rate than Danes. In-migrants had 6% higher non-participation than long-term residents. Compared with self-supported subjects aged 30–64, both publicly supported subjects of this age and younger and older subjects had higher non-participation rates: 16%, 16%, and 13%, respectively. Compared with self-supported, long-term residents, publicly supported in-migrants had 23% higher non-participation. Conclusions: Only about one third of subjects invited to LOFUS participated. Yet, this is a relatively high participation rate compared with other recent health examination surveys in Denmark. Furthermore, there was a relatively flat social gradient in the non-participation rate across the studied determinants.

Inequality and COVID-19 in Sweden: Relative risks of nine bad life events, by four social gradients, in pandemic vs. prepandemic years.

The COVID-19 pandemic struck societies directly and indirectly, not just challenging population health but disrupting many aspects of life. Different effects of the spreading virus-and the measures to fight it-are reported and discussed in different scientific fora, with hard-to-compare methods and metrics from different traditions. While the pandemic struck some groups more than others, it is difficult to assess the comprehensive impact on social inequalities. This paper gauges social inequalities using individual-level administrative data for Sweden's entire population. We describe and analyze the relative risks for different social groups in four dimensions-gender, education, income, and world region of birth-to experience three types of COVID-19 incidence, as well as six additional negative life outcomes that reflect general health, access to medical care, and economic strain. During the pandemic, the overall population faced severe morbidity and mortality from COVID-19 and saw higher all-cause mortality, income losses and unemployment risks, as well as reduced access to medical care. These burdens fell more heavily on individuals with low income or education and on immigrants. Although these vulnerable groups experienced larger absolute risks of suffering the direct and indirect consequences of the pandemic, the relative risks in pandemic years (2020 and 2021) were conspicuously similar to those in prepandemic years (2016 to 2019).

Reflecting on parental insights into healthy lifestyles: a qualitative study

BackgroundChildren living in the most deprived regions are more than twice as likely as their affluent peers to be obese. One way we can explain the social gradient of health (determined by relative position on the scale of social disadvantage or advantage) is by identifying the barriers and drivers to health that different groups of people experience. This study explored the understanding and perceptions of (and barriers and drivers to) a healthy lifestyle to investigate how commissioned services can better support residents to enable behaviour change in an area of high social deprivation. This community engagement activity was also conducted to inform commissioning decisions in children's public health services. MethodsWe used a qualitative study design with a semi-structured interview schedule. Four focus groups (5–8 participants, n=26) were conducted in an area of high deprivation in northwest England. Parents or carers were invited to attend anonymously by the Public Health Community Engagement Officer (in June 2022). The inclusion criteria were previous attendance on a weight management programme. Data were analysed using thematic analysis. Engagement activities do not require ethics approval. All participants provided written informed consent to take part. No further information was collected about personal characteristics. FindingsThe study participants demonstrated an awareness and understanding of factors affecting child and family health and health behaviours: healthy eating, exercise, mental health and emotional wellbeing, family values and attitudes towards a healthy lifestyle, cooking and budgeting, wider social connections, access to open spaces, availability of local activities, costs (including hidden costs), and structural barriers. InterpretationUsing the finding that participants recognise barriers and drivers to behaviour change beyond knowledge and skills, we reflect on why there was no take up for a commissioned intervention that aimed to address childhood obesity in the Lancashire area. These reflections inform arguments for an alternative model of service commission that relies less on established randomised trial evidence base and more on participatory codesign and a place-based approach (working with populations' existing knowledge and skills) and is particularly sensitive to people's own perception of the specific drivers and barriers they experience to behaviour change. Limitations include sampling from an area with low diversity and selection of participants who have previously agreed to uptake a weight management intervention. FundingNone.

Harnessing mobility data to capture changing work from home behaviours between censuses

AbstractThis paper provides an analysis of working from home patterns in England using data from the 2021 Census to understand (1) how patterns of working from home (WFH) in England have shifted since the COVID‐19 pandemic and (2) whether human mobility indicators, specifically Google Community Mobility Reports, provide a reliable proxy for WFH patterns recorded by the 2021 Census, providing a formal evaluation of the reliability of such datasets, whose applications have grown exponentially over the COVID‐19 pandemic. We find that WFH patterns recorded by the 2021 Census were unique compared with previous UK censuses, reflecting an unprecedented increase likely caused by persistent changes to employment during the COVID‐19 pandemic, with a clear social gradient emerging across the country. We also find that Google mobility in ‘Residential’ and ‘Workplace’ settings provides a reliable measurement of the distribution of WFH populations across Local Authorities, with varying uncertainties for mobility indicators collected in different settings. These findings provide insights into the utility of such datasets to support population research in intercensal periods, where shifts may be occurring, but can be difficult to quantify empirically.

