Socioeconomic disparities in health in the US: an agenda for action

Inequality of income and wealth in the US has been growing rapidly since 1972. Evidence of socioeconomic effects on health is documented for many endpoints, and there is evidence that socioeconomic disparities in health are increasing. In Europe, equity in health and health care is a target of the World Health Organization, and has led to a variety of activities to reduce socioeconomic disparities in morbidity and mortality. In the US, activities in the public and private sectors have increased in recent years but attention, especially among the public-at-large in addition to elites, needs to be shifted to socioeconomic disparities. The paper suggests action strategies drawn from the European experience and other US efforts to place public health priorities on the policy agenda. A first step is to create a climate of unacceptability for socioeconomic disparities in health. Recommended activities include improvement and utilization of existing data; dissemination to broad audiences; building on existing initiatives; creating multi-sectoral alliances; formation of state and community task forces; attention to human capital as well as social justice issues; creative use of media; attraction of new funders; and implementation of quantitative targets.     

Socioeconomic disparities in health: pathways and policies

Socioeconomic status (SES) underlies three major determinants of health: health care, environmental exposure, and health behavior. In addition, chronic stress associated with lower SES may also increase morbidity and mortality. Reducing SES disparities in health will require policy initiatives addressing the components of socioeconomic status (income, education, and occupation) as well as the pathways by which these affect health. Lessons for U.S. policy approaches are taken from the Acheson Commission in England, which was charged with reducing health disparities in that country.     

The role of health-related behaviors in the socioeconomic disparities in oral health

This study aimed to examine the socioeconomic disparities in health-related behaviors and to assess if behaviors eliminate socioeconomic disparities in oral health in a nationally representative sample of adult Americans. Data are from the US Third National Health and Nutrition Examination Survey (1988–1994). Behaviors were indicated by smoking, dental visits, frequency of eating fresh fruits and vegetables and extent of calculus, used as a marker for oral hygiene. Oral health outcomes were gingival bleeding, loss of periodontal attachment, tooth loss and perceived oral health. Education and income indicated socioeconomic position. Sex, age, ethnicity, dental insurance and diabetes were adjusted for in the regression analysis. Regression analysis was used to assess socioeconomic disparities in behaviors. Regression models adjusting and not adjusting for behaviors were compared to assess the change in socioeconomic disparities in oral health. The results showed clear socioeconomic disparities in all behaviors. After adjusting for behaviors, the association between oral health and socioeconomic indicators attenuated but did not disappear. These findings imply that improvement in health-related behaviors may lessen, but not eliminate socioeconomic disparities in oral health, and suggest the presence of more complex determinants of these disparities which should be addressed by oral health preventive policies.     

Socioeconomic disparities and health: impacts and pathways

Growing socioeconomic disparity is a global concern, as it could affect population health. The author and colleagues have investigated the health impacts of socioeconomic disparities as well as the pathways that underlie those disparities. Our meta-analysis found that a large population has risks of mortality and poor self-rated health that are attributable to income inequality. The study results also suggested the existence of threshold effects (ie, a threshold of income inequality over which the adverse impacts on health increase), period effects (ie, the potential for larger impacts in later years, specifically after the 1990s), and lag effects between income inequality and health outcomes. Our other studies using Japanese national representative survey data and a large-scale cohort study of Japanese older adults (AGES cohort) support the relative deprivation hypothesis, namely, that invidious social comparisons arising from relative deprivation in an unequal society adversely affect health. A study with a natural experiment design found that the socioeconomic gradient in self-rated health might actually have become shallower after the 1997-98 economic crisis in Japan, due to smaller health improvements among middle-class white-collar workers and middle/upper-income workers. In conclusion, income inequality might have adverse impacts on individual health, and psychosocial stress due to relative deprivation may partially explain those impacts. Any study of the effects of macroeconomic fluctuations on health disparities should also consider multiple potential pathways, including expanding income inequality, changes in the labor market, and erosion of social capital. Further studies are needed to attain a better understanding of the social determinants of health in a rapidly changing society.     

