Monitoring socioeconomic disparities in death: comparing individual-level education and area-based socioeconomic measures

We compared all-cause mortality rates stratified by individual-level education and by census tract area-based socioeconomic measures for Massachusetts (1999-2001). Among persons aged 25 and older, the age-adjusted relative index of inequality was slightly higher for the census tract than for the individual education measures (1.5 vs 1.2, respectively). Only the census tract socioeconomic measures could provide a relative index of inequality (2-3) for deaths before age 25 or detect expected socioeconomic disparities for deaths among persons 65 and older (relative index of inequality= approximately 1.2 vs 0.8 for census tract measures and individual education, respectively).     

Socioeconomic Disparities and Influenza Hospitalizations,Tennessee, USA

We examined population-based surveillance data from the Tennessee Emerging Infections Program to determine whether neighborhood socioeconomic status was associated with influenza hospitalization rates. Hospitalization data collected during October 2007–April 2014 were geocoded (N = 1,743) and linked to neighborhood socioeconomic data. We calculated age-standardized annual incidence rates, relative index of inequality, and concentration curves for socioeconomic variables. Influenza hospitalizations increased with increased percentages of persons who lived in poverty, had female-headed households, lived in crowded households, and lived in population-dense areas. Influenza hospitalizations decreased with increased percentages of persons who were college educated, were employed, and had health insurance. Higher incidence of influenza hospitalization was also associated with lower neighborhood socioeconomic status when data were stratified by race.     

Neighbourhood characteristics, individual level socioeconomic factors, and depressive symptoms in young adults: the CARDIA study

STUDY OBJECTIVE: To investigate the relation between neighbourhood socioeconomic and ethnic characteristics with depressive symptoms in a population based sample. DESIGN: Cross sectional data from the CARDIA study, including the Center for Epidemiological Studies depression scale score (CES-D). Neighbourhoods were 1990 US census blocks of 1000 people; six census variables reflecting wealth/income, education, and occupation investigated separately and as a summary score; neighbourhood racial composition (percentage white and black) and individual level income and education were also examined. SETTING: Participants recruited in 1985/86 from community lists in Birmingham, AL; Chicago, IL; Minneapolis MN; from a health plan in Oakland, CA. PARTICIPANTS: 3437 adults aged 28-40 years in 1995/96: 24% white men, 27% white women, 20% black men, 29% black women. MAIN RESULTS: For each race-sex group, CES-D was inversely related to neighbourhood score and individual income and education. Associations of neighbourhood score with CES-D became weak and inconsistent after adjusting for individual level factors; personal income remained strongly and inversely associated with CES-D. Age adjusted mean differences (standard errors) in CES-D between the lowest and highest income categories were 3.41 (0.62) for white men, 4.57 (0.64) for white women, 5.80 (0.87) for black men, and 5.74 (0.83) for black women. For both black and white participants, CES-D was associated negatively with percentage of white people and positively with percentage of black people in their census block, before, but not after, adjustment for individual and neighbourhood socioeconomic variables. CONCLUSIONS: Neither neighbourhood socioeconomic characteristics nor ethnic density were consistently related to depressive symptoms once individual socioeconomic characteristics were taken into account.     

Study of the factors associated with the inability to perform household tasks among aged persons on the Ile-de-France. Application to the sub-regional planning of home-help services

The aim of this paper is to present the preliminary results of a planning project in the area of health and social services for the elderly, which makes it possible to estimate the number of persons likely to seek help from such services at the administrative area levels with decisional powers. This involves identifying predictors of disability from raw data routinely available in the census and at various administrative area levels, the municipality being the preferred level. From the epidemiological data collected at the regional level, an indicator of disability has been constructed. Initially, those factors possibly associated with disabilities were identified by regrouping the variables in four dimensions (discriminant analysis): socio-economic, physical environment, human environment, local administrative area environment (district data from census, medical-social services offered in the area, ect.). Subsequently, a logistic regression made it feasible to calculate the coefficients attached to these predictors of disability. In our sample, sex, age and level of housing amenities in the dwelling place appear to be predictors of disability. The application of the coefficients obtained at the region level--by means of an epidemiological approach to distributions by sex, age and dwelling amenities characterizing a municipality or group of municipalities (territorial approach)--enabled us to estimate the number of persons 65 and over likely to seek help from home-assistance services at whatever administrative area level chosen. In certain of its quantitative aspects, this mixed approach (individual and area) helps in determining need, the first step in the planning process.     

