Researching health inequalities in adolescents: the development of the Health Behaviour in School-Aged Children (HBSC) family affluence scale

Socioeconomic inequalities in adolescent health have been little studied until recently, partly due to the lack of appropriate and agreed upon measures for this age group. The difficulties of measuring adolescent socioeconomic status (SES) are both conceptual and methodological. Conceptually, it is unclear whether parental SES should be used as a proxy, and if so, which aspect of SES is most relevant. Methodologically, parental SES information is difficult to obtain from adolescents resulting in high levels of missing data. These issues led to the development of a new measure, the Family Affluence Scale (FAS), in the context of an international study on adolescent health, the Health Behaviour in School-Aged Children (HBSC) Study. The paper reviews the evolution of the measure over the past 10 years and its utility in examining and explaining health related inequalities at national and cross-national levels in over 30 countries in Europe and North America. We present an overview of HBSC papers published to date that examine FAS-related socioeconomic inequalities in health and health behaviour, using data from the HBSC study. Findings suggest consistent inequalities in self-reported health, psychosomatic symptoms, physical activity and aspects of eating habits at both the individual and country level. FAS has recently been adopted, and in some cases adapted, by other research and policy related studies and this work is also reviewed. Finally, ongoing FAS validation work is described together with ideas for future development of the measure.     

To what extent does socioeconomic status explain differences in health between Roma and non-Roma adolescents in Slovakia?

The Roma make up one of the largest ethnic groups in Europe. The few studies that are available report health among the Roma as considerably worse than that of the majority population, and virtually nothing is known about the health status of Roma adolescents. The purpose of this study was to compare the self-reported health outcomes of Roma adolescents living in Roma settlements with adolescents from the majority population and to assess the impact of socioeconomic status on the results obtained. We conducted a survey among Roma adolescents (N = 330, mean age = 14.5) and non-Roma adolescents (N = 722, mean age = 14.9) living in eastern Slovakia. We gathered data on sociodemographic position, self-rated health (using the SF-36), the occurrence of accidents and injuries during the past year, healthcare utilization during the past year, health complaints, mental health and social desirability. Roma adolescents reported poorer self-rated health, more accidents and injuries during the past year and more frequent use of healthcare during the past year, though fewer health complaints. Furthermore, they reported more prosocial behaviour than non-Roma. No differences appeared in total difficulties. Socioeconomic status decreased the association of ethnicity with health outcomes. Adjustment for social desirability had a significant effect on the differences for all outcomes, except for accidents and injuries during the past year.     

Income inequality and alcohol use: a multilevel analysis of drinking and drunkenness in adolescents in 34 countries

BACKGROUND: Economic inequality has been hypothesized to be a health determinant, independent of poverty and household income. The goal of this study was to explore the contextual influences of income inequality on alcohol use and frequency of drunkenness in adolescents. METHODS: The Health Behaviour in School-aged Children study surveyed 162 305 adolescents (ages 11, 13 and 15 years) in 34 countries, providing self-report data on family affluence, alcohol consumption and episodes of drunkenness. Country-level data on income inequality and overall wealth were retrieved from the United Nations Development Program. RESULTS: Multilevel logistic regression revealed that 11- and 13-year-olds in countries of high income inequality consumed more alcohol than their counterparts in countries of low income inequality (after adjustment for sex, family affluence and country wealth). No such effect on alcohol consumption was found in 15-year-olds. Eleven-year-olds in countries of high income inequality reported more episodes of drunkenness than their counterparts in countries of low income inequality. No such effect of income inequality on drunkenness was found in 13- or 15-year-olds. CONCLUSIONS: Income inequality may have a contextual influence on the use of alcohol among younger adolescents. Findings suggest that economic policies that affect the distribution of wealth within societies may indirectly influence the use of alcohol during early and mid-adolescence.     