Exploring health advice by dental professionals in USA: A secondary data analysis of NHANES (2015–2018)

ObjectivesTo examine socioeconomic and ethnic variations in the provision of health advice by dental professionals. MethodsData were from the National Health and Examination Survey (NHANES) (2015–2018). Socioeconomic position (Poverty-income ratio and education) and ethnicity were the main exposures. The outcome variable of interest was whether participants received health advice regarding the "benefits of quitting cigarettes," "benefits of monitoring blood sugar levels," and "importance of oral cancer screening". Logistic regression analysis was used to examine the relationship between socioeconomic factors/ethnicity, and health advice after adjusting for covariates. ResultsThe analysis included a total of 5524 people aged eighteen and above who had complete data. Black and Hispanic individuals had higher odds of receiving advice on smoking (OR = 1.49, 95% CI: 1.04–2.12 and OR = 1.48, 95% CI: 1.05–2.07, respectively) and glucose monitoring (OR = 3.00, 95% CI: 2.03–4.43 and OR = 3.14, 95% CI: 2.04–4.82, respectively), but no significant difference for cancer screening advice.Higher poverty-income ratios (PIR) were associated with lower odds of receiving smoking advice (OR = 0.91, 95% CI: 0.84–0.98), but no significant associations were observed for glucose monitoring or cancer screening advice. The study's findings reveal a social gradient in the provision of cancer advice, with individuals having higher education levels, particularly university education (OR = 1.69, 95% CI: 1.24–2.31), showing significantly higher odds of receiving cancer screening advice ConclusionThe study highlights significant variations in health advice provision in dental settings, with education level, ethnicity, and smoking status playing prominent roles, emphasizing the need for targeted interventions to promote equity and cultural competence in delivering health advice in dental settings. Practice implicationThe results emphasize the importance of strong policies and ongoing education for dental professionals to ensure optimal treatment and prevention.

Social gradient in quality of life according to microscale neighbourhood features, Limassol, Cyprus

Abstract Background Beyond indices of socio-economic disadvantage (SED), not standard practice in Cyprus, neighbourhood audits provide information about environmental inequity not captured by other methods. Lack of spatial thinking often leads to attributing geographical differences to socio-demographic composition. Methods A random sample of 45 neighbourhoods along the SED continuum were audited using the Cyprus Neighborhood Observational Tool (CyNOTes). SED was defined according to a purposefully developed postcode level index (N = 124), by factor analyzing a set of census indicators. A sample of 10 residents aged 45-64 per neighborhood responded to a door-to-door SF-36 quality of life (QoL) survey (N = 450). Associations of QoL with SED and audit scores, organized in 9 domains, were explored in random-effect regression models adjusting for gender, age, education and income. Results The SED index captured a stepwise decrease across tertiles with increasing disadvantage in both Physical (-1.79 95% CI -2.84, -0.73; p < 0.001) and Mental (-1.42 95%CI -2.46, -0.59; p = 0.008) SF-36 Component Scores. Associations attenuated but remained statistically significant after adjusting for person-based social position. Re-classifying neighbourhoods according to audit ratings also revealed a social gradient for most CyNOTes domains. The domain with the strongest association with both Physical (-1.84 95%CI -2.88, -0.80; p < 0.001) and Mental SF-36 Scores (-1.88 95%CI -2.83, -0.93; p < 0.001) was “Pedestrian and Cycling Environment”. Associations persisted in adjusted models and appeared similar, if not stronger, to associations with the SED index. Conclusions The study depicted the social gradient in quality of life among late working-life residents across Limassol neighbourhoods. Other than the expected patterning according to SED, audit indicators of environmental inequity also captured a social gradient, linking micro-scale neighborhood features to the residents’ quality of life. Key messages • A social gradient in quality of life was demonstrated along the socio-economic and environmental disadvantage in Limassol. • Depicting neighborhood microenvironment inequity can trigger and contextualize conversations about health and place among the local Public Health research and policy community.

