Socioeconomic Position Research Articles

The Legacy of Redlining: Increasing Childhood Asthma Disparities through Neighborhood Poverty.

Rationale: Identifying the root causes of racial disparities in childhood asthma is critical for health equity. Objectives: To determine whether the racist policy of redlining in the 1930s led to present-day disparities in childhood asthma by increasing community-level poverty and decreasing neighborhood socioeconomic position (SEP). Methods: We categorized census tracts at the birth address of participants from the Children's Respiratory and Environmental Workgroup birth cohort consortium into categories A, B, C, and D as defined by the Home Owners Loan Corporation, with D being the highest perceived risk. Surrogates of present-day neighborhood-level SEP were determined for each tract, including the percentage of low-income households, the CDC's Social Vulnerability Index, and other tract-level variables. We performed causal mediation analysis, which, under the assumption of no unmeasured confounding, estimates the direct and mediated pathways by which redlining may cause asthma disparities through tract-level mediators adjusting for individual-level covariates. Measurements and Main Results: Of 4,849 children, the cumulative incidence of asthma through age 11 was 26.6%, and 13.2% resided in census tracts with a Home Owners Loan Corporation grade of D. In mediation analyses, residing in Grade-D tracts (adjusted odds ratio = 1.03 [95% confidence interval = 1.01, 1.05]) was significantly associated with childhood asthma, with 79% of this increased risk mediated by percentage of low-income households; results were similar for the Social Vulnerability Index and other tract-level variables. Conclusions: The historical structural racist policy of redlining led to present-day asthma disparities in part through decreased neighborhood SEP. Policies aimed at reversing the effects of structural racism should be considered to create more just, equitable, and healthy communities.

Representation of Dalit Characters and Reflection of Their Consciousness in Nepali Short Stories

The paper attempts to explore the position of Dalit characters and their consciousness on the contexts, contents, and issues as portrayed in the select stories from “Nepali Kathama Dalit [Dalits in Nepali Stories]” published by Nepal Academy. The stories written on Dalit subject matters and issues primarily portray the socio-economic and political positions, problems and issues of exclusion of Dalits in different forms. The characters of the stories demonstrate the miserable condition of Dalits; however, they speak up against the oppression and discrimination for their rights, equality, justice and liberation. For the purpose, the researcher has selected the stories of Khagendra Sangroula’s “Sangram Bahadur Sarki”, Narayan Dhakal’s “Sunakhari Tol”, Matrika Pokharel’s “Itihasko Chihanmathi Ubhiyera” and Krishna Bam Malla’s “Pudke Damai”. The stories are plotted on the context, issues, and problems of Dalits and their resistance against the caste system. The study basically explores the representation of the Dalit characters, their socio economic and political positions, consciousness and protest for the change. Hence, the stories are studied from the perspectives class consciousness connecting with caste consciousness. The researcher has employed the qualitative approach with descriptive and exploratory methods.

Oral health inequities over time among older adults of different racial/ethnic backgrounds: a comparative decomposition analysis across Australia and the United States.

Although the prevalence of poor oral health among older populations in Australia and the United States is higher, the contribution of ethnicity status is unknown. We aimed to estimate the contribution of social inequalities in oral health among older populations in Australia and the United States. Cross-sectional study design using data from Australia's National Survey of Adult Oral Health (NSAOH 2004-06 and 2017-18) and the United States' National Health and Nutrition Examination Survey (NHANES 2003-04 and 2011-16). Participants included in the analysis were aged 65 + years. Oaxaca-Blinder type decomposition analysis was used to assess the contribution of demographic (age, sex), socioeconomic position (educational attainment, household income) and dental behaviors (last dental visit) to changes in prevalence of edentulism and non-functional dentition, and mean number of missing teeth by ethnicity status over time in Australia and the United States. The number of participants aged 65 + years who provided clinical and sociodemographic/dental behaviour data was 1043 and 1269 in NSAOH 2004-06 and 2017-18, and 1372 and 1328 in NHANES 2003-04 and 2011-16 respectively. The prevalence of edentulism was from 13 percent (NHANES 2011-16) to 28 percent (NSAOH 2004-06), while the prevalence of non-functional dentition was from 41 percent (NSAOH 2017-18 and NHANES 2011-16) to 61 percent (NHANES 2003-04). The mean number of missing teeth was from 11 (NSAOH 2017-18) to 18 (NHANES 2003-04). The prevalence of edentulism and non-functional dentition, and the mean number of missing teeth were higher among older Australians identifying as White and the opposite results were observed among older Americans identifying as Non-White. For older adults in Australia, risk factors with the greatest impact on oral health outcomes by ethnicity status were educational attainment and household income. For older adults in the United States, the most dominant risk factor for non-optimal oral health outcomes by ethnicity status was last dental visit. There are important policy translation implications from our findings, as they indicate that social and structural systems in Australia and the United States operate differently in the context of oral health over time among culturally diverse older citizens. This information will help inform initiatives that both target effective oral health promotion for older, culturally-diverse populations and provide evidence for the distribution of resources in the public dental health setting for this age group and cultural demographic.

