Social inequity in health : Explanation from a life course and gender perspective

Background: A boy child born in a Gothenburg suburb has a life expectancy that is nine years shorter than that of another child just 23 km away, and among girls the difference is five years. There is no necessary biological reason to this observed difference. In fact, like life length, most diseases follow a social gradient, even in a country like Sweden where many believe there is no class inequity. This social inequity in health tells us that some of us are not achieving our potential in health or in life length compared to our more fortunate fellow citizens. Aim: This thesis attempts to explore the patterns of health inequities and the pathways by which health inequities develop from a life course and gender perspective. In particular focuses on the importance of material, behavioural, health related and psychosocial circumstances from adolescence to adulthood in explaining social inequity in musculoskeletal disorders (MSDs), obesity, smoking, and social mobility. Method: All four papers of this thesis were based on quantitative analyses of data from a 14-year follow-up study. The baseline survey was conducted in 1981 in Luleå, Sweden. The survey included all 16-year-old pupils born in 1965. A total of 1081 pupils (575 boys and 506 girls) were surveyed. They were followed up at ages 18, 21 and 30 years with comprehensive self-administered questionnaires. The response rate was 96.5% throughout the 14-year follow-up. In addition to the questionnaires data, school records, and interviews with nurse and teachers’ were used. Results: There were no class or gender differences in MSDs and in obesity during adolescence, but significantly more girls than boys were smokers. Class and gender differences had emerged when they reached adulthood with more women reporting to have MSDs but more men being overweight and obese. Women continued to be smokers at a higher rate than men through to adulthood. When an intersection between class and gender was considered, a more complex picture emerged. For example, not all women had higher prevalence of MSDs or smoked more than men, rather men with high socioeconomic position (SEP) had lower prevalences of MSDs and smoking than women with high SEP; and these high SEP women had lower prevalences than men with low SEP. The worst-off group was women with low SEP. The obesity pattern was quite the contrary, where women with high SEP had a lower prevalence of obesity than women with low SEP; and these low SEP women had a lower prevalence than men with high SEP. The worst-off group was men with low SEP. Regarding social mobility, health status (other than height in women) and ethnic background were not associated with mobility either for men or women. The results indicated that unequal distribution of material, psychosocial, health and health related behavioural factors during adolescence, young adulthood and adulthood accounted for the observed social gradients and social mobility. However, several factors from adolescence appeared to be more important for women while recent factors were more important for men. Important adolescent factors for social inequity and downward mobility were: unfavourable material circumstances defined as low SEP of parent, unemployed family member, and had no own room during upbringing; unfavourable psychosocial circumstances defined as parental divorce, poor contact with parents, being less liked in school, and low school control; and poor health related behaviour defined as smoking and physical inactivity. Among these factors, being less liked in school showed consistent association with all outcome measures of this thesis. Being less liked by the teachers and students was found to be more common among adolescents whose parents had low SEP. Men and women who were less liked in school during their adolescence were more likely as adults to be smokers, obese (only women), and downwardly mobile. The dominant adult life factor that contributed to class inequity in MSDs for men and women was physical heavy working conditions, which attributed to an estimated 46.9% (women) and 49.5% (men) of the increased risk in MSDs of the lower SEP group. High alcohol consumption among men with low SEP was an additional factor that contributed to class inequities in health and social mobility. Conclusion: Social patterning of health in this cohort was gendered and age specific depending on the outcome measures. Unfavourable school environment in early years had long lasting negative influence on later health, health behavior and SEP. The thesis supports the notion of accumulation of risk that social inequities in health occurs due to accumulation of multiple adverse circumstances among the lower SEP group throughout their life course. Schools should be used as a setting for interventions aimed at reducing socioeconomic inequities in health. The detailed policy implications for reduction of social inequities in health among men and women are discussed

Assessment of selection bias in a health survey of children and families – the IDEFICS Sweden-study