Socioeconomic status and weight change in adults: a review

In developed countries, obesity is inversely associated with socioeconomic status (SES) among women, and less consistently among men; whereas, in developing countries, the association is direct. However, the relationship of SES to weight change over time is unknown. This relationship was the focus of the present literature review. It was hypothesized that, compared with persons of higher SES, persons of low SES would show greater weight gain or risk of weight gain over time. A search of electronic databases identified 34 relevant articles from developed countries reporting on studies that assessed the relationship of various measures of SES with weight change over time in adults (there were too few papers from developing countries (n = 1) to include). Results of the methodologically strongest studies (those which obtained objectively measured adiposity data and used a follow-up period of 4 years or more) showed that, among non-black samples, there were relatively consistent inverse associations between occupation and weight gain for men and women. When SES was assessed using education, evidence was slightly less consistent, but still provided some support for the hypothesized relationship. However, when income was used as the indicator of SES, findings were inconsistent, although there were fewer studies available. There was little support for a relationship between SES and weight gain for black samples. In the context of the worldwide epidemic of obesity, these findings suggest that in developed countries, weight gain prevention efforts might best be focused on those who are most socioeconomically disadvantaged, particularly those in lower status occupations.     

Race disparities in health among older adults: examining the role of productive engagement

Productive engagement is a potential pathway to health for older adults, but this relationship varies by race. This study examines the relationship of productive engagement to the health and observed health disparities of older African American and white adults. Productive activities include formal and irregular paid employment, caregiving, volunteering, and informal social assistance. The authors analyzed longitudinal panel data on individuals ages 60 and older from the Americans' Changing Lives survey with generalized estimating equations methods. Indicators of self-rated health and functional status were regressed separately on measures of productive engagement after accounting for sociodemographic differences and prior levels of health. Analyses were stratified by race and compared. Engagement in productive activities predicts better functional status for both groups, but higher self-rated health only among white adults. Number of activities performed was positively related to both health measures for all individuals, and hours of engagement and the ratio of paid to unpaid hours did not predict health outcomes.     

Socioeconomic status, self-rated health, and mortality in a multiethnic sample of US adults

Objective

To examine the association between socioeconomic status (SES), self-rated health (SRH), and mortality separately by race-ethnicity in a nationally representative sample of US adults.

Methods

We analyzed data from 16 716 adult women and men who were followed up for mortality for up to 12 years as part of the third National Health and Nutrition Examination survey (NHANES III). Poverty-income ratio (PIR) and education were assessed as measures of SES. All-cause mortality (n = 2850) was recorded from the NHANES III linked mortality file.

Results

Lower PIR was associated with mortality after adjustment for lifestyle, clinical risk factors, and SRH in all racial-ethnic groups (P-trend <0.005). In contrast, after adjusting for lifestyle and clinical risk factors, lower education was not associated with all-cause mortality in non-Hispanic whites (P-trend = 0.16), whereas the association remained significant after adjustment for SRH and lifestyle and clinical risk factors in other race-ethnicities (P-trend = 0.005; P-interaction between education categories and race-ethnicity was 0.02).

Conclusions

Our results suggest that lower PIR was associated with mortality in all racial-ethnic groups. In contrast, lower education was significantly associated with mortality only in racial-ethnic groups other than non-Hispanic whites. Our results indicate that, beyond lifestyle and clinical risk factors, adjusting for SRH resulted in only a modest change in the association of SES and mortality.Key words: education, income, self-rating of health, ethnicity, mortality, United States     

Relationships between hours of sleep and health-risk behaviors in US adolescent students

ObjectiveTo examine associations between insufficient sleep (< 8 h on average school nights) and health-risk behaviors.Methods2007 national Youth Risk Behavior Survey data of U.S. high school students (n = 12,154) were analyzed. Associations were examined on weighted data using multivariate logistic regression.ResultsInsufficient sleep on an average school night was reported by 68.9% of students. Insufficient sleep was associated with higher odds of current use of cigarettes (age-adjusted odds ratio [AOR], 1.67; 95% confidence interval [CI], 1.45–1.93), marijuana (AOR, 1.52; 95% CI, 1.31–1.76), and alcohol (AOR, 1.64; 95% CI, 1.46–1.84); current sexual activity (AOR, 1.41; 95% CI, 1.25–1.59); seriously considered attempting suicide (AOR, 1.86; 95% CI, 1.60–2.16); feeling sad or hopeless (AOR, 1.62; 95% CI, 1.43–1.84); physical fighting (AOR, 1.40; 95% CI, 1.24–1.60), not being physically active at least 60 min ≥ 5 days in the past 7 days (AOR, 1.16; 95% CI, 1.04–1.29), using the computer ≥ 3 h/day (AOR, 1.58; 95% CI, 1.38–1.80), and drinking soda/pop > 1 time/day (AOR, 1.14; 95% CI, 1.03–1.28).ConclusionTwo-thirds of adolescent students reported insufficient sleep, which was associated with many health-risk behaviors. Greater awareness of the impact of sleep insufficiency is vital.     