Unusually strong association between education and mortality in young adults in a community with a high rate of injection-drug users

BACKGROUND: To examine the association between education and mortality for various causes of death in young adults in a community with a high rate of injection-drug users. METHODS: Linked mortality study based on mortality records for 1996 and 1997 and on 1996 population census data from the Region of Madrid (Spain). The association between educational level and mortality was estimated by the mortality rate ratio. RESULTS: After adjustment for age and other socioeconomic variables the mortality rate in men and women aged 25-44 years with no education was, respectively, 4.7 and 3.7 times higher than in men and women with the highest educational level. The causes of death with the strongest association were chronic liver disease and cirrhosis, AIDS and diseases of the heart in both sexes and suicide in men. For these causes of death the mortality rate ratio between persons with the lowest and highest educational level ranged from 6.8 to 21.8 in men and from 4.1 to 16.9 in women. CONCLUSIONS: These causes of death are the leading specific causes of death in persons aged 25-44 years. Given that probably a substantial part of deaths from diseases of the heart in this age category are drug-related, the common denominator of the excess mortality related poor education seems to be drug injection.     

Relationship between socioeconomic factors and severe childhood injuries

The objective was to examine the relationship between injury rates and socioeconomic factors for children in Hamilton County, Ohio, using small-area analysis. The subjects were county residents less than 15 years old who were hospitalized or died of injuries between January 1, 1993, and December 31, 1995; they were identified through a population-based trauma registry. The census tract was the unit of analysis; the rate of injury per 100,000 population was the dependent variable. Risk factors included median income, level of education, percentage below the poverty level, percentage unemployment, percentage non-Caucasian, and percentage families headed by females. There were 2,437 children meeting the case definition; injuries per census tract ranged from 0 to 2,020.2 per 100,000 per year. Census tracts with higher injury rates had lower median incomes, more people with less than a high school education, more unemployment, more families headed by females, more people living below the poverty level, and more non-Cancasians han those with lower rates. In a regression model, percentage of people living below poverty level, percentage of those who did not graduate from high school, and percentage unemployment were significant risk factors for injuries, P<.001. Since small-area analysis examines associations on an ecological level rather than an individual level, these studies should always be interpreted with caution because an association found at the level of the census tract may not apply at the individual level. Inverventions to reduce injuries should target socioeconomically disadvantaged children living below the poverty level and those in areas with fewer high school graduates and more unemployment.     

Factors associated with mortality after widowhood.

A non-concurrent prospective study in Washington County, Maryland identified 4,032 (1,204 male, 2,828 female) White persons aged 18 and over who were enumerated in a 1963 non-official census and who became widowed between 1963 and 1974, and an equal number of married persons, each matched to a widowed as to race, sex, year of birth and geography of residence. All were followed to 1975, the date of a second census. Mortality rates based on person-years at risk were about the same for widowed as for married females, but significantly higher for male widowed than male married, even after adjustment for a number of demographic, socioeconomic, and behavioral variables. Mortality rates among widowed males who remarried were very much lower than among those who did not remarry, but no significant difference was observable among widowed females who did nor did not remarry. Multiple regression analysis also showed that, for both sexes and independently of other factors, moving into a nursing home or other chronic care facility was associated with higher mortality than any other residential change or no change, and living alone was associated with higher mortality than living with someone else in the household.     

Coronary heart disease rates within a small urban area in Belgium.