Childhood socioeconomic position relates to adult decision-making: Evidence from a large cross-cultural investigation.

Early exposure to poverty may have profound and enduring impacts on developmental trajectories over the lifespan. This study investigated potential links between childhood socioeconomic position, recent economic change, and temporal discounting in a large international cohort (N = 12,951 adults from 61 countries). Temporal discounting refers to the tendency to prefer smaller immediate rewards over larger rewards delivered after a delay, and connects to consequential outcomes including academic achievement, occupational success, and risk-taking behaviors. Consistent with multiple theories about the impacts of stress exposure, individuals who reported lower socioeconomic positions in childhood exhibited greater temporal discounting in adulthood compared to peers who did not. Furthermore, an interaction emerged between childhood socioeconomic position and recent economic change, such that the steepest temporal discounting was found among those from lower childhood socioeconomic positions who also recently experienced negative economic change as a result of the COVID pandemic. These associations remained significant even when accounting for potentially confounding factors like education level and current employment. Findings provide new evidence that childhood socioeconomic position relates to greater temporal discounting and steeper devaluation of future rewards later in adulthood, particularly in response to contemporaneous economic change. This suggests childhood socioeconomic position may have longer-term impacts on developmental trajectories. Speculatively, childhood socioeconomic position may shape adult behavior through increased life stress, diminished access to resources, and lower perceived trust and reliability in social systems. These findings underscore the long-term implications of socioeconomic gaps, cycles of disadvantage and economic marginalization.

Is poor self-rated health associated with higher caries experience in adults? The HUNT4 Oral Health Study.

The association between lower socioeconomic status and a higher risk of dental caries is well established, but the independent association between general health status and dental caries on a population level is less investigated. The aim of this study was to assess the association between self-rated general health and caries experience in an adult Norwegian population and to assess if the associations were modified by age and sex. Data was collected as part of the Trøndelag Health Study (HUNT4) conducted 2017-2019 and a randomly selected subsample (20%) were invited for the HUNT4 Oral Health Study. This cross-sectional study included 4,880 dentate participants aged 19-94 years (response rate 67%). Participants underwent clinical and radiographic oral examinations and caries experience was measured by numbers of decayed (DT), missing (MT), and filled teeth (FT), DMFT index. The DT component consisted of primary and secondary caries in dentine, cavitated root caries and remaining roots. Questionnaires were used to assess self-rated general health and socioeconomic position, denoted by education, household income and employment status. Associations between self-rated health and caries experience (DMFT) and components (DT, MT, and FT) were assessed using negative binomial regression models. Ratios of means (RMs) with 95% confidence intervals (CI) for the associations were estimated, adjusting for socioeconomic position. Individuals with poor self-rated general health had a 29% higher mean number of MT (RM 1.29 (95%CI 1.13-1.46)), a 22% higher mean number of DT (RM 1.22 (95%CI 1.07-1.39)), and a 7% higher mean number of DMFT (RM 1.07 (95%CI 1.04-1.11)) than individuals reporting very good health. Age stratified analyses presented a more pronounced association between self-rated health and caries experience for individuals below the age of 55 years than for those 55 years or older. Similarly, the association was more evident for women, with significantly higher mean values for DMFT, MT and FT among women reporting poor health. The present study demonstrated an independent association between poor self-rated health and a higher burden of caries experience, adjusted for education, income and employment status. The association was stronger for women and individuals below the age of 55 years. These findings add new evidence in understanding caries inequalities through self-rated health.