Socioeconomic disparities in the seroprevalence of cytomegalovirus infection in the US population: NHANES III

There is a strong relationship between socioeconomic status (SES) and health outcomes in the United States, although the mechanisms are poorly understood. Increasing evidence points to links between lifelong exposure to infectious disease and subsequent chronic disease. Exposure and susceptibility to infections may be one way SES affects long-term health, although little population-based research to date has examined social patterning of infections in the United States. This paper tests the relationship between income, education, race/ethnicity and seroprevalence of cytomegalovirus (CMV) infection at different ages in a representative sample of the US population, and tests potential mediators for these relationships. The study finds significant racial and socioeconomic disparities in CMV seroprevalence beginning at early ages and persisting into middle age. Potential exposures do not explain the relationship between SES and CMV positivity. Because reactivation of latent CMV infections may contribute to chronic disease and immune decline later in life, future research should determine the exposure or susceptibility pathways responsible for these disparities in the prevalence of CMV infection.     

The Boston Puerto Rican Health Study,a longitudinal cohort study on health disparities in Puerto Rican adults: challenges and opportunities

Background  

The Boston Puerto Rican Health Study is an ongoing longitudinal cohort study designed to examine the role of psychosocial stress on presence and development of allostatic load and health outcomes in Puerto Ricans, and potential modification by nutritional status, genetic variation, and social support.     

Predictors of health behaviors after the economic downturn: A longitudinal study

Economic declines and their associated stress, shortage of financial resources, and changes in available time can impair health behaviors. This study tested the association between change in working hours, change in employment status, and financial strain and health behaviors measured after the 2008 recession after controlling for pre-recession levels of the health behaviors. The moderating influences of demographic factors and pre-recession levels of the health behaviors on the association between change in working hours and employment status and financial strain and the health behaviors were also tested. Participants (N = 3984) were from a longitudinal study of a U.S. Midwestern community-based sample. Regression analyses tested the unique relations between change in hours worked per week, change in employment status, and financial strain and five health behaviors over and above demographic factors and pre-recession levels of the same behavior. Models included predictor by covariate interactions. Participants who reported higher levels of financial strain engaged in lower levels of all but one of the five health behaviors, but there were no significant main effects of a change in the number of hours worked per week or change in employment status. Significant interactions revealed moderation of these relations by demographic characteristics, but findings differed across health behaviors. Financial strain negatively affected engagement in multiple healthy behaviors. Promoting the maintenance of healthy behaviors for disease prevention is an important public health goal during times of economic decline.     

Stage of change movement across three health behaviors: the role of self-efficacy

PURPOSE: In this study, we examined the influence of self-efficacy in predicting stage of change (SOC) movement, without intervention, over a 1-month period for smoking cessation, exercise adoption, and dietary fat reduction. DESIGN: The design of this study was longitudinal. Patients' stage of change and self-efficacy were assessed at baseline, and stage of change was reassessed at a 1-month follow-up. Patients were categorized as (1) Regressors (moved backward at least one stage), (2) Stables (no change), or (3) Progressors (moved forward at least one stage). Chi-square analyses were used to determine the ability of self-efficacy to predict stage movement at 1-month follow-up. SETTING: The data were collected at a large, inner city, academic hospital in the southeastern United States. Patients were attending primary care clinics. SUBJECTS: Five hundred fifty-four low income, predominantly African-American, individuals attending primary care clinics were participants in the study. MEASURES: Previously validated scales of stage of change and self-efficacy from Prochaska's laboratory were used in this study. RESULTS: Results showed statistically significant differences between predicted and actual SOC movement for smoking cessation, exercise adoption, and dietary fat intake reduction. Baseline self-efficacy ratings were significantly related to stage progression, regression, and stability of stage of change for all three health behaviors. Thirty-seven percent of smokers who were predicted to progress on the basis of their self-efficacy scores progressed. For exercise adoption and dietary fat reduction, 50% and 44%, respectively, of individuals expected to progress at least one stage on the basis of self-efficacy scores progressed. CONCLUSION: Self-efficacy influences SOC movement for smoking cessation, dietary fat reduction, and exercise adoption.     

