Socioeconomic Gradients In Health Research Articles

An estimate of the longitudinal pace of aging from a single brain scan predicts dementia conversion, morbidity, and mortality.

To understand how aging affects functional decline and increases disease risk, it is necessary to develop accurate and reliable measures of how fast a person is aging. Epigenetic clocks measure aging but require DNA methylation data, which many studies lack. Using data from the Dunedin Study, we introduce an accurate and reliable measure for the rate of longitudinal aging derived from cross-sectional brain MRI: the Dunedin Pace of Aging Calculated from NeuroImaging or DunedinPACNI. Exporting this measure to the Alzheimer's Disease Neuroimaging Initiative and UK Biobank neuroimaging datasets revealed that faster DunedinPACNI predicted participants' cognitive impairment, accelerated brain atrophy, and conversion to diagnosed dementia. Underscoring close links between longitudinal aging of the body and brain, faster DunedinPACNI also predicted physical frailty, poor health, future chronic diseases, and mortality in older adults. Furthermore, DunedinPACNI followed the expected socioeconomic health gradient. When compared to brain age gap, an existing MRI aging biomarker, DunedinPACNI was similarly or more strongly related to clinical outcomes. DunedinPACNI is a "next generation" MRI measure that will be made publicly available to the research community to help accelerate aging research and evaluate the effectiveness of dementia prevention and anti-aging strategies.

Better off by risk adjustment? Socioeconomic disparities in care utilization in Sweden following a payment reform

AbstractReducing socioeconomic health inequalities is a key goal of most health systems. A challenge in this regard is that healthcare providers may have incentives to avoid or undertreat patients who are relatively costly to treat. Due to the socioeconomic gradient in health, individuals with low socioeconomic status (SES) are especially likely to be negatively affected by such attempts. To counter these incentives, payments are often risk adjusted based on patient characteristics. However, empirical evidence is lacking on how, or if, risk adjustment affects care utilization. We examine if a novel risk adjustment model in primary care affected socioeconomic differences in care utilization among individuals with a chronic condition. The new risk adjustment model implied that the capitation—the monthly reimbursement paid by the health authority to care providers for each enrolled patient—increased substantially for chronically ill low‐SES patients. Yet, we do not find any robust evidence that their access to primary care improved relative to patients with high SES, and we find no effects on adverse health events (hospitalizations). These results suggest that the new risk adjustment model did not reduce existing health inequalities, indicating the need for more targeted incentives and interventions to reach low‐SES groups.

Health shocks, health and labor market dynamics, and the socioeconomic-health gradient in older Singaporeans

Health disparities by socioeconomic status (SES) are potentially shaped by how an individual's health status and work capacity are affected by the incidence of illness, and how these effects vary across SES groups. We examine the impact of illness on the dynamics of health status, work activity and income in older Singaporeans to gain new insights on how ill health shapes the socioeconomic health gradient. Our data comprise of 60 monthly waves (2015–2019) of panel survey data containing 445,464 person-observations from 11,827 unique respondents from Singapore. We apply a matched event-study difference-in-differences research design to track how older adults' health and work changes following the diagnosis of heart disease and cancer. Our focus is how the dynamics of health and work differ for different SES groups, which we measure by post-secondary education attainment. We find that the dynamics of how self-assessed health recovers following the diagnosis of a new heart disease or cancer do not vary significantly across SES groups. Work activity however varies significantly, with less well-educated males and females being significantly less likely to be in active employment and have income from work, and are marginally more likely to be in retirement following the onset of ill health. By contrast, more well-educated males work more, and earn more a year after the health shock than they did before they fell ill. Occupational differences likely played a role in how work activity of less well-educated men decline more after an acute health event compared with more well-educated men. Understanding the drivers of the socioeconomic health gradient necessitates a focus on individual-level factors, as well as system-level influences, that affect health and work.

Childhood neighborhoods and cause-specific adult mortality in Sweden 1939–2015

The socioeconomic health gradient has widened in recent decades. We study how childhood socioeconomic neighborhood conditions influence gender- and cause-specific adult mortality. Using uniquely detailed geocoded longitudinal microdata for a Swedish town (1939–1967), with a follow-up in national registers (1968–2015), we apply Cox proportional hazards models and estimate individual neighborhoods at the address-level. We find that childhood neighborhood social class has a lasting influence on male adult mortality (ages 40–69), even when adjusting for class position, class origin, neighborhood physical attributes and school districts. This impact was particularly pronounced for preventable causes of death, pointing to lifestyle and behavioral factors as important mechanisms.