Socioeconomic disparities in Plasmodium falciparum infection risk in Southern Malawi: mediation analyses

This study investigated the mediators of the association between socioeconomic position (SEP) and Plasmodium falciparum (Pf) infection in Southern region of Malawi. We utilized data from the 2014 International Center of Excellence for Malaria Research (ICEMR) surveys from Malawi in which blood samples of all individuals from selected households in Blantyre, Thyolo and Chikhwawa were tested for Pf parasitemia. We assessed household SEP and potential mediators – housing quality, food security, education status of household heads, and use of long-lasting Insecticide-treated nets (LLINs) and nutritional status. We conducted causal mediation analyses to assess the proportion of SEP effect that is attributed to each mediator and combination of mediators. The mediation analysis shows that during the rainy season, improved housing and educational attainment explained 39.4% and 17.0% of the SEP effect on Pf infection, respectively, and collectively 66.4%. In the dry season, housing, educational attainment, and LLIN usage collectively mediated 33.4% of SEP’s effect with individual contributions of 15.6%, 11.2%, and 3.8%, respectively. Nutrition also played a role, particularly for children, mediating 9.2% of SEP’s effect in the rainy season and 3.7% in the dry season. The study concluded that multifaceted interventions targeting housing, education, LLIN usage, and nutrition are vital to reducing socioeconomic disparities in Pf infection risk in the Southern region of Malawi.

Tooth-loss related masticatory and aesthetic experiences among middle-aged and older adult Danes.

To determine whether tooth loss relates to patient experiences of masticatory or aesthetic problems and is a useful measure of oral health and treatment needs and to compare experiences of tooth loss among middle-aged and older Danes. Cross sectional online- and telephone interview questionnaire study. 1,060 Danish citizens aged 40 years or older. Experiences of difficulties eating/enjoying food or smiling/showing of teeth due to tooth related problems within the last 6 months. Data analysis used tests of proportions and ordinal logistic regression. Half the participants had a full or almost full dentition. Among those with tooth loss, 21-44% reported difficulties eating/enjoying food. In ordinal logistic regression, difficulties eating were associated with being younger, having fewer teeth and having visibly missing teeth. Being unwilling to smile or show one's teeth was associated with being younger, having fewer teeth, having lower socioeconomic position and having visibly missing teeth. Wearing a prosthesis did not ameliorate eating difficulties or unwillingness to smile. Tooth loss is a meaningful measure of oral health but cannot stand alone. Many adults with even substantial tooth loss did not experience functional or aesthetic problems. Tooth loss is associated with negative masticatory and aesthetic experiences among middle-aged than older adults. Removable prostheses were not associated with better functional or esthetic outcomes.

Associations of childhood socioeconomic position and health with trajectories of grip strength from middle to older ages in populations from China and from England

BackgroundWe investigated associations of childhood socioeconomic position and health with trajectories of grip strength from middle to older ages in two distinct populations. MethodsWe used data from the China Health and Retirement Longitudinal Study (CHARLS, n = 16,701) and English Longitudinal Study of Ageing (ELSA, n = 12,695). Hand grip strength was measured at three timepoints in CHARLS (2011–2015) and four in ELSA (2001−2020). Random-effects growth models were applied to assess associations between each childhood factor and age trajectories of grip strength. FindingsLower parental education was associated with weaker grip strength, by 0·36 kg(95 % CI:0·17,0·56) for participants of illiterate (vs literate) parents in CHARLS and 1·88 kg(0·43,3·33) for participants of parents without education (vs ≥ high school) in ELSA, after adjusting for parental occupation and own adult socioeconomic position. Low parental occupation was associated with weaker grip strength, although the difference diminished after adjustment for adult socioeconomic position. Financial hardship was associated with weaker grip strength only in CHARLS, by 0·19 kg(0·01,0·38) after adjustment. Self-rated poor childhood health and school absenteeism were associated with weaker grip strength (both studies). Being confined to bed and hospitalised for more than a month due to health were associated with weaker grip strength only in CHARLS. Each additional childhood illness (only reported in ELSA) was associated with 0·52 kg(0·28,0·81) lower mean grip strength. Reported poor childhood health (CHARLS), low parental education and school absenteeism (ELSA) were associated with grip strength decline. InterpretationLower socioeconomic position and poor health in childhood were associated with weaker grip strength in later life in both Chinese and English populations. Addressing socioeconomic disparities and promoting health of children may enhance life-course physical capacity, promote healthy ageing and reduce age-related adversities.