Explaining socio-economic status differences in walking for transport: An ecological analysis of individual,social and environmental factors

The identification of potential mechanisms of influence (mediators) of socio-economic status (SES) on walking for transport is important, because the likely opposing forces of influence may obscure pathways for intervention across different SES groups. This study examined individual, and perceived social and physical environmental mediators of the relations of individual- and area-level SES with walking for transport. Two mailed surveys, six months apart, collected data on transport-related walking and its hypothesized individual, social and environmental correlates. The sample consisted of 2194 English-speaking adults (aged 20–65) living in 154 Census Collection Districts (CCDs) of Adelaide, Australia. Individual-level SES was assessed using data on self-reported educational attainment, household income, and household size. Area-level SES was assessed using census data on median household income and household size for each selected CCD. Bootstrap generalized linear models examined associations between SES, potential mediators, and total weekly minutes and frequency of walking for transport. The product-of-coefficient test was used to assess mediating effects. Individual, social–environmental, and physical environmental factors significantly contributed to the explanation of the relations between SES and transport-related walking frequency. Educational attainment and area- and individual-level income played independent roles in explaining frequency of walking for transport, through opposing common and distinct pathways. While engagement in leisure-time physical activity was the most influential mediator of the association between educational attainment and frequency of walking for transport, the number of motorized vehicles and perceived levels of environmental aesthetics and greenery were the strongest mediators of the relations of frequency of transport-related walking with individual- and area-level income, respectively. Environmental interventions aimed at increasing residential density, reducing physical barriers to walking and traffic load, developing social-support networks, and creating greener and more aesthetically pleasing environments in more-disadvantaged areas may help to reduce SES inequalities in participation in physical activity, by facilitating walking for transport.     

Trajectories of functional health: the 'long arm' of childhood health and socioeconomic factors

Few studies have specifically examined trajectories of functional health status or estimated the extent to which they are influenced by childhood health and socioeconomic conditions. This study examines how circumstances associated with early life may shape the level and progression of functional limitations among adults at or near retirement. Employing data from the US Health and Retirement Study (HRS), it estimates latent growth curve models (LGM) of functional limitation. The results demonstrate that functional health trajectories in old age continue to be shaped by childhood health and socioeconomic circumstances. Poor childhood health and disadvantaged social origins are associated with both more functional limitations at baseline and higher rates of increase over time. This association is net of baseline adult chronic disease and socioeconomic status. While both childhood and adult factors influence the baseline level of functional limitation, only childhood health and socioeconomic status are associated with the rate of change in limitations over time.     

Socioeconomic inequalities in health dynamics: A comparison of Britain and the United States

Drawing on theory and research on the fundamental causes of health, the life course, and the welfare state, we investigate social inequalities in dynamic self-rated health for working-aged Britons and Americans. We use data from the British Household Panel Survey and Panel Study of Income Dynamics (1990–2004) and a mixture latent Markov model to test a theoretical model of health as a discrete state that may remain stable or change over time. Our contributions are threefold. First, our finding of three distinctive types of health processes (stable good health, stable poor health, and a “mover” health trajectory) represents a more differentiated profile of long-term health than previously shown. Second, we characterize health trajectories in structural terms by suggesting who was more likely to experience what type of health trajectory. Third, our more differentiated picture of dynamic health leads to a more nuanced understanding of comparative health: Although the health advantage of Britons was confirmed, our results also indicate that they were more likely to experience health change. Moreover, the socioeconomic gradient in long-term health was steeper in the US, raising provocative questions about how state policies and practices may affect population health.     

Educational inequalities in the co-occurrence of mental health and substance use problems,and its adult socio-economic consequences: a longitudinal study of young adults in a community sample

Objectives

To examine the relationship between the co-occurrence of mental health and substance use problems and socio-economic status (SES).

Study design

A prospective longitudinal study of 808 males and females followed to age 30.

Methods

Survey data were used to derive latent classes (profiles) of mental health (depression, anxiety) and substance use (alcohol, nicotine, and marijuana [cannabis]) problems at age 27. Analyses examined the associations of these profiles with earlier educational attainment (high school diploma) and indicators of SES at age 30.

Results

Latent Class Analysis produced four profiles: a low disorder symptoms group, a licit substance use disorder symptoms group (alcohol and nicotine), a mental health disorder symptoms group, and a comorbid group. Earning a high school diploma by age 21 decreased the odds of belonging to the comorbid group or the licit substance use disorder symptoms group when compared to the low disorder symptoms group. These disorder profiles also were found to adversely impact subsequent adult SES. The adverse impact was more evident in income maintenance and wealth accumulation by age 30 than market or non-market labour force participation.