Can Wealth Buy Health? A Model of Pecuniary and Non-Pecuniary Investments in Health

Abstract In this paper, we develop a life cycle model that features pecuniary and non-pecuniary investments in health in order to rationalize the socioeconomic gradients in health and life expectancy in the United States. Agents accumulate health capital, which affects labor productivity, utility, the distribution of medical spending shocks, and life expectancy. We find that unequal health insurance coverage plays a negligible role in generating the observed gaps in health and longevity. Universal health insurance increases preventive medical spending but not time spent in health promoting activities, as individuals are no longer worried about avoiding high curative medical expenditure shocks due to increased health insurance coverage. Our findings suggest that differences in lifetime income, preferences, and health shocks are the main determinants of inequality in life expectancy.

A qualitative study of perceptions of control over potential causes of death and the sources of information that inform perceptions of risk

ABSTRACT Background Investigating perceptions of control over mortality risk may be fundamental to understanding health behaviours and tackling socioeconomic gradients in health. Few studies have explored perceptions of control over different causes of death and there is a lack of qualitative risk research. Our aim was to examine participants’ perceptions of control over potential causes of death and the sources that inform perceptions of risk. Method We conducted semi-structured interviews with 24 participants (14 female and 10 male) and conducted a template analysis to analyse the transcripts. Findings We identified six themes to represent participants’ perceptions of control over potential mortality risks and the sources that inform these perceptions: Health-Related Mortality Risks, External Causes of Risk, Finding Balance, Family Medical History, Online Sources of Risk and Health-Related Information, and Health Misinformation. Dying from heart disease was broadly reported as being a controllable risk, whereas cancer was mostly discussed as uncontrollable. Gender-specific cancers were perceived as posing a significant risk to life, however controlling this risk was discussed in terms of screening and treatment, not prevention. Family medical history was discussed as an informative source for longevity predictions, but less so for specific causes of death. Most risk information is retrieved from ‘Dr Google’, though trusted sources, such as NHS websites, are used for validation. Health misinformation online was seen as a problem experienced by other people, rather than the individual. Conclusions Causal pathways between behaviours and specific cancers may not be obvious to individuals. Messages emphasising the broader links between diet, alcohol and general cancer risk may highlight the controllability of cancer risk through improved health behaviours. Furthermore, given the rise in health misinformation, and the belief that it is other people not ourselves that are typically susceptible to believing misinformation online, further attempts are needed to combat this growing ‘infodemic’.

A comparison of health and socioeconomic gradients in health between the United States and Canada

Data from the early 2000s indicated worse overall health and larger socioeconomic (SES) health inequalities in the U.S. than in Canada. Yet, sociopolitical contexts, health levels, and SES-health inequalities have changed in both countries during the intervening two decades. Drawing on new data, we update the comparison of health levels and SES-health gradients between the two countries.Analyses, focused on self-rated health, are based on two complementary sets of data sources: Resilience and Recovery (RR) data, a harmonized U.S.-Canada survey of social conditions collected in 2020 (N = 3743); and a pair of leading nationally representative health data sources from each country: the National Health Interview Surveys (NHIS, N = 104,027) and the Canadian Community Health Survey (CCHS, N = 97,605), both collected in 2017–2018. Health levels and disparities, net of demographic and socioeconomic covariates, were estimated using modified Poisson models for relative comparisons; descriptives and predicted levels of fair/poor health show the comparisons from absolute perspective.Both data sources show that U.S. adults continue to have significantly worse health than Canadians; the disadvantage may be due to SES differences between the two populations. However, the two data sources yield conflicting findings on SES-health inequalities: the RR data indicate no difference between the two countries in socioeconomic health gradients, while the NHIS/CCHS data show a significantly steeper gradient in the U.S. than in Canada for both education and income.Canadian adults continue to report better health than their U.S. peers, but it is unclear whether health inequalities remain smaller as well. We discuss potential reasons for the conflicting findings and call for a large new cross-national data collection, which will enable scholars and policymakers to better understand health and wellbeing in the U.S. and Canadian contexts.