Socioeconomic inequalities linked to the transitioning to neurocognitive disorders and mortality

Research on socioeconomic position (SEP) and mild neurocognitive impairment, considered a transient state between normal cognitive function and dementia is limited. The purpose of this study was to determine the role of SEP in transitioning between different cognitive states and mortality risk. Using nationally representative English data and utilising a multistate model association between SEP and the risk of transitioning from no cognitive impairment (NOCI) to Cognitive impairment no dementia (CIND), dementia and death were investigated. The potential reverse transition from CIND to NOCI was also explored. The probabilities of transitioning between cognitive states and time spent in each state differed significantly between those with lower and higher levels of SEP. Higher wealth was associated with a reverse transition from CIND to NOCI [HR = 1.56, CI (1.42,1.72)]. Socioeconomic advantage might protect against the progression to the early stages of neurocognitive disorders (CIND) and facilitate the potential reversion from mild cognitive impairment to a healthy cognitive state in later life. Lower levels of education affect the risk of mortality after the onset of dementia.

The impact of high exposure to perfluoroalkyl substances and risk for hormone receptor-positive breast cancer – A Swedish cohort study

IntroductionPerfluoroalkyl substances (PFAS) are persisting chemicals with endocrine disruptive and carcinogenic properties. Previous studies involving cohorts with high PFAS exposure have not shown an increased risk of breast cancer. Research on PFAS and breast cancer according to hormone receptor status is limited. This study aims to investigate the association between PFAS exposure and hormone receptor-positive breast cancer. Materials and MethodsIn 2013, high levels of PFAS (sum of PFAS > 10,000 ng/L), dominated by perfluorooctane sulfonic acid (PFOS) and perfluorohexane sulfonic acid (PFHxS) were found in the drinking water from one of the two waterworks in Ronneby, Sweden. Breast cancer diagnoses and information of adjuvant endocrine therapy were retrieved from the Swedish Cancer Register and The Prescribed Drug Register 2006–2016 for a cohort of women residing in the municipality between 1985 and 2013 (n = 24,509). Individual exposure was assessed based on municipality waterworks distribution data linked to annual residential addresses. Cox proportional hazards models were used in the analysis. The highest achieved educational level was used as an indicator of socioeconomic position. Sensitivity and subgroup analysis were performed for prepubertal exposure and diagnosis before or after age 50 (assumed menopause). ResultsThere were 313 cases of malignant breast cancer among women ≤ 85 years between 2006 and 2016. Of these, 224 cases (72 %) were considered hormone receptor-positive based on the first prescription of adjuvant endocrine therapy, antiestrogens (40 %) or aromatase inhibitor (60 %). Among women ever living at a residential address with high PFAS exposure, the hazard ratio (HR) for breast cancer classified as hormone receptor-positive was 0.84; 95 % confidence interval (CI) 0.61, 1.14. Findings were similar before and after menopause. ConclusionHigh PFAS exposure from drinking water, dominated by PFOS and PFHxS, was not associated with an elevated risk of hormone receptor-positive breast cancer.

Disparities in Food Insecurity and Academic Achievement Among California Public University Students: An Intersectional Approach.

Background/Objectives: Historically racialized status (HRS) and low socioeconomic position (SEP) are independent risk factors for food insecurity and poor academic achievement among college students. Despite increased enrollment of students from historically racialized groups and low SEP, little is known regarding the intersectional experience of these contemporary student characteristics with food security status or academic achievement. The purpose of this study was to examine the intersections of racialized status and SEP with food insecurity and academic achievement among undergraduate students attending a public university system in California. Methods: This cross-sectional study included 1170 undergraduates who utilized their campus food pantry between June and August 2019 at nine University of California campuses. Racialized status and SEP were used to construct four distinct intersectional positions: (1) White, not low SEP (i.e., traditional students; reference), and three contemporary student groups: (2) White, low SEP; (3) HRS, not low SEP; and (4) HRS, low SEP. Using regression analyses, these intersectional positions were examined with food insecurity and grade point average (GPA), while controlling for other student characteristics. Results: HRS, low SEP students had significantly higher odds of experiencing food insecurity (OR = 2.72; 95% CI: 1.52-4.97) and lower GPA (B = -0.14, p = 0.05) than traditional students, after adjustment. Conclusions: Contemporary students are at increased risk of food insecurity and lower academic achievement compared to traditional students.