The social gradient in adolescent mental health problems and the role of physical activity

Abstract Background In Sweden, the share of 13 and 15-year-old students reporting ≥ 2 psychosomatic symptoms (PSS) more than once a week doubled between 1985/1986 and 2017/2018, during which there were increases in both income inequalities and adolescents with insufficient physical activity (PA). PA during non-school time has been shown to be negatively associated with stress and PSS among adolescents. We aimed to explore whether there is a socioeconomic status (SES)-related gradient in adolescent mental health problems, and if so, whether non-school sedentary time (SED) and PA mediate this social gradient. Methods We used data from STARS, a prospective and observational cohort study of 2283 7th grade students in Västra Götaland, Sweden. A total of 1235 participants (mean age 13.6±0.394 years, 59% females) returned with valid accelerometer data (≥ 10 hours per day for ≥ 4 days), answered questionnaires regarding stress and PSS, and had parents’ earned income registry data. Ordinary least square for linear regressions and bootstrapping for mediation analysis were used with 95% CI, repeated for males and females separately. Results We found that higher income was associated (α = 5%) with less stress (-0.1108, p ≤ 0.001 and PSS (-0.1315, p ≤ 0.001). For stress, we found that non-school PA partly mediated this association. This was true for light PA (LPA) (-0.0040, [-0.0093-0.0003]), moderate to vigorous PA (MVPA) (-0.0077, [-0.0152-0.0023]) and vigorous PA (VPA) (-0.0090, [-0.0166, -0.0031]). When separated by sex, mediation via PA was found only in females. For PSS, mediation effect was found for MVPA (-0.0071, [-0.0137, -0.0018]) and VPA (-0.0103, [-0.0182, -0.0039]), but not when separated by sex. Conclusions There is a social gradient in both stress and psychosomatic symptoms among adolescents, mediated by physical activity although to a relatively small part. This shows the relevance to inform policy on the need to enable extracurricular sports activities for adolescents. Key messages • Physical activity partly explains the social gradient in adolescent mental health. • Supporting extracurricular sports activities may help to reduce the social gradient in adolescent mental health.

Measuring Digital Health Literacy in Europe – Scope, determinants and consequences

Abstract Background Increasing access to health-related digital information/resources of varied quality warrants sufficient Digital Health Literacy (DHL) in the population. Public health researchers, practitioners, and policy makers need to consider DHL for improving people's ability to use digital resources. The M-POHL HLS19 study objectives were to construct and validate a DHL measure, and identify its determinants and consequences. Methods A scale was constructed with 8 items on dealing with digital health resources. Two additional items examined interactive use of resources. The scale was applied among a sample of 29,060 respondents in 13 countries using CAPI, CATI, CAWI, PAPI and mixed methods. A standardized score was calculated for DHL, range: 0-100. Results Appraising the reliability of digital resources was perceived particularly difficult. The scale showed acceptable reliability (Cronbach's α 0.7-0.87/country). A confirmatory factor model loading onto a single latent variable indicated an acceptable fit for all countries. The DHL scale was sufficiently unidimensional based on principal component analysis of Rasch model residuals combined with dependent t-tests. Linear regression models with 5 DHL predictors showed a social gradient with explained variance of 6% (2-23%/country). The highest predictor was financial deprivation: ß=−0.15 (0.08--0.27), then age: ß=−0.13 (0.15--0.26); self-assessed social status: ß=0.08 (0.05-0.13). General health literacy was a strong predictor: ß=0.51 (0.43-0.67). In linear regressions to explain variance in self-assessed health, the DHL coefficient was significantly different from zero in 9 countries (ß=−0.05-0.10). Conclusions The new DHL scale had acceptable psychometric properties. The relevance of DHL is reflected in the high proportions with lower DHL, a social gradient, and health consequences in most countries. The study offers an evidence base for tailoring DHL intervention strategies and organizational health literacy policy. Key messages • Digital Health Literacy of populations in Europe was estimated through a validated measure with associations that predict public health and healthcare consequences in most countries. • Public health practitioners and policy makers should be aware of populations with lower Digital Health Literacy (DHL), and both promote DHL while also adjusting interventions/services to DHL needs.