STUDY OBJECTIVE--To identify geographical differences in coronary heart disease (CHD) attack rates in a small urban area and to relate these to indicators of socioeconomic class. DESIGN--CHD attack rates were calculated from data of the Ghent MONICA myocardial infarct register for the period 1983-87. The city of Ghent is subdivided into 201 sectors based on morphological, and socioeconomic characteristics. During the national census of 1981, the main determinants of residential differentiation were measured. These sector variables were linked with the CHD attack rates. PATIENTS--All residents of the city aged 25-69 years are prospectively followed with regard to heart attacks. Between 1982 and 1987, 1728 suffered an acute heart attack according to MONICA criteria. MAIN RESULTS--Significant (p < 0.05) differences in age and sex standarised attack rates were observed between city sectors. These differences were related to an index of socioeconomic status. CONCLUSION--Within a small urban area, significant geographical differences occur in CHD attack rates and these are related to socioeconomic status.     

Socioeconomic inequalities in coronary heart disease in Italy: a multilevel population-based study

This longitudinal study evaluates the role of individual and contextual socioeconomic determinants in the socioeconomic inequalities in incidence and mortality for coronary events in Turin, Italy, using hierarchical models. All residents aged 35-74 at the start of 1997 were included in the study population. We considered as outcomes all incident cases and deaths that occurred in the study population in the period 1997-2002. The socioeconomic indicators were educational level, job status and median income per census tract. A neighbourhood deprivation index was also used, which combines, in an aggregated measure, a series of poor individual socioeconomic conditions. The analyses were performed using hierarchical Poisson models, with individuals (n = 523,755) considered as level I units and neighbourhoods (n = 23) as level II units. Among men, we observed an inverse gradient in incidence by educational level and an excess risk for persons who were not actively employed. More marked excesses were found for mortality (RR: 1.63; 95% CI: 1.05-2.55, for unemployed persons compared to employed persons). Among women, greater socioeconomic differences were observed for both incidence and mortality; all of the individual indicators contributed to these differences. The differentials in mortality were particularly great for the retired and for housewives (RR: 1.98; 95% CI: 1.40-2.81). Slight excesses in incidence were observed among men for the most deprived areas. The results of this study reveal that job status is the most important individual factor explaining socioeconomic inequalities for coronary events, whereas context seems to play a marginal role.     

雅安市15岁以上人群乙型病毒性肝炎表面抗体水平调查

目的 了解雅安市15岁以上人群乙型病毒性肝炎(简称乙肝)免疫抗体水平,探讨防控乙肝策略与措施.方法 采取整群抽样法,采集15岁以上中学生、大学生、工人、从业人员人群血清4 693份,应用ELISA初筛检测乙肝表面抗体(抗-HBs),阴性者再用固相放射免疫法(RIA)复检抗-HBs,并对结果进行统计分析.结果 初筛和复检乙肝抗-HBs阳性率分别为41.62％、54.55％,初筛低于2006年全国和四川省水平,复检则高于2006年全国和四川省水平；男女乙肝抗-HBs阳性率差异无统计学意义；初筛和复检后阳性率均以从业人员最高,分别达57.32％和67.94％,中学生最低,初筛和复检后仅为33.57％和49.07％,4类人群(中学生、大学生、工人、从业人员)乙肝抗-HBs阳性率差异有统计学意义；乙肝抗-HBs阳性率在25～岁组和50～岁组有两个高峰,各年龄组乙肝抗-HBs阳性率差异有统计学意义；复检后与初筛比较,乙肝抗-HBs抗体阳性率提高近13个百分点.结论 建议今后在做好儿童乙肝疫苗接种同时,应考虑将乙肝防控重点向15岁以上群体倾斜；ELISA检测乙肝抗-HBs敏感性明显低于RIA,需在今后工作中区别应用.     

Street connectivity and obesity in Glasgow,Scotland: Impact of age,sex and socioeconomic position

This study investigated associations of street connectivity with body mass index (BMI), and whether these associations varied by sex, age and socioeconomic position, amongst adults in Glasgow, Scotland. Data on socio-demographic variables, height and weight were collected from 1062 participants in the Greater Glasgow Health and Well-being Study, and linked with neighbourhood-level census and geo-referenced data on area level deprivation and street connectivity. Results of multilevel models showed that, after adjustment for individual level covariates, street connectivity was not significantly associated with either BMI or BMI category; nor were there any significant interactions between age, sex or socioeconomic position and street connectivity.     

Population predictors of community health and social service use in Northern Ireland.