Use, perceptions, and effectiveness of e-cigarettes for smoking cessation among older adults in England: a population study, 2014–2024

BackgroundThis study aimed to characterise patterns of tobacco smoking and vaping among older adults (≥ 65 years) in England, to explore harm perceptions of e-cigarettes among those who smoke, and to estimate the real-world effectiveness of e-cigarettes for helping older adults to stop smoking.MethodsData were collected as part of a representative monthly cross-sectional household survey in England between April 2014 and April 2024 (n = 197,219). We analysed differences between older (≥ 65 years) and younger/middle-aged adults (18–64 years) in (a) time trends in tobacco smoking and vaping, (b) harm perceptions of e-cigarettes vs. cigarettes (adjusting for gender, socioeconomic position, and vaping status), and (c) the real-world effectiveness of e-cigarettes for smoking cessation (adjusting for gender, socioeconomic position, characteristics of the quit attempt, and use of other evidence-based cessation aids).ResultsTobacco smoking prevalence remained relatively unchanged over time among older adults (at ~ 9%; 9.5% [8.5–10.6%] in April 2014 and 8.7% [7.7–9.8%] in April 2024) but vaping prevalence increased (from 2.1% [1.6–2.7%] to 3.7% [3.0–4.6%], respectively). These trends differed from those observed among younger/middle-aged adults, among whom there was a clear decline in smoking (from 21.8% [21.0–22.7%] to 18.2% [17.3–19.0%]) and a larger increase in vaping (from 5.6% [5.2–6.1%] to 16.2% [15.3–17.0%]). Older adults were consistently less likely than younger/middle-aged adults to use e-cigarettes to support attempts to quit smoking (26.8% [17.2–39.3%] vs. 43.7% [39.6–48.0%] in April 2024). Older smokers reported greater uncertainty about the harms of e-cigarettes compared with cigarettes (ORadj = 2.48 [2.28–2.69]). E-cigarettes appeared to be effective for helping older adults to stop smoking (ORadj = 1.50 [0.96–2.34]); whether effectiveness was lower than for younger/middle-aged adults was inconclusive.ConclusionsOver the past decade, smoking prevalence has remained stable among older adults while decreasing among the rest of the adult population in England. Older adults are more unsure about the relative harms of e-cigarettes and less likely to use them to support attempts to quit smoking, despite evidence that they are effective for smoking cessation in this population.

Geospatial Hot Spots and Cold Spots in US Cancer Disparities and Associated Risk Factors, 2004-2008 to 2014-2018.

Despite declining cancer death rates in the US, cancer remains the second deadliest disease and disparities persist. Although research has focused on identifying risk factors for cancer deaths and associated disparities, few studies have examined how these relationships vary over time and space. The primary objective of this study was to identify cancer mortality hot spots and cold spots - areas where cancer death rates decreased less than or more than neighboring areas over time. A secondary objective was to identify risk factors of cancer mortality hot spots and cold spots. We analyzed county-level cancer death rates from 2004 through 2008 and 2014 through 2018, exploring disparities in changes over time for socioeconomic and demographic variables. We used hot spot analysis to identify areas with larger decreases (cold spots) and smaller decreases (hot spots) in cancer death rates and random forest machine learning analysis to assess the relative importance of risk factors associated with hot spots and cold spots. We mapped spatial clustering areas. Geospatial analysis showed hot spots predominantly in the Plains states and Midwest and cold spots in the Southeast, Northeast, 2 Mountain West states (Utah and Idaho), and a portion of Texas. Factors with the strongest influence on hot spots and cold spots were unemployment, preventable hospital stays, mammography screening, and high school education. Geospatial disparities in changes in cancer death rates point out the critical role of access to care, socioeconomic position, and health behaviors in persistent cancer mortality disparities. Study results provide insights for interventions and policies that focus on addressing health care access and social determinants of health.

