Differential vulnerability and susceptibility: how to make use of recent development in our understanding of mediation and interaction to tackle health inequalities

This paper discusses the concepts of vulnerability and susceptibility and their relevance for understanding and tackling health inequalities. Tackling socioeconomic inequalities in health is based on an understanding of how an individual’s social position influences disease risk. Conceptually, there are two possible mechanisms (not mutually exclusive): there is either some cause(s) of disease that are unevenly distributed across socioeconomic groups (differential exposure) or the effect of some cause(s) of disease differs across groups (differential effect). Since differential vulnerability and susceptibility are often used to denote the latter, we discuss these concepts and their current use and suggest an epidemiologically relevant distinction. The effect of social position can thus be mediated by causes that are unevenly distributed across social groups and/or interact with social position. Recent improvements in the methodology to estimate mediation and interaction have made it possible to calculate measures of relevance for setting targets and priorities in policy for health equity which include both mechanisms, i.e. equalize exposure or equalize effects. We finally discuss the importance of differential susceptibility and vulnerability for the choice of preventive strategies, including approaches that target high-risk individuals, whole populations and vulnerable groups

Cost-effectiveness of changes in alcohol taxation in Denmark:a modelling study

INTRODUCTION: Excessive alcohol consumption is a public health problem in many countries including Denmark, where 6% of the burden of disease is due to alcohol consumption, according to the new estimates from the Global Burden of Disease 2010 study. Pricing policies, including tax increases, have been shown to effectively decrease the level of alcohol consumption. METHODS: We analysed the cost-effectiveness of three different scenarios of changed taxation of alcoholic beverages in Denmark (20% and 100% increase and 10% decrease). The lifetime health effects are estimated as the difference in disability-adjusted life years between a Danish population that continues to drink alcohol at current rates and an identical population that changes their alcohol consumption due to changes in taxation. Calculation of cost offsets related to treatment of alcohol-related diseases and injuries, was based on health care system costs from Danish national registers. Cost-effectiveness was evaluated by calculating cost-effectiveness ratios (CERs) compared to current practice. RESULTS: The two scenarios of 20% and 100% increased taxation could avert 20,000 DALY and 95,500 DALY respectively, and yield cost savings of -€119 million and -€575 million, over the life time of the Danish population. Both scenarios are thus cost saving. The tax decrease scenario would lead to 10,100 added DALY and an added cost of €60 million. For all three interventions the health effects build up and reach their maximum around 15–20 years after implementation of the tax change. CONCLUSION: Our results show that decreased taxation will lead to an increased burden of disease and related increases in health care costs, whereas both a doubling of the current level of alcohol taxation and a scenario where taxation is only increased by 20% can be cost-saving ways to reduce alcohol related morbidity and mortality. Our results support the growing evidence that population strategies are cost-effective and should be considered for policy making and prevention of alcohol abuse

School-related mediators in social inequalities in smoking: a comparative cross-sectional study of 20,399 adolescents

<p>Abstract</p> <p>Background</p> <p>The aim of this study was to examine the associations between social inequalities and daily smoking among 13 and 15 year olds, and to determine the role of students' academic achievement and school satisfaction in these associations.</p> <p>Methods</p> <p>HBSC is an international study including adolescents from 32 countries in Europe, Israel, and North America. The present study was based on information from 20,399 adolescents from Denmark, Sweden, Norway, Finland and the United Kingdom. Data were analysed by regression models.</p> <p>Results</p> <p>The initial analyses showed significant inequality in daily smoking in all countries except for Sweden. When adjusted for the mediating role of academic achievement, estimates were attenuated, but remained significant in three countries.</p> <p>Conclusion</p> <p>The study found social inequality in daily smoking in Denmark, Sweden, Norway, Finland and United Kingdom, as well as inequalities in students' academic achievement and school satisfaction. The analyses also showed that above average academic achievement was associated with lower OR of smoking. Teachers and politicians may find this information useful, and allocate resources to give higher priority to a supportive environment in schools especially for children and adolescents in lower social groups. Subsequently this prioritisation might contribute to reducing smoking in this group.</p

Health promotion in primary and secondary schools in Denmark:time trends and associations with schools' and students' characteristics

BACKGROUND: Schools are important arenas for interventions among children as health promoting initiatives in childhood is expected to have substantial influence on health and well-being in adulthood. In countries with compulsory school attention, all children could potentially benefit from health promotion at the school level regardless of socioeconomic status or other background factors. The first aim was to elucidate time trends in the number and types of school health promoting activities by describing the number and type of health promoting activities in primary and secondary schools in Denmark. The second aim was to investigate which characteristics of schools and students that are associated with participation in many (≥3) versus few (0–2) health promoting activities during the preceding 2–3 years. METHODS: We used cross-sectional data from the 2006- and 2010-survey of the Health Behaviour in School-aged Children study. The headmasters answered questions about the school’s participation in health promoting activities and about school size, proportion of ethnic minorities, school facilities available for health promoting activities, competing problems and resources at the school and in the neighborhood. Students provided information about their health-related behavior and exposure to bullying which was aggregated to the school level. A total of 74 schools were available for analyses in 2006 and 69 in 2010. We used chi-square test, t-test, and binary logistic regression to analyze time trends and differences between schools engaging in many versus few health promoting activities. RESULTS: The percentage of schools participating in ≥3 health promoting activities was 63% in 2006 and 61% in 2010. Also the mean number of health promoting activities was similar (3.14 vs. 3.07). The activities most frequently targeted physical activity (73% and 85%) and bullying (78% and 67%). Schools’ participation in anti-smoking activities was significantly higher in 2006 compared with 2010 (46% vs. 29%). None of the investigated variables were associated with schools’ participation in health promoting activities. CONCLUSION: In a Danish context, schools’ participation in health promotion was rather stable from 2006 to 2010 and unrelated to the measured characteristics of the schools and their students

Helping chronically ill or disabled people into work: what can we learn from international comparative analyses?

This project has added to knowledge in five main areas: It has mapped the range and types of policies and interventions that have been implemented in Canada, Denmark, Norway, Sweden and the UK that may influence employment chances for chronically ill and disabled people. By doing so it has added to understanding about what has actually been tried in each country and what might be considered in others. It has refined a typology of the focussed interventions that have been identified, based on the underlying programme logic of the intervention, which aids strategic thinking about national efforts to help chronically ill and disabled people into work. It has produced systematic reviews of the impact of the focussed interventions on the employment chances of chronically ill and disabled people and demonstrated the use of the typology in helping to interpret the results of the evaluations. The project’s empirical analyses of individual-level data have identified how chronically ill people from different socio-economic groups have fared in the labour markets of the five countries over the past two decades. It has then tested these findings against hypotheses about the impact of macro-level labour market policies on chronically ill people to provide insights into the influence of the policy context. The project has contributed to methodological development in evidence synthesis and the evaluation of natural policy experiments. By studying a small number of countries in great depth, we gained greater understanding of the policies and interventions that have been tried in these countries to help chronically ill and disabled people into work, against the backdrop of the wider labour market and macro-economic trends in those countries. We then integrated evidence from the wider policy context into the findings of systematic reviews of effectiveness of interventions, to advance interpretation of the natural policy experiments that have been implemented in these countries