STUDY OBJECTIVE: To investigate the characteristics of elderly populations associated with variations in their use of community health and personal social services and to test the hypotheses that the variations are related to: (a) the age structure of an elderly population; (b) the population's socioeconomic composition, including the level of deprivation; and (c) household or living arrangements. DESIGN: A common file of 1991 population census and 1994 NHS community trust operational variables was constructed for 67 postcode sectors, with the independent variables describing the age-sex groups to be studied. Clear criteria for the exclusion of "empty" sectors were developed. Relationships using bivariate and multivariate correlation and stepwise multiple regression were explored. SETTING: Eastern Health and Social Services Board area, Northern Ireland (Belfast and hinterland). PARTICIPANTS: Population of statutory pensionable age; in aggregate, younger and older age bands. MAIN RESULTS: The age structure or mean age of the elderly population had only a weak association with the community health and social service client rate, but there were strong associations with socio-economic variables, particularly the percentage of those living alone who were without a car and the percentage of pensioner households that included an adult of below pensionable age. Parsimonious multiple regression models accounted for between 46% and 80% of the variation in the NHS community trust client rate. Greater explanations were achieved for the young elderly population than for those aged 75+ years and, when the population was divided between young and old age bands, for men than for women. CONCLUSIONS: Community health and social services for elderly people in eastern Northern Ireland were focused on those with a low income and those who were not co-resident with adults of working age. When local elderly populations are compared, per capita morbidity and dependency are often higher where the mean age is low, and vice versa, because of the inverse relationship between socioeconomic status and survival in old age. Capitation scales for resource allocation with positive age weighting will be of little use if no account is taken of the relative prevalence of need in the youngest or base age group.     

A further analysis of race differences in the National Longitudinal Mortality Study.

OBJECTIVES: The purpose of this study was to investigate associations between race and specific causes of mortality among adults 25 years and older in the National Longitudinal Mortality Study. METHODS: Mortality hazard ratios between races during 9 years of follow-up were estimated with Cox proportional hazards models, with control for multiple indicators of socioeconomic status (SES) and SES-relevant variables. RESULTS: Black persons younger than 65 years were at higher risk than others for all-cause and cardiovascular mortality; the strongest effects were observed among persons aged 25 through 44 years. CONCLUSIONS: Race, independent of SES, is related to mortality in American society, but these effects vary by age and disease categories.     

Neighborhood environment,racial position,and risk of police-reported domestic violence: a contextual analysis

OBJECTIVES: The purpose of this study was to examine the contribution of neighborhood socioeconomic conditions to risk of police-reported domestic violence in relation to victim's race. Data on race came from police forms legally mandated for the reporting of domestic violence and sexual assault. METHODS: Using 1990 U.S. census block group data and data for the years 1996-1998 from Rhode Island's domestic violence surveillance system, the authors generated annual and relative risk of police-reported domestic violence and estimates of trends stratified by age, race (black, Hispanic, or white), and neighborhood measures of socioeconomic conditions. Race-specific linear regression models were constructed with average annual risk of police-reported domestic violence as the dependent variable. RESULTS: Across all levels of neighborhood poverty (< 5% to 100% of residents living below the federal poverty level), the risk of police-reported domestic violence was higher for Hispanic and black women than for white women. Results from the linear regression models varied by race. For black women, living in a census block group in which fewer than 10% of adults ages > or = 25 years were college-educated contributed independently to risk of police-reported domestic violence. Block group measures of relative poverty (> or = 20% of residents living below 200% of the poverty line) and unemployment (> or = 10% of adults ages > or = 16 years in the labor force but unemployed) did not add to this excess. For Hispanic women, three neighborhood-level measures were significant: percentage of residents living in relative poverty, percentage of residents without college degrees, and percentage of households monolingual in Spanish. A higher degree of linguistic isolation, as defined by the percentage of monolingual Spanish households, decreased risk among the most isolated block groups for Hispanic women. For white women, neighborhood-level measures of poverty, unemployment, and education were significant determinants of police-reported domestic violence. CONCLUSION: When data on neighborhood conditions at the block group level and their interaction with individual racial position are linked to population-based surveillance systems, domestic violence intervention and prevention efforts can be improved.     