Diminished Returns in Europe: Socioeconomic Status and Ethno-Racial Health Disparities Across 30 Countries in the European Social Survey.

Ethnic and racial minorities in many countries experience worse relative health outcomes and earlier mortality compared to national averages or outcomes of the majority population. Although socioeconomic status often contributes to a portion of ethno-racial health disparities, there are many unanswered questions about the relationship between socioeconomic status and ethno-racial health disparities across contexts. Recent scholarship in the USA has found support for a "diminished returns" effect in which the socioeconomic health gradient is systematically smaller for marginalized groups, yet it is unclear whether this pattern exists in other national contexts. This study tests the interaction between socioeconomic status and ethno-racial minority status in 30 countries across six waves of the European Social Survey. The results include evidence of the diminished returns pattern, particularly for populations with origins in Sub-Saharan Africa and the Middle East. Multilevel mixed-effects models find variation across countries in the interaction between socioeconomic status and ethno-racial minority status. The findings suggest racism and socioeconomic status interact to affect health and health disparities in multiple contexts and highlight the importance of cross-national comparison to further understand variation across countries.

A decade of socioeconomic inequality in type 2 diabetes area-level prevalence: an unshakeable status quo?

It is well known that there is a socioeconomic gradient in the prevalence of many chronic diseases, including type 2 diabetes (T2DM). We present a simple assessment of the macro-level association between area socioeconomic disadvantage and the area-level prevalence of T2DM in Danish municipalities and the development in this relationship over the last decade. We used readily available public data on the socioeconomic composition of municipalities and T2DM prevalence to illustrate this association and report the absolute and relative summary measures of socioeconomic inequality over the time period 2008-2018. The results show a persistent relationship between municipality socioeconomic disadvantage and T2DM prevalence across all analyses, with a modelled gap in T2DM prevalence between the most and least disadvantaged municipalities, the slope index of inequality, of 1.23 [0.97;1.49] in 2018. These results may be used to indicate areas with specific needs, to encourage systematic monitoring of socioeconomic gradients in health, and to provide a descriptive backdrop for a discussion of how to tackle these socioeconomic and geographic inequalities, which seem to persist even in the context of the comprehensive welfare systems in Scandinavia.

Aging into disadvantage: Disability crossover among Mexican immigrants in America

The “Hispanic paradox” refers to the accepted finding that Mexican immigrants have lower mortality compared to the US-born population, despite having lower levels of income, educational attainment, and health insurance coverage. However, Mexican immigrants' mortality advantage is not matched by lower disability rates, particularly later in the life course. Past studies have identified a crossover in disability rates for Mexican immigrants using age-specific disability rates but confound the effects of aging and duration of residence. By using the synthetic cohort method, I extend prior work on the disability crossover by tracing immigrant cohorts across the life course and disentangling newly arrived immigrants from those already established in the U.S. I use American Community Survey (ACS) 2015–2019 data to test whether the acculturation or cumulative disadvantage hypotheses account for the disability crossover. I find that, contrary to the expected finding of a socioeconomic health gradient in disability rates, Mexican immigrants' high disability rates converge regardless of education level or immigrant cohort. In addition, Mexican female immigrants are doubly disadvantaged, living in a protracted period of disability compared to males of the same education level. My findings support the negative health acculturation hypothesis as the dominant pathway for Mexican immigrants’ later-life disability trajectories and consequently the explanation behind the disability crossover.

Using Latent Class Analysis to Explore Complex Associations Between Socioeconomic Status and Adolescent Health and Well-Being

PurposeResearch demonstrates a strong socioeconomic gradient in health and well-being. However, many studies rely on unidimensional measures of socioeconomic status (SES) (e.g. educational qualifications, household income), and there is often a more limited consideration of how facets of SES combine to impact well-being. This paper develops a multidimensional measure of SES, drawing on family and school-level factors, to provide more nuanced understandings of socioeconomic patterns in adolescent substance use and mental well-being. MethodsData from the Student Health and Wellbeing Survey from Wales, UK was employed. The sample compromised 22,372 students and we used latent class analysis to identify distinct groups using three measures of SES. These classes were then used to estimate mental well-being, internalizing symptoms, and substance use. ResultsThe five-class solution offered the best fit. Findings indicated distinct classes of families as follows: “nonworking,” “deprived working families,” “affluent families in deprived schools,” “lower affluence,” and “higher affluence.” There was a clear relationship among the classes and mental well-being, internalizing symptoms, smoking, and cannabis use; alcohol was the exception to this. ConclusionsThe identification of these classes led to a fuller understanding of the health and well-being effects of SES, showing clearer patterning in health behaviors that often is not captured in research. The implications for adolescent health and well-being are discussed, including considerations for future research.