Socioeconomic inequalities in COVID-19 - An analysis of health insurance data

Abstract Background Evidence on socioeconomic inequalities in COVID-19 outcomes largely rests on ecological studies. Only few studies investigated inequalities in different COVID-19 outcomes prospectively on an individual level. We therefore conducted an analysis of German health insurance data to assess socioeconomic inequalities in COVID-19 incidence and hospitalizations within a cohort of insured individuals. Methods We used data of 3.17 million working-aged individuals (18 to 67 years) from various statutory health insurances in Germany. Educational level and occupational position were used as measures of socioeconomic position (SEP). We calculated directly age-standardized incidence rates per 1000 person-weeks (IR) and incidence rate ratios (IRR) among the sample population for COVID-19 incidence and COVID-19 hospitalizations for each exposure during the first four pandemic waves (01.01.2020-31.12.2021). Results Age-standardized IR and IRR of COVID-19 incidence and hospitalizations showed social gradients with higher rates in socioeconomically more disadvantaged groups. Incidence risk was higher among those in a low occupational position (IRR low vs. high: 1.29, 95% CI 1.27-1.31) and with a low level of education (IRR low vs. high: 1.36, 95% CI 1.34-1.38). Inequalities in COVID-19 hospitalizations were more pronounced with an IRR for low vs. high occupational position of 2.29 (95% CI 2.10-2.50) and an IRR for low vs. high level of education of 1.86 (95% CI 1.72-2.03). Conclusions We found socioeconomic inequalities in COVID-19 by education and occupational position, with inequalities in hospitalizations being more pronounced than those in incidence risk. These results show a high potential of prevention to improve population health and health equity in pandemics with novel respiratory pathogens. Further research on the underlying mechanisms of these inequalities in COVID-19 is needed. Key messages • Socioeconomically more disadvantaged individuals have a higher risk of COVID-19 and a severe disease progression. • These inequalities should be addressed in future pandemic preparedness planning in order to minimize the unequal health impacts of pandemics with new emerging diseases.

Impact of child poverty and adversity on perceived family support in adolescence

Abstract Background Emotional support from family members may have an important effect on adolescent health outcomes, and has been identified as a target for policy to protect against the impacts of poverty and adversity. However, few studies have assessed the extent to which poverty and adversity themselves influence the nature of emotional support that parents can provide to adolescents. We therefore aimed to investigate the impact of trajectories of poverty and family adversities on young people's relationships with their families and perceived emotional support received. Methods We analysed longitudinal data on 10976 children from the nationally representative UK Millennium Cohort Study. Exposure trajectories of poverty and family adversities were characterised using group-based multi-trajectory models. The outcomes were perceived emotional support and quality of family relationships, measured by the three-item Short Social Provisions Scale (SPS-3) and levels of parent-adolescent closeness and conflict, measured at age 14. ORs and 95% CIs were estimated using multivariable logistic regression models. Results At age 14 the overall prevalence of low perceived emotional support was 13%. Children of mothers with lower socioeconomic status (SES) were more likely to report low emotional support, with a clear social gradient. Compared with children exposed to low levels of poverty and adversity, children in the persistent adversity trajectory groups experienced higher odds of low emotional support and low-quality parent-adolescent relationship; those exposed to both persistent poverty and poor parental mental health were particularly at increased risk of experiencing poor family relationships and low perceived emotional support (aOR 2·2; 95% CI 1·7- 2·9). Conclusions Policies to improve levels of family support for UK adolescents should focus on improving modifiable determinants such as child poverty and family mental health. Key messages • Children of parents with lower socioeconomic status are more likely to experience low perceived emotional support in adolescence. • Children who experience persistent poverty and poor parental mental health are at increased risk of poor family relationships and low perceived emotional support in adolescence.

Barriers to and facilitators of human papillomavirus vaccination in an ethnically diverse group of migrant parents: A qualitative mixed methods study