BACKGROUND: A health survey was performed in 2007-2008 in the IDEFICS/Sweden study (Identification and prevention of dietary- and lifestyle-induced health effects in children and infants) in children aged 2-9 years. We hypothesized that families with disadvantageous socioeconomic and -demographic backgrounds and children with overweight and obesity were underrepresented. METHODS: In a cross-sectional study, we compared Swedish IDEFICS participants (N=1,825) with referent children (N=1,825) using data from Statistics Sweden population registers. IDEFICS participants were matched for age and gender with a referent child living in the same municipality. Longitudinal weight and height data from birth to 8 years was collected for both populations (n=3,650) from the children's local health services. Outcome measures included the family's socioeconomic and demographic characteristics, maternal body mass index (BMI) and smoking habits before pregnancy, the children's BMI standard deviation score (SDS) at the age of inclusion in the IDEFICS study (BMISDS-index), and the children's BMI-categories during the age-span. Comparisons between groups were done and a multiple logistic regression analysis for the study of determinants of participation in the IDEFICS study was performed. RESULTS: Compared with IDEFICS participants, referent families were more likely to have lower education and income, foreign backgrounds, be single parents, and have mothers who smoked before pregnancy. Maternal BMI before pregnancy and child's BMISDS-index did not differ between groups. Comparing the longitudinal data-set, the prevalence of obesity was significantly different at age 8 years n= 45 (4.5%) versus n= 31 (2.9%) in the referent and IDEFICS populations, respectively. In the multivariable adjusted model, the strongest significant association with IDEFICS study participation was parental Swedish background (odds ratio (OR) = 1.91, 95% confidence interval (CI) (1.48-2.47) followed by parents having high education OR 1.80, 95% CI (1.02-3.16) and being married or co-habiting OR 1.75 95% CI (1.38-2.23). CONCLUSION: Families with single parenthood, foreign background, low education and income were underrepresented in the IDEFICS Sweden study. BMI at inclusion had no selection effect, but developing obesity was significantly greater among referents. © 2013 Regber et al.; licensee BioMed Central Ltd

Young patients with heart failure: clinical characteristics and outcomes. Data from the Swedish Heart Failure, National Patient, Population and Cause of Death Registers

Aims The prevalence and hospitalizations of patients with heart failure (HF) aged &amp;lt;55 years have increased in Sweden during the last decades. We aimed to compare characteristics of younger and older patients with HF, and examine survival in patients All patients &amp;gt;= 18 years in the Swedish Heart Failure Register from 2003 to 2014 were included. Data were merged with National Patient and Cause of Death Registers. Among 60 962 patients, 3752 (6.2%) were &amp;lt;55 years, and were compared with 7425 controls from the Population Register. Compared with patients &amp;gt;= 55 years, patients &amp;lt;55 years more frequently had registered diagnoses of obesity, dilated cardiomyopathy, congenital heart disease, and an ejection fraction &amp;lt;40% (9.8% vs. 4.7%, 27.2% vs. 5.5%, 3.7% vs. 0.8%, 67.9% vs. 45.1%, respectively; allP &amp;lt; 0.001). One-year all-cause mortality was 21.2%, 4.2%, and 0.3% in patients &amp;gt;= 55 years, patients &amp;lt;55 years, and controls &amp;lt;55 years, respectively (allP &amp;lt; 0.001). Patients &amp;lt;55 years had a five times higher mortality risk compared with controls [hazard ratio (HR) 5.48, 95% confidence interval (CI) 4.45-6.74]; the highest HR was in patients 18-34 years (HR 38.3, 95% CI 8.70-169; bothP &amp;lt; 0.001). At the age of 20, the estimated life-years lost was up to 36 years for 50% of patients, with declining estimates with increasing age. Conclusion Patients with HF &amp;lt;55 years had different comorbidities than patients &amp;gt;= 55 years. The highest mortality risk relative to that of controls was among the youngest patients.Funding Agencies|Swedish Research CouncilSwedish Research Council [2013-5187 SIMSAM]; Swedish state [ALFGBG-433211, ALFGBG-725081, ALFGBG-717211]; Swedish Heart and Lung FoundationSwedish Heart-Lung Foundation [2013-0307, 2018-0419, 2015-0438]; Vastra Gotaland Region; Gothenburg Society of Medicine [GLS-328971]; Swedish Council for Health, Working Life and Welfare (FORTE) [2013-0325]; Cardiology Research Foundation at the Medical Clinic at Sahlgrenska University Hospital/Ostra; Swedish National Board of Health and Welfare; Swedish Association of Local Authorities and Regions; Swedish Society of Cardiology and Cardiology Research Foundation</p

Young patients with heart failure: clinical characteristics and outcomes. Data from the Swedish Heart Failure, National Patient, Population and Cause of Death Registers