The Socioeconomic Gradient in Epigenetic Ageing Clocks: Evidence from the Multi-Ethnic Study of Atherosclerosis and the Health and Retirement Study

ABSTRACT Epigenetic clocks have been widely used to predict disease risk in multiple tissues or cells. Their success as a measure of biological ageing has prompted research on the connection between epigenetic pathways of ageing and the socioeconomic gradient in health and mortality. However, studies examining social correlates of epigenetic ageing have yielded inconsistent results. We conducted a comprehensive, comparative analysis of associations between various dimensions of socioeconomic status (SES) (education, income, wealth, occupation, neighbourhood environment, and childhood SES) and eight epigenetic clocks in two well-powered US ageing studies: The Multi-Ethnic Study of Atherosclerosis (MESA) (n = 1,211) and the Health and Retirement Study (HRS) (n = 4,018). In both studies, we found robust associations between SES measures in adulthood and the GrimAge and DunedinPoAm clocks (Bonferroni-corrected p-value < 0.01). In the HRS, significant associations with the Levine and Yang clocks were also evident. These associations were only partially mediated by smoking, alcohol consumption, and obesity, which suggests that differences in health behaviours alone cannot explain the SES gradient in epigenetic ageing in older adults. Further analyses revealed concurrent associations between polygenic risk for accelerated intrinsic epigenetic ageing, SES, and the Levine clock, indicating that genetic risk and social disadvantage may contribute additively to faster biological aging.

'Cycling On Prescription': a gear change or a wrong turn?

COVID-19 has taught us in the most tragic terms that socioeconomic gradients in health apply in a pandemic just as they do in chronic disease. I have a background of research into cycling and I am now a practice nurse, so for me, the UK Government’s Gear change policy,1 heralding a ‘bold vision for cycling and walking’ on the back of a boom in bike sales and journeys, has been a welcome development amid the headlines of sadness and uncertainty. The most ear-catching part of the announcement was that of GPs prescribing cycling. But cycling advocates treat grand policy announcements with caution, mindful of the chasm between funding allocated to road building and cycle infrastructure. My last research activity was a 3-year study, Cycle Boom,2 on cycling in the older population. I interviewed 50–80 year-olds about their cycling histories to find the contexts in which there was continuation, rediscovery, disengagement, or absence of …

Cautionary tails of grip strength in health inequality studies: An analysis from the Canadian longitudinal study on aging.

Self-rated health is widely used in studies of the socioeconomic gradient of health in community-based populations. Its subjectivity may lead to under- or over-estimation of a true underlying socioeconomic gradient and has increased interest in searching for alternative, objective measures of health. Grip strength has emerged as one such alternative for community-based older populations, yet no study has directly assessed the relationship between these two measures and compared their associations with socioeconomic status and health behaviours. Using 26,754 participants aged 45-85 years in the baseline data of the Canadian Longitudinal Study on Aging Comprehensive Cohort, we estimated adjusted-grip strength through indirect standardization using age, sex, height, weight, and their square terms and used ANOVA to assess the variance of adjusted-grip strength within and between each self-rated health category. We ran four separate logistic regression models, examining unhealthy tails (those reporting poor health vs. not and those at the bottom 8th percentile of adjusted-grip strength vs. above) and healthy tails (those reporting excellent health vs. not and those at the top 20th percentile of adjusted-grip strength vs. below). Stronger adjusted-grip strength correlated with better self-rated health, but only 2% of the total variance of adjusted-grip strength was explained by variance between the self-rated health categories. While self-rated health largely showed the expected socioeconomic gradients and positive relationships with health enhancing behaviours, adjusted-grip strength showed no clear, consistent associations with either socioeconomic or health behaviour variables. The results give caution about using grip strength as an objective alternative to self-rated health in studies of social inequalities in health. Empirical approaches demand careful considerations as to which dimensions of health and corresponding measures of health are most relevant to the context being studied.