Conclusions

Earning a high school diploma lessens the risk of co-occurring mental health and substance use problems which contribute to economic instability in young adulthood. Findings underscore the importance of public health programmes to reduce the incidence of mental health and substance use problems and their associated high costs to individuals and to society.     

Social determinants of child and adolescent traffic-related and intentional injuries: A multilevel study in Stockholm County

Several significant developmental and socialisation processes in the life of children and adolescents take place in the area where they live. The extent to which they can feel and be safe in this environment is an important component of the success of those processes. This study highlights the independent contribution of neighbourhood and individual-level demographic and socioeconomic attributes to child and adolescent injuries. All individuals between the ages of 7 and 16 years living in Stockholm County in January 1998 (n = 184?545) were followed up for their injuries during a five-year period considering injuries sustained as a pedestrian/cyclist/motor-vehicle rider and intentional injuries (violence-related and self-inflicted). A series of two-level logistic regressions were conducted to examine the association between the occurrence of injuries and individual (compositional) characteristics nested into parish of residence as well as contextual characteristics. For children and adolescents living in Stockholm County, contextual socioeconomic and social attributes of their place of residence were significant for injuries sustained as motor-vehicle riders but not for those sustained as pedestrians/cyclists or those inflicted intentionally. In the latter case, only the highest concentration of social benefit recipients was associated with significantly higher odds ratios. This emphasises that each injury mechanism has its own socioeconomic and social pathway, where contextual and compositional factors come into play to varying degrees.     

Early origins of health disparities: Burden of infection,health, and socioeconomic status in U.S. children

Recent work in biodemography has suggested that lifetime exposure to infection and inflammation may be an important determinant of later-life morbidity and mortality. Early exposure to infections during critical periods can predispose individuals to chronic disease, in part through the reallocation of energy away from development needed for immune and inflammatory responses. Furthermore, markers of inflammation are known to vary by socioeconomic status in adults and may contribute to overall socioeconomic health inequalities, but little is known about how the sources of this inflammation differ over the life course. This paper uses novel biomarker data from the Third National Health and Nutrition Examination Survey (NHANES III) to test the association of the burden of common chronic infections (Helicobacter pylori (H. pylori), cytomegalovirus (CMV), herpes simplex virus-1 (HSV-1), hepatitis A and hepatitis B) with height-for-age and asthma/chronic respiratory conditions in U.S. children ages 6 and older, and the association of these chronic infections to children's socioeconomic status. A higher burden of infection is found to be associated with lower height-for-age as well as an increased likelihood of asthma net of race/ethnicity, family income, and parental education. Children with lower family income, lower parental education, and non-white race/ethnicity have a higher likelihood of infection with several individual pathogens as well as the overall burden of infection. Differential exposure and/or susceptibility to infections may be one mechanism through which early social factors get embodied and shape later-life health outcomes.     

The association of sexual orientation with self-rated health,and cigarette and alcohol use in Mexican adolescents and youths

Evidence of health inequities associated with sexual orientation has been gathered for industrialized countries. The situation for lesbians, gay males, and bisexuals (LGB) from middle- or low-income countries may be worse than those in industrialized nations. Here, we analyze the relationship of sexual orientation with self-rated health and cigarette and alcohol use among a representative sample of Mexican adolescents and youths between the ages of 12 and 29 years, in order to explore whether this association is mediated by discrimination and violence. Three dimensions of sexual orientation (affective attraction, sexual behavior, and identity) were assessed. The outcomes were self-rated health and cigarette and alcohol use. Compared to heterosexuals, LGB youths more frequently smoked ≥6 cigarettes per day, reported having experienced family violence, having crimes perpetrated against them, and having experienced violations of their rights. Among males, gays and bisexuals exhibited a higher risk of poor health than heterosexuals. Compared to heterosexual women, lesbians and bisexual women were more likely to consume alcohol. Many differences in self-rated health and substance use according to sexual orientation were explained by having experienced discrimination and violence. We concluded that lesbian and bisexual females have a higher prevalence of cigarette and alcohol use. It is necessary to develop policies and programs aimed at the reduction of substance abuse among LGB youths (focusing on females who engage in sexual contact with persons of the same gender) and to work against discrimination and violence experienced by LGB people, particularly against non-heterosexual males.     