Area characteristics and determinants of hospitalised childhood burn injury: a study in the city of Cape Town

OBJECTIVES: To investigate the impact of local living circumstances on the level of childhood burn injuries. STUDY DESIGN/METHOD: This study was an ecological investigation encompassing the 634 residential areas of the city of Cape Town (about 668,900 children aged 12 years and younger). Fifteen socio-physical features of these areas that describe the population, household, dwelling types and services were considered using data from the 2001 census. Data of childhood burn injuries were gathered from the Red Cross Children's Hospital's register over 1999-2000 (n=923). Area features were synthesized into three main dimensions using factor analysis (principal axis method). Each dimension was split into three (exposure) levels, and the effect of each dimension on childhood burn injury was measured, compiling odds ratios with 95% confidence intervals and using the most favourable exposure level as the reference category within each dimension. RESULTS: The main dimensions of contextual exposure were defined as housing conditions (five variables), child dependency (three variables) and socio-economic barriers (three variables). Each aspect had a significant impact on the risk of burn injury, with increased levels of exposure leading to increased risk of burns. For housing conditions (Factor 1) and socio-economic barriers (Factor 3), a graded relationship was observed with noteably increased odds for increased levels of exposure. CONCLUSIONS: The occurrence of child burn injury is highly influenced by various features of the local environment. These features may be essential targets for sustainable childhood burn injury control and prevention programmes.     

What determines geographical variation in rates of acceptance onto renal replacement therapy in England?

OBJECTIVE: To determine the independent effects of need and supply factors on the known geographical variation in acceptance rates onto renal replacement therapy (RRT) in England. METHODS: Data were obtained from all renal units in England on the characteristics of all cases aged 16 years and over, resident in England, who were accepted onto RRT in 1991 and 1992. Of these, 5715 (94.5%) had a valid postcode that could be matched to a census ward. Multilevel modelling using Poisson regression was used. The number of acceptances in each census ward within age bands 16-34, 35-64 and 65+ was the dependent variable. Independent effects modelled were: (1) individual factors (age, sex); (2) census ward need factors--ethnicity (expressed as the percentage of the ward population that was Asian or African-Caribbean), socio-economic deprivation--and supply factors--'access' to the nearest renal unit using crowfly and road travel time and distance, and services available to each ward expressed as number of haemodialysis stations per 100,000 catchment population of the nearest renal unit; (3) district health authority level effects. RESULTS: Age was a major determinant of acceptance, with a 7-fold higher rate in males aged over 64 years compared with younger men. Acceptance rates were lower in females, with a negative age-sex interaction in females aged over 64 years. The percentage of both Asian and African-Caribbean populations per ward was a highly significant positive determinant. Deprivation was also a significant determinant, best represented by a customised index. There was an inverse relation of acceptance with distance, especially road travel time. Other supply side variables had a significant effect though there was no independent district effect. There was some variation in the strength of these relationships by type of area (Greater London, urban and non-urban). CONCLUSIONS: Need and supply factors influence service use as expressed as acceptance onto RRT. Pressure to expand RRT services needs to be aimed at areas with large minority ethnic populations and those living far from existing units.     

Inequalities in health and socioeconomics: an epidemiological undertaking in an urban area of Argentina]

OBJECTIVES: To understand how certain socioeconomic factors interact with health indicators at the local level, so that health inequalities may be better addressed. METHODS: Several epidemiological methods were applied to study the 431 census block groups of the Lanús municipality in the province of Buenos Aires, Argentina, from January 1995 to December 2002. Using a cluster study, the block groups were categorized according to demographic and socioeconomic traits. A spatial distribution analysis was conducted of each health-related event in terms of its geographic location (georeference), and comparisons were drawn using box-plot charting for each group. Four types of demographic and socioeconomic data were gathered from the 1991 National Population and Housing Census: housing adequacy, overcrowding, percentage of persons 65 and older in the household, and level of education. The health indicators studied were vaccination coverage among children entering primary school, teen pregnancy rates, and breast cancer mortality rates in women over 40 years old. RESULTS: Teen pregnancy rates fell as socioeconomic conditions improved (chi(2) = 60.7452; P = 4.074 x 10(-13)). In contrast, the breast cancer mortality rate among women over 40 was higher among those with a better standard of living (chi(2) = 12.9766; P = 0.0047). Although the average number of children with incomplete vaccination schedules at school entry decreased with improved socioeconomic conditions, the difference was not statistically significant (chi(2) = 6.3993; P = 0.0937). CONCLUSIONS: The combined methodologies confirmed the correlation between socioeconomic factors and health indicators, especially regarding teen pregnancy and breast cancer mortality rates. The results should be extremely helpful in designing interventions aimed at reducing health inequalities at the local level.     