Assessing childhood health outcome inequalities with area-based socioeconomic measures: a retrospective cross-sectional study using Manitoba population data.

Socioeconomic gradients in health exist in Canada. Although multiple Canadian area-based socioeconomic measures (ABSM) have been developed, none have been specifically validated against pediatric outcomes. Our objective was to compare the strength of association between key pediatric health outcomes and a number of ABSM, including income quintile. This was a retrospective cross-sectional assessment of the association between socioeconomic status (SES) measured by ABSM and 20 specific pediatric health outcomes. Data from the Manitoba Population Research Data Repository were used for residents aged 0-19 years from 2010 to 2015. Outcomes included birth-related events (e.g. mortality), vaccination uptake, hospitalizations, and teen pregnancy. Regression goodness of fit was used to assess the strength of individual associations. Inequality was measured by slope index of inequality (SII) and relative index of inequality (RII). Overall, 19 of 20 outcomes had socioeconomic gradients identified by SII and RII. The multidimensional CAN-Marg indices had the best explanatory power in standard regression models. The simplest ABSM-income quintile-detected 16 of 19 confirmed inequalities, more than any other single measure. At all ages, many pediatric health outcomes in Manitoba were associated with significant socioeconomic inequalities; while income quintile detected most, CAN-Marg composite indices had the best explanatory power.

Differences in ill health and in socioeconomic inequalities in health by ethnic groups: a cross-sectional study using 2011 Scottish census

ABSTRACT Objectives: We compare rates of ill health and socioeconomic inequalities in health by ethnic groups in Scotland by age. We focus on ethnic differences in socioeconomic inequalities in health. There is little evidence of how socioeconomic inequalities in health vary by ethnicity, especially in Scotland, where health inequalities are high compared to other European countries. Design: A cross-sectional study using the 2011 Scottish Census (population 5.3 million) was conducted. Directly standardized rates were calculated for two self-rated health outcomes (poor general health and limiting long-term illness) separately by ethnicity, age and small-area deprivation. Slope and relative indices of inequality were calculated to measure socioeconomic inequalities in health. Results: The results show that the White Scottish population tend to have worse health and higher socioeconomic inequalities in health than many other ethnic groups, while White Polish and Chinese people tend to have better health and low socioeconomic inequalities in health. These results are more salient for ages 30–44. The Pakistani population has high rates of poor health similar to the White Scottish for ages 15–44, but at ages 45 and above Pakistani people have the highest rates of poor self-rated health. Compared to other ethnicities, Pakistani people are also more likely to experience poor health in the least deprived areas, particularly at ages 45 and above. Conclusions: There are statistically significant and substantial differences in poor self-rated health and in socioeconomic inequalities in health between ethnicities. Rates of ill health vary between ethnic groups at any age. The better health of the younger minority population should not be taken as evidence of better health outcomes in later life. Since socioeconomic gradients in health vary by ethnicity, policy interventions for health improvement in Scotland that focus only on deprived areas may inadvertently exclude minority populations.

Psychosocial, psychopharmacological and demographic predictors of changes in psychological distress over a course of computerised cognitive behavioural therapy (cCBT)

Social group identification, socioeconomic deprivation, and a number of other clinical and demographic factors have been found to predict severity of psychological distress prior to treatment in those referred to receive computerised cognitive behavioural therapy (cCBT) as an intervention for mild to moderate depression. The aim of the current study is to investigate whether the same key factors are able to predict magnitude of change in psychological distress across treatment in a sample receiving cCBT. Participants (N = 1158) consisted of individuals completing the ‘Beating the Blues’ (BtB) programme. Participants completed three versions of the group identifications scale (GIS), one for each of three groups: family, community, and a social group of choice. Changes in psychological distress showed statistically significant improvements between pre- and post-treatment assessment in all outcome measure subscales. Significantly greater changes (reductions) in psychological distress were found in those who had more severe pre-treatment psychological distress, those who lived in a lesser state of socioeconomic deprivation, those who identified with more social groups, and those taking antidepressant medication (ADM) concurrently. These findings provide valuable information on the likely course of treatment in those receiving cCBT, and highlight both the potential of social group identification as a ‘social cure’ for poor psychological health and the inequalities of the socioeconomic health gradient.