Influence of socioeconomic status, wealth and financial empowerment on gender differences in health and healthcare utilization in later life: evidence from India

Empirical studies from developed countries observe that women report worse health and higher healthcare utilization than men, but the health disadvantage diminishes with age; gender differences in self-rated health often vanish or are reversed in older ages. Comparable assessments of health during later life from developing countries are limited because of the lack of large-scale surveys that include older women. Our study attempts to address the shortage of developing country studies by examining gender differences in health and healthcare utilization among older adults in India. Both ordered and binary logit specifications were used to assess significant gender differences in subjective and objective health, and healthcare utilization after controlling for demographics, medical conditions, traditional indicators of socioeconomic status like education and income, and additional wealth indicators. The wealth indicators, measured by property ownership and economic independence, are regarded as financially empowering older adults to exercise greater control over their health and well-being. Data are drawn from a nationally representative decennial socioeconomic and health survey of 120,942 Indian households conducted during 1995-1996. The study sample comprises 34,086 older men and women aged >or= 60 years. Our results indicate that older women report worse self-rated health, higher prevalence of disabilities, marginally lower chronic conditions, and lower healthcare utilization than men. The health disadvantage and lower utilization among women cannot be explained by demographics and the differential distribution of medical conditions. While successive controls for education, income, and property ownership narrows the gender gap in both health and healthcare utilization, significant differentials still persist. Upon controlling for economic independence, gender differentials disappear or are reversed, with older women having equal or better health than otherwise similar men. Financial empowerment might confer older women the health advantage reflected in developed societies by enhancing a woman's ability to undertake primary and secondary prevention during the life course.     

The role of defamilialization in the relationship between partnership and self-rated health: A cross-national comparison of Canada and the United States

Partnered individuals live longer, healthier lives. In explaining this association, processes involving both social causation (in which partnership provides health benefits to individuals) and health selection (in which those who find partners were healthier than those who do not) have been invoked. Since much of this literature is focused in the U.S., comparative studies of the potential impact of policy on the causation and selection components of this association have been scant. Using comparable data from the U.S. Panel Study of Income Dynamics (N = 25,862, followed from 1984 to 2005) and the Canadian Survey of Labour and Income Dynamics (N = 15,632, followed from 1999 to 2005), we test the selective and causal relationships evident during entrance into partnership. We use fixed change-point analysis with multilevel models to fit trajectories of change in both the U.S. and Canada. In Canada, partnership benefits were evident, while health selection was limited. In contrast, in the U.S., health selection was prominent in both men and women, but partnership benefits were not significant. We argue that the differences in the extent of defamilialization of social policy between the two countries may impact the way and extent to which people choose partners and benefit from those partnerships.     

The relative importance of family socioeconomic status and school-based peer hierarchies for morning cortisol in youth: An exporatory study

This paper examines the relative importance of family socioeconomic status (SES) and school-based peer hierarchies for young people's psychoneuroendocrine response, represented by cortisol level. Data are drawn from a study of 2824, 15-year-olds in 22 Scottish secondary schools in 2006 who provided information on family SES (parental occupation, material deprivation and family affluence) and social position in school hierarchies, together with two morning salivary cortisol samples. School social position was assessed by participants placing themselves on seven ‘ladders’, from which three factors were derived, termed scholastic, peer and sports hierarchies. Controlling for confounds, there was little or no variation in cortisol by any SES measure. By contrast, each school hierarchy was independently associated with cortisol, but in different ways. For the scholastic hierarchy, an inverse linear relationship was found for females, cortisol increasing with lower position. For peer hierarchy, an opposite (direct) linear relationship occurred for males, while for females elevated cortisol was associated only with ‘top’ position. For sports, elevated cortisol among males was associated with ‘bottom’ position, among females with all except the ‘top’. These results are interpreted in the context of Sapolsky's (Sapolsky, 2005) predictions for stress responses to hierarchical position in stable and unstable social systems, the former represented by the scholastic hierarchy involving elevated cortisol in lower positions, the latter by peer hierarchy with elevated cortisol in higher positions. Overall, the results highlight the greater importance of school-based peer groups than family SES for young people's psychoneuroendocrine response.     