Socioeconomic disparities in the mental health of Indigenous children in Western Australia

ABSTRACT: BACKGROUND: The burden of mental health problems among Aboriginal and Torres Strait Islander children is a major public health problem in Australia. While socioeconomic factors are implicated as important determinants of mental health problems in mainstream populations, their bearing on the mental health of Indigenous Australians remains largely uncharted across all age groups. METHODS: We examined the relationship between the risk of clinically significant emotional or behavioural difficulties (CSEBD) and a range of socioeconomic measures for 3993 Indigenous children aged 4--17 years in Western Australia, using a representative survey conducted in 2000--02. Analysis was conducted using multivariate logistic regression within a multilevel framework. RESULTS: Almost one quarter (24%) of Indigenous children were classified as being at high risk of CSEBD. Our findings generally indicate that higher socioeconomic status is associated with a reduced risk of mental health problems in Indigenous children. Housing quality and tenure and neighbourhood-level disadvantage all have a strong direct effect on child mental health. Further, the circumstances of families with Indigenous children (parenting quality, stress, family composition, overcrowding, household mobility, racism and family functioning) emerged as an important explanatory mechanism underpinning the relationship between child mental health and measures of material wellbeing such as carer employment status and family financial circumstances. CONCLUSIONS: Our results provide incremental evidence of a social gradient in the mental health of Aboriginal and Torres Strait Islander children. Improving the social, economic and psychological conditions of families with Indigenous children has considerable potential to reduce the mental health inequalities within Indigenous populations and, in turn, to close the substantial racial gap in mental health. Interventions that target housing quality, home ownership and neighbourhood-level disadvantage are likely to be particularly beneficial.     

Physical activity levels and determinants of change in young adults: a longitudinal panel study

Background  

There is growing concern about physical inactivity in adolescents and young adults. Identifying determinants that are associated with low levels of physical activity and with changes in physical activity levels will help to develop specific prevention strategies. The present study describes the prevalence and potential determinants of physical activity behavior and behavior changes of young adults. The study is based on the Swiss Household Panel (SHP), a longitudinal study assessing social changes in a representative sample of Swiss households since 1999.     

Socioeconomic health inequalities in Latvia: a cross-sectional study

AIMS: Socioeconomic health differences have been studied elaborately for many Western societies. Relatively little is know about the social variations in health in the former communist states of Eastern Europe. This study investigated socioeconomic health inequalities in Latvia. METHODS: Cross-sectional analysis was undertaken of the 1999 Norbalt-II Living Conditions Survey, a random population-based sample in Latvia, and included males and females aged 25 to 70. RESULTS: Lower educated subjects had higher rates of self-assessed poor health than those with tertiary education (men OR 2.21; 1.31-3.71 95% CI, and women OR 2.48; 1.74-3.54 95% CI). After adjusting for income, educational differences were significant only for women. Income differences were larger than educational differences in self-assessed poor health for both genders (OR of highest vs. lowest quintile for men: 5.10; 2.26-11.5 95% CI, women: OR 3.26; 1.92-5.51 95% CI). For long-standing health problems socioeconomic differences were smaller. After adjusting for income no educational differences were found, but income differences were significant (men: OR 2.06; 1.15-3.69 95% CI, women: OR 1.42; 1.12-2.63 95% CI). The economically non-active were in worse health than the (self-)employed subjects (men: OR 6.12; 3.65-10.3 95% CI, women: OR 2.79; 1.66-3.39 95% CI). CONCLUSIONS: Substantial social inequalities in self-assessed poor health and longstanding health problems exist in Latvia for both sexes. Inequalities by material circumstances, as measured by income, appear to be larger than educational differences. Economic activity was also strongly associated with health. There were no inequalities with regard to urbanization and ethnic differences were found only for long-standing health problems among women.     

HABITAT: A longitudinal multilevel study of physical activity change in mid-aged adults

Background  

Little is known about the patterns and influences of physical activity change in mid-aged adults. This study describes the design, sampling, data collection, and analytical plan of HABITAT, an innovative study of (i) physical activity change over five years (2007–2011) in adults aged 40–65 years at baseline, and (ii) the relative contribution of psychological variables, social support, neighborhood perceptions, area-level factors, and sociodemographic characteristics to physical activity change.