Does domiciliary welfare rights advice improve health-related quality of life in independent-living, socio-economically disadvantaged people aged ≥60 years? Randomised controlled trial, economic and process evaluations in the North East of England.

BackgroundThere are major socio-economic gradients in health that could be influenced by increasing personal resources. Welfare rights advice can enhance resources but has not been rigorously evaluated for health-related impacts.MethodsRandomised, wait-list controlled trial with individual allocation, stratified by general practice, of welfare rights advice and assistance with benefit entitlements, delivered in participants’ homes by trained advisors. Control was usual care. Participants were volunteers sampled from among all those aged ≥60 years registered with general practices in socio-economically deprived areas of north east England. Outcomes at 24 months were: CASP-19 score (primary), a measure of health-related quality of life; changes in income, social and physical function, and cost-effectiveness (secondary). Intention to treat analysis compared outcomes using multiple regression, with adjustment for stratification and key covariates. Qualitative interviews with purposive samples from both trial arms were thematically analysed.FindingsOf 3912 individuals approached, 755 consented and were randomised (381 Intervention, 374 Control). Results refer to outcomes at 24 months, with data available on 562 (74.4%) participants. Intervention was received as intended by 335 (88%), with 84 (22%) awarded additional benefit entitlements; 46 did not receive any welfare rights advice, and none of these were awarded additional benefits. Mean CASP-19 scores were 42.9 (Intervention) and 42.4 (Control) (adjusted mean difference 0.3 [95%CI -0.8, 1.5]). There were no significant differences in secondary outcomes except Intervention participants reported receiving more care at home at 24m (53.7 (Intervention) vs 42.0 (Control) hours/week (adjusted mean difference 26.3 [95%CIs 0.8, 56.1]). Exploratory analyses did not support an intervention effect and economic evaluation suggested the intervention was unlikely to be cost-effective. Qualitative data from 50 interviews suggested there were improvements in quality of life among those receiving additional benefits.ConclusionsWe found no effects on health outcomes; fewer participants than anticipated received additional benefit entitlements, and participants were more affluent than expected. Our findings do not support delivery of domiciliary welfare rights advice to achieve the health outcomes assessed in this population. However, better intervention targeting may reveal worthwhile health impacts.

An economic theory of depression and its impact on health behavior and longevity

In this paper, I propose an economic theory of depression and its impact on health behavior and longevity. Based on studies from happiness research, depression is conceptualized as a drastic loss of utility and value of life for unchanged fundamentals. The model is used to explain how untreated depression leads to unhealthy behavior and adverse health outcomes: depressed individuals are predicted to save less, invest less in their health, consume more unhealthy goods, and exercise less. As a result, they age faster and die earlier than non-depressed individuals. I calibrate the model for an average American and discus how depression enlarges the socioeconomic gradient of health and consider feedback effects of depression on earnings and of physical exercise on depression as well as a variety of depression shocks. Delays in treatment for depression in young adulthood are predicted to have significant repercussions on late-life health outcomes and longevity.

Longevity and Lifespan Variation by Educational Attainment in Spain: 1960-2015.

For a long time, studies of socioeconomic gradients in health have limited their attention to between-group comparisons. Yet, ignoring the differences that might exist within groups and focusing on group-specific life expectancy levels and trends alone, one might arrive at overly simplistic conclusions. Using data from the Spanish Encuesta Sociodemográfica and recently released mortality files by the Spanish Statistical Office (INE), this is the first study to simultaneously document (1) the gradient in life expectancy by educational attainment groups, and (2) the inequality in age-at-death distributions within and across those groups for the period between 1960 and 2015 in Spain. Our findings suggest that life expectancy has been increasing for all education groups but particularly among the highly educated. We observe diverging trends in life expectancy, with the differences between the low- and highly educated becoming increasingly large, particularly among men. Concomitantly with increasing disparities across groups, length-of-life inequality has decreased for the population as a whole and for most education groups, and the contribution of the between-group component of inequality to overall inequality has been extremely small. Even if between-group inequality has increased over time, its contribution has been too small to have sizable effects on overall inequality. In addition, our results suggest that education expansion and declining within-group variability might have been the main drivers of overall lifespan inequality reductions. Nevertheless, the diverging trends in longevity and lifespan inequality across education groups represent an important phenomenon whose underlying causes and potential implications should be investigated in detail.