Social determinants of ever initiating smoking differ from those of quitting: a cross-sectional study in Estonia

BACKGROUND: To study the association of socioeconomic and demographic indicators with ever initiating regular smoking and quitting smoking among ever regular smokers in Estonia in order to identify target groups for equity-oriented tobacco control policies. METHODS: Data for 4277 individuals in the 25-64 age group come from three cross-sectional studies conducted in 2000, 2002 and 2004. Age-standardized prevalence rates and odds ratios with 95% confidence intervals were calculated. RESULTS: High rates of ever initiation were observed for lower educated men and women after controlling for other socioeconomic indicators. This association was not observed for women above age 50. Independent, although weaker associations were found among men who were unemployed or with a low occupational status. Low cessation rates were observed among men who were unemployed, who had a lower occupational position or who had a low income. These associations remained after controlling for other socioeconomic variables. The effect of income became stronger in the older age groups among men. Rates of ever initiation and cessation also varied strongly in relationship to some demographic variables. The highest initiation rates were found among divorced women and among women living in the capital city. The lowest cessation rates were found among divorced women, and among Russian men. CONCLUSIONS: While educational level was the strongest predictor of ever initiating regular smoking, smoking cessation was related more directly to aspects of social disadvantage originating in adult life. To be effective, tobacco control interventions should not only target lower educated, but also those in material disadvantage.     

Heart disease mortality in nonsmokers living with smokers

A private census of Washington County, Maryland, in 1963 obtained information on smoking habits of all adults in the census, and death certificates of all residents who died in the next 12 years were coded for underlying cause of death and matched to the census. Among the white population aged 25 and over, 4,162 men and 14,873 women had never smoked. In this group, death rates from arteriosclerotic heart disease were significantly higher among men (relative risk (RR) = 1.31, 95% confidence interval (CI) 1.1-1.6) and women (RR = 1.24, 95% CI 1.1-1.4) who lived with smokers in 1963, after adjustment for age, marital status, years of schooling, and quality of housing. Among women, the relative risk increased significantly (p less than 0.005) with increasing level of exposure; among men, there was little evidence of a dose-response relation. The relative risks for nonsmokers who lived with smokers were greatest among both men and women who were younger than age 45 in 1963, but the number of deaths in these groups was small, and confidence intervals were broad. These results suggest a small but measurable risk for arteriosclerotic heart disease among nonsmokers who live with smokers.     

The incidence of active tuberculosis in a large urban area

The authors reviewed all cases of active tuberculosis newly reported to a population-based registry between 1970 and 1985 to compare a large urban area with the mostly rural remainder of the province of British Columbia, Canada. Although incidence rates have declined steadily in the rural area, they have not done so in the urban area. Within the urban area, there was a striking relation between tuberculosis incidence and socioeconomic level. Incidence rates in those born in Canada were observed to be higher for men than for women and higher for men who had never married than for those who had ever married, a difference no longer present within census tract groups. The greatest difference in incidence was between unemployed and employed men. Cases in the poorest census tracts more commonly had advanced, infectious pulmonary disease and were more likely to be alcoholics. The incidence of tuberculosis in the poorest census tracts did not decline as rapidly as in other areas. The characteristics of the disease in the poorest urban census tracts suggest the possibility of selective migration of persons at risk for tuberculosis and of continuing transmission of the disease and call for imaginative case-finding and treatment programs to address this problem.