Childhood socioeconomic differences in type 2 diabetes: longitudinal results of The Maastricht study

Abstract Background Type 2 diabetes mellitus (T2DM) is a common chronic disease that disproportionally affects disadvantaged groups. People with a low socioeconomic position (SEP) have an increased risk of developing T2DM. Knowing the potential influence of early life on T2DM risk later in life, this study aims to examine longitudinal associations between childhood SEP and type 2 diabetes, independent of adult SEP. Methods Longitudinal data was used from 6,727 participants of The Maastricht Study without T2DM at baseline (participants with prediabetes were included in the study sample). T2DM status was determined by a standardized oral glucose test. Sample mean (SD) age was 58.7 (8.7) years and 55.2% was female. Childhood SEP was determined by the highest level of completed education for father and mother and a measurement for childhood income inadequacy. Adult SEP was determined by the highest completed level of education, equivalent household income and occupational position. Incident T2DM was self-reported yearly. Associations were studied annually over a 12-year period (median (IQR) 8.2 (4.9) years) with Cox regression analyses. Results A total of 247 participants (3.7%) without T2DM at baseline reported incident T2DM. Incident T2DM was more common in people with low childhood SEP versus high childhood SEP (4.5% vs. 2.7%, p = 0.008) and for people with low adult SEP versus high adult SEP (5.2% vs. 2.1%, p < 0.001). The impact of parental education on incident T2DM is mitigated by adult SEP. Childhood income inadequacy did predict T2DM independently of adult SEP, with a HR of 1.22 (1.01, 1.45). Conclusions Socioeconomic inequalities in childhood and adulthood are both predictive for incident T2DM. Experiencing income inadequacy in childhood increases the risk of developing T2DM in later life, independent of adulthood SEP. More attention is needed for deprivation in childhood and its impact on T2DM. Key messages • People who have experienced income inadequacy as a child have a higher risk of developing T2DM in later life, independent of their adult SEP. • More attention and research is needed for the impact of childhood poverty on developing T2DM in later life.

Do poor psychosocial resources mediate health inequalities in type 2 diabetes? The Maastricht Study

Abstract Low socioeconomic position (SEP) has been identified as a risk factor for type 2 diabetes mellitus (T2DM). A potential pathway of this association is psychosocial resources. Disadvantageous environmental conditions result in low control beliefs through adverse resources and inferiority beliefs through social comparison for people with a low SEP. We examined two poor psychosocial resources, low control beliefs and inferiority beliefs, to explain socioeconomic inequalities in T2DM. We analysed mediating roles of low control beliefs and inferiority beliefs by using counterfactual mediation analysis. 8293 participants aged 40-75 living in Limburg, the Netherlands participated in The Maastricht Study starting from September 2010 to October 2020 and were followed up to 10 years with annual questionnaires with a median follow-up time of 7.18 years. SEP (education, income, occupation), control and inferiority beliefs, and (pre)diabetes by oral glucose tolerance test were measured at baseline. Incident T2DM was self-reported per annum. 3.2%(N = 203) of the participants without T2DM at baseline reported incident T2DM. People with low SEP had more often prevalent and incident T2DM (e.g., low education:HR=2.13, 95%CI:1.53-2.97). Lower control beliefs and higher inferiority beliefs were more common among people with low SEP than people with high SEP. Moreover, lower control beliefs and higher inferiority beliefs were risk factors for T2DM (e.g., low control beliefs: HR = 1.50, 95%CI:1.08-2.09). The relationship between SEP and T2DM was partially mediated by control beliefs (7.98-13.56%) and inferiority beliefs (2.16-4.53%). Poor psychosocial resources are important in socioeconomic inequalities in diabetes. Researchers and practitioners should consider the psychosocial profile of people with lower SEP might differ from those with higher SEP and this might interfere with the development, treatment, and prevention of T2DM. We should aim to work with such beliefs, instead of against it. Key messages • Socioeconomic health inequalities in diabetes has many underlying mechanism including psychosocial pathways. • Interventions and research should consider the different environment of low SEP and psychosocial profiles of people. We should aim to work with it, instead of against it.