ABSTRACT A disparity in the uptake of the Human papillomavirus vaccine (HPVV) among immigrants and refugees leads to a social gradient in health. Recognizing that immigrants and refugees may encounter unique barriers to accessing prevention and care, this study seeks to determine barriers to and facilitators of HPVV among these subgroups to uncover high-resolution quality improvement targets of investment for under-immunized pockets of the population. The study undertook a qualitative inquiry into understanding immigrant and refugee parents’ perspectives on HPV infection and HPVV experience through school-based programs. We collected data first through short online surveys (N = 15) followed by one-on-one interviews (N = 15) and then through detailed online surveys (N = 16) followed by focus group discussions (N = 3) with 4–6 participants per group discussion from different groups: Black, South Asian and West Asian. Analysis of surveys and interviews identified that: information, awareness, and education about HPV infection and HPVV were among the most cited barriers that impede the uptake of HPVV. Moreover, vaccine-related logistics were equally important, including not having immunization information packages in different languages and relying solely on the child to bring home packages in paper copies from school-based vaccine programs. A multi-component intervention remains instrumental in enhancing HPV immunization rates, given the inconsistent uptake of HPVV by these subgroups who voice unique barriers and facilitators. An educational campaign that involves educating parents who consent for their child(ren) for HPVV, the children receiving the vaccination, and training staff providing HPVV through school-based immunization programs would be paramount.

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

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

Covid and the coalfield: Covid-19 vaccine hesitance in Wales and Appalachia

BackgroundVaccine hesitancy is a barrier to Covid-19 vaccine uptake and displays a social gradient, compounding health disparities. While social gradients are a vital concept in health, they flatten distinctions between types of disadvantaged community. This paper focuses on vaccine hesitance in post-industrial and de-industrialising coalfields. The social consequences of the decline of coal mining may present barriers to vaccine uptake. MethodsWe ran parallel surveys in Wales (N = 4187) and US states overlapping with central Appalachia (N = 4864), to examine whether vaccine attitudes and uptake varied between areas with different coal mining histories. These surveys were accompanied by qualitative interviews of 36 residents of these coalfields to explore vaccination decisions and triangulate with survey data. ResultsFactor analysis identified four axes of attitudes in the survey data: vaccine confidence, covid scepticism, vaccine individualism, and concerned confusion. These themes were echoed in the interviews. Vaccine confidence was lower; and covid scepticism, vaccine individualism, and concerned confusion higher, in residents of areas of Wales with greater mining extent and where pits closed during certain periods. Residents of former US coal counties had lower vaccine confidence and higher covid scepticism, while those in current coal counties had greater vaccine individualism and concerned confusion. In former US coal counties and Welsh areas where pits closed since 1980, vaccine uptake was lower. Differences could not be explained by respondents’ income and education. In the interviews, norms of social solidarity were often invoked by vaccinated respondents, while unvaccinated respondents did not frame decisions in the context of the industrial history of their areas. DiscussionThe legacy of coal-mining's decline presents barriers to public health campaigns. We show evidence of this across two historically significant coalfields. Attention is needed to avert negative public health consequences of global energy transition.

Assessing perceived and functional health literacy among parents in Cyprus: A cross-sectional study.

Parents often must take decisions regarding their children's health, which requires certain skills and competences. Parental health literacy (HL) is important in establishing positive health-promoting behaviours and better health outcomes to their children. Limited parental HL has been associated with various negative children's health outcomes. The aim of the study was to explore perceived and functional HL among parents in Cyprus. A cross-sectional study was conducted with a convenience sample of 416 parents of children, aged 6 months to 15 years old, presenting in pediatric outpatient departments across three Cypriot cities. Participants completed the HLS-EU-Q47, a self-reported measure of HL, and the NVS (Newest Vital Sign), a performance-based measure of HL. Associations with socio-demographic characteristics and health behaviors were explored. Based on suggested ranges, among 416 parents, mostly mothers (83.2%), almost half of parents (42.6%) were classified as having inadequate or problematic perceived HL. Consistently, 62.8% showed high likelihood or significant possibility of limited functional HL, based on the NVS with a mean score of 2.73 out of 6 (SD = 2.02). Nevertheless, no correlation was observed between the two measures of HL. Limited parental perceived HL was statistically significantly associated with lower educational attainment, lower number of children in the family, increased self-assessed health status, and limited exercise habits. Limited parental functional HL was statistically significantly associated with female gender, younger age, lower educational attainment, receiving financial aid, lower family income, and lower alcohol consumption. Even though there was lack of agreement in the classification according to the HLS-EU-Q47 and the NVS, moderate-to-low levels of perceived HL appear consistent with a performance-based measure of HL. As a high number of parents may face challenges in assessing and applying health information to improve outcomes for their children, with evidence of social gradient, healthcare services should be oriented towards identifying problematic HL while Public Health interventions are needed to enhance parental HL.