西部农村地区基层医疗卫生机构卫生人员离职意愿及影响因素分析——以陕西省为例

目的:以陕西省为例,分析西部农村地区基层医疗卫生机构卫生人员的离职意愿及其影响因素。方法:利用探索性因子分析对工作压力和工作满意度进行降维分析;对工作压力、工作满意度和离职意愿进行单因素分析;对离职意愿进行二元Logistic回归分析。结果:25.6%的样本卫生人员有离职意愿;工作压力、工作满意度、个人学历、职称和机构类别是卫生人员产生离职意愿的显著影响因素;工作压力和工作满意度对离职意愿分别具有正向促进和反向抑制作用,工作压力对离职意愿具有完全中介效应;学历高、职称低、乡镇卫生院和县医院的卫生人员具有较高的离职意愿。结论:通过调整薪酬水平,提高基层医疗卫生机构卫生人员的收入满意度;扩充基层医疗卫生机构卫生人员队伍,适当降低现有卫生人员的工作压力;对农村地区卫生人员的工作与生活条件加以改善。     

Assessing patient outcomes in acute exacerbations of chronic bronchitis: The measure your medical outcome profile (MYMOP), medical outcomes study 6-item general health survey (MOS-6A) and EuroQol (EQ-5D)

There is little published information on the measurement of health status or quality of life in acute exacerbations of chronic bronchitis. The measure yourself medical outcome profile (MYMOP), the medical outcomes study 6-item general health survey (MOS-6A), and EuroQoL (EQ-5D) were evaluated in 81 patients with acute exacerbations of Type-1 chronic bronchitis presenting at a single general practice centre in Glasgow. The questionnaires were administered at the first clinic visit and at a second visit within 1 week of treatment completion. Item scores for MYMOP were generally more responsive than those for the other instruments, as assessed by standardised response means and an index of responsiveness for those patients reporting minimal change between visits. Construct validity was demonstrated for the MYMOP by the gradient in score change with the patient's perceived change in clinical condition and by the relationship between score change and the physician's assessment of clinical outcome. This study demonstrated that the MYMOP is a valid and potentially useful instrument for the assessment of patient outcomes in acute exacerbations of chronic bronchitis and is more responsive than the MOS-6A or EQ-5D in this setting. The choice of instrument will vary according to the objective of the study. This revised version was published online in June 2006 with corrections to the Cover Date.     

The simultaneous detection of trivalent & hexavalent chromium in exhaled breath condensate: A feasibility study comparing workers and controls

The analytical method outlined in this feasibility study has been used to show that trivalent chromium (Cr(III)) and hexavalent chromium (Cr(VI)) can be detected and measured in exhaled breath condensate (EBC) samples. EBC samples and urine samples were collected from a cohort of 58 workers occupationally exposed to hexavalent chromium compounds and 22 unexposed volunteers (control group). Levels of Cr(III) and Cr(VI) were determined in EBC samples and total chromium levels were determined in urine samples. Pre and post working week samples for both EBC and urine were collected in tandem. Total chromium in urine samples was analysed by inductively coupled plasma mass spectrometry (ICP-MS). Analysis of Cr(III) and Cr(VI) in EBC samples used a hyphenated micro liquid chromatography (μLC) system coupled to an ICP-MS. Separation was achieved using an anion exchange micro-sized column. The results showed that the occupationally exposed workers had significantly higher levels of Cr(III) and Cr(VI) in their EBC samples than the control group, as well as higher levels of total chromium in their urine samples. However, for the exposed workers no significant difference was found between pre and post working week EBC samples for either Cr(III) or Cr(VI). This study has established that Cr(III) and Cr(VI) can simultaneously be detected and measured in ‘real’ EBC samples and will help in understanding inhalation exposure.