Sex differences in cardiovascular disease in relation to socioeconomic position in the NAKO study

Abstract Background Low socioeconomic position (SEP) is associated with cardiovascular disease (CVD) risk; yet, the underlying pathways are not fully clear and may affect sexes differently. We investigated sex differences in the relationship of SEP with prevalent CVD, cardiovascular risk factors (CRF) and estimated cardiovascular risk in a contemporaneous German population. Methods Data derived from the baseline examination of 204,780 participants in population-based German National Cohort (NAKO). Logistic, multinomial, and linear regression models were used to estimate sex-specific odds ratios (OR) and beta-coefficients with 95% confidence intervals (CI) of CVD, CRF and very high-risk score (SCORE2 ≥7.5% (age 40-49 years) or ≥ 10% (age 50-69 years)) associated with educational attainment and relative income. Women-to-men ratios of ORs (RORs) with 95%-CI were estimated. Results In women compared to men, low vs. high SEP was more strongly associated with obesity, overweight, self-reported myocardial infarction and hypertension, elevated blood pressure values, antihypertensive medication, and alcohol consumption, but less strongly related to smoking. In women with the lowest vs. highest educational level, the OR for a very high 10-year CVD risk was 3.61 (95%-CI 2.88; 4.53), compared to 1.72 (95%-CI 1.51; 1.96) in men. The women-to-men-ROR was 2.33 (95%-CI 1.78; 3.05), attenuated after age-adjustments. For the comparison of low vs. high relative income, the odds of having a very high 10-year CVD risk was 2.55 (95%-CI 2.04; 3.18) in women, and 2.25 (95%-CI 2.08; 2.42) in men (women-to-men ROR, 1.31 (95%-CI 1.05; 1.63). Conclusions In both sexes, there was an inverse graded relationship between SEP and the likelihood of prevalent CVD and CRF, with stronger associations in women than in men. Although women had a lower estimated 10-year CVD risk compared to men, the likelihood of having a very high CVD risk conferred by low SEP vs. a high one was higher in women than in men.

The role of class stigma in socioeconomic inequalities in type 2 diabetes: The Maastricht Study

Abstract Background Low socioeconomic position (SEP) is a risk factor for type 2 diabetes mellitus (T2DM). An underlying mechanism behind socioeconomic health inequalities can be stigma, particularly classism. Studying the influence of class stigma in the context of (pre)diabetes and socioeconomic inequalities may shed light on the societal factors influencing diabetes. Methods Data from 1947 participants aged 49-88 who participated in the second phase of The Maastricht Study starting between November 2020 and April 2023 were used. SEP (education, income, occupation) and 6-item classism scale were measured through self-reported questionnaires. (Pre)diabetes was measured through an oral glucose tolerance test. We conducted multinomial logistic regression analyses to investigate the associations between SEP, classism, and diabetes status. Results 20.9% (N = 406) of the study sample had T2DM (Mage=69.8(±6.8) years; 31.3% women). People with low SEP had more often T2DM (e.g., income OR = 2.13, 95%CI:1.54-2.82) and reported perceived classism (e.g., education OR = 2.07, 95%CI:1.33-3.21) than people with high SEP. Classism was not statistically significantly associated with T2DM (OR = 0.78, 95%CI:0.48-1.29). Conclusions Social health inequalities are apparent in T2DM; however, our results suggest that class stigma might not be a major factor in underlying processes. Further research can investigate the role of chronic stress and intersection of multiple stigmas. Key messages • The underlying factors behind socioeconomic health disparities are complex. Social and psychological environment in low SEP should be investigated carefully. • Although low SEP is strongly associated with T2DM and perceived classism, class stigma might not be a major target in explaining socioeconomic pathways in diabetes.

Geographical variation in prostate cancer testing explained by socio-economic position in Stockholm

Abstract Background Prostate cancer screening using prostate-specific antigen (PSA) testing is controversial but remains prevalent in many countries. Despite its prevalence there is little information in Sweden or globally on the spatial heterogeneity in PSA testing. This study aims to describe the spatio-temporal variation in PSA testing in the Stockholm region specifically at the municipality and small area level. Additionally, it aims to quantify the extent to which socio-economic position (SEP) indicators such as education, income, and country of birth explain the observed variation in PSA testing. Methods A retrospective population-based register study was conducted, encompassing men aged 40 years and older residing in the Stockholm region from 2007 to 2016. Utilizing spatial smoothing techniques, we calculated the age-standardised proportion of men undergoing PSA testing prior to any prostate cancer diagnosis within each area for every calendar year. Furthermore, we used Bayesian logistic regression models with spatial random effects to estimate the individual-level association between PSA testing and socio-economic position. The proportion of variance in PSA testing explained by various measures of SEP was also estimated at both the municipality and small area levels. Results Significant geographical disparities in PSA testing were observed across small areas within Stockholm. The proportion of variance explained in PSA testing at the small area level was highest for income (32.6%), followed by education (9.7%) and country of birth (7.4%). Incorporating all SEP measures led to a higher proportion of explained variance at the small area level (41.6%) compared to the municipality level (24.8%). Conclusions PSA testing was significantly associated with various socio-economic indicators and some of the spatial variation could be explained by SEP. It would be useful to ascertain whether similar patterns are observed in other regions or countries. Key messages • The findings suggested widespread and consistent opportunistic prostate cancer screening practices within the Stockholm region, raising concerns regarding potential overdiagnosis and overtreatment. • The socio-economic differences in prostate cancer screening could partially explain the differences in cancer incidence and mortality.

A repositioning nudge to encourage healthier snack purchases at a supermarket in a deprived area

Abstract Background Diet quality positively correlates with socio-economic position (SEP). While nudges are often proposed as promising policy tools for promoting health behavior among lower SEP groups, research addressing their impact within lower SEP groups is limited. This study aimed to 1) examine the efficacy of a checkout repositioning nudge in a supermarket in a deprived area in encouraging purchases of healthier snacks, and 2) describe customers’ preferences and needs regarding grocery shopping and healthy eating. Methods Daily sales data were collected over four-week control and intervention periods. During the intervention, unhealthy snacks at the checkout were replaced by healthier snacks. Additionally, questionnaires were administered among customers (N = 90). Results The intervention led to a significant increase in daily sales of healthier snacks (M = 3.14, SD = 2.45) compared to the control period (M = 0.54, SD = 0.96), t(27) = 5.62, p < .001. Despite a statistically significant nudge-effect, the absolute daily sales of healthier snacks remains extremely low. No difference in daily sales of unhealthy snacks was observed between both periods. Questionnaire data showed that customers report to seldomly purchase snacks at the checkout, find it important to eat healthily, think well about what they buy in a supermarket, and long for a healthier and more affordable food offer within the supermarket. Conclusions Interventions that are effective among higher SEP groups, such as repositioning nudges, may not be suitable for the circumstances and needs of lower SEP groups. To combat existing health inequalities, interventions must be tailored to lower SEP groups. More system-level interventions that target the healthiness and affordability of the offer may be needed. Key messages • Although nudging is often proposed as a promising policy approach for improving health behavior among lower SEP groups, repositioning nudges may not suit their circumstances and needs. • To combat health inequalities, interventions must be tailored to lower SEP groups and integrated with system-level policies (e.g., targeting the healthiness and price of the offer in supermarkets).

Do changes in BMI during the COVID-19 pandemic persist in the post-pandemic period in a pediatric population attending health care clinics? A longitudinal study.

The long-term effect of the COVID-19 pandemic on body weight has not been sufficiently analyzed. This study aimed to analyze changes in body mass index (BMI) during and after the COVID-19 pandemic among a large pediatric population attending health care clinics. This retrospective longitudinal cohort study utilized electronic medical data of 106,871 children (52.1% males, median age 8.2 years at pre-pandemic assessment). Each child had at least one BMI measurement recorded pre-pandemic and two additional measurements: one during the pandemic and one post-pandemic. Obesity rates increased from 12.8% pre-pandemic to 15.4% during the pandemic, slightly decreasing to 15.0% post-pandemic. BMI-standard deviation scores (SDSs) increased during the pandemic, in both sexes, across all ages and all socioeconomic position (SEP) clusters, and in children with pre-pandemic underweight or normal weight (all P<0.001). Post-pandemic, BMI-SDS decreased but remained above pre-pandemic levels, particularly in younger children (aged 2-6 years) and those from low/medium SEP clusters (all P<0.001). BMI-SDS continued to increase in children aged 6.1-16 years, those of Arab ethnicity, and those in the high SEP cluster. The COVID-19 pandemic correlated with an overall increase in BMI-SDS, which decreased post-pandemic but remained above pre-pandemic levels. Effective policy interventions to prevent pediatric obesity are crucial.