Aims The prevalence and hospitalizations of patients with heart failure (HF) aged &amp;lt;55 years have increased in Sweden during the last decades. We aimed to compare characteristics of younger and older patients with HF, and examine survival in patients All patients &amp;gt;= 18 years in the Swedish Heart Failure Register from 2003 to 2014 were included. Data were merged with National Patient and Cause of Death Registers. Among 60 962 patients, 3752 (6.2%) were &amp;lt;55 years, and were compared with 7425 controls from the Population Register. Compared with patients &amp;gt;= 55 years, patients &amp;lt;55 years more frequently had registered diagnoses of obesity, dilated cardiomyopathy, congenital heart disease, and an ejection fraction &amp;lt;40% (9.8% vs. 4.7%, 27.2% vs. 5.5%, 3.7% vs. 0.8%, 67.9% vs. 45.1%, respectively; allP &amp;lt; 0.001). One-year all-cause mortality was 21.2%, 4.2%, and 0.3% in patients &amp;gt;= 55 years, patients &amp;lt;55 years, and controls &amp;lt;55 years, respectively (allP &amp;lt; 0.001). Patients &amp;lt;55 years had a five times higher mortality risk compared with controls [hazard ratio (HR) 5.48, 95% confidence interval (CI) 4.45-6.74]; the highest HR was in patients 18-34 years (HR 38.3, 95% CI 8.70-169; bothP &amp;lt; 0.001). At the age of 20, the estimated life-years lost was up to 36 years for 50% of patients, with declining estimates with increasing age. Conclusion Patients with HF &amp;lt;55 years had different comorbidities than patients &amp;gt;= 55 years. The highest mortality risk relative to that of controls was among the youngest patients.Funding Agencies|Swedish Research CouncilSwedish Research Council [2013-5187 SIMSAM]; Swedish state [ALFGBG-433211, ALFGBG-725081, ALFGBG-717211]; Swedish Heart and Lung FoundationSwedish Heart-Lung Foundation [2013-0307, 2018-0419, 2015-0438]; Vastra Gotaland Region; Gothenburg Society of Medicine [GLS-328971]; Swedish Council for Health, Working Life and Welfare (FORTE) [2013-0325]; Cardiology Research Foundation at the Medical Clinic at Sahlgrenska University Hospital/Ostra; Swedish National Board of Health and Welfare; Swedish Association of Local Authorities and Regions; Swedish Society of Cardiology and Cardiology Research Foundation</p

Six-year mortality associated with living alone and loneliness in Swedish men and women born in 1930

Abstract Background This study examined how living alone and loneliness associate with all-cause mortality in older men and women. Methods Baseline data from the Gothenburg H70 Birth Cohort Studies, including 70-year-olds interviewed in 2000 and 75-year-olds (new recruits) interviewed in 2005 were used for analyses (N = 778, 353 men, 425 women). Six-year mortality was based on national register data. Results At baseline, 36.6% lived alone and 31.9% reported feelings of loneliness. A total of 72 (9.3%) participants died during the 6-year follow-up period. Cumulative mortality rates per 1000 person-years were 23.9 for men and 9.6 for women. Mortality was increased more than twofold among men who lived alone compared to men living with someone (HR 2.40, 95% CI 1.34–4.30). Elevated risk remained after multivariable adjustment including loneliness and depression (HR 2.56, 95% CI 1.27–5.16). Stratification revealed that mortality risk in the group of men who lived alone and felt lonely was twice that of their peers who lived with someone and did not experience loneliness (HR 2.52, 95% CI 1.26–5.05). In women, a more than fourfold increased risk of mortality was observed in those who experienced loneliness despite living with others (HR 4.52, 95% CI 1.43–14.23). Conclusions Living alone was an independent risk factor for death in men but not in women. Mortality was doubled in men who lived alone and felt lonely. In contrast, mortality was particularly elevated in women who felt lonely despite living with others. In the multivariable adjusted models these associations were attenuated and were no longer significant after adjusting for mainly depression in men and physical inactivity in women. Gender needs to be taken into account when considering the health consequences of living situation and loneliness

Parental perceptions of and concerns about child's body weight in eight European countries - the IDEFICS study: Parents' perception of their child's weight

Objectives: To evaluate parental perceptions of and concern about child's body weight and general health in children in a European cohort. Design: Cross-sectional multi-centre study in eight European countries. Participants 16220 children, ages 29 years. Methods: Parents completed a questionnaire regarding children's health and weight and concern about overweight and underweight. Objective children's weight categories from the International Obesity Task Force were used. Logistic regression models were utilized to identify predictors of accurate weight perception. Results: Parental weight perception corresponded overall to children's mean body mass index (BMI) z-scores, with important exceptions. About one-third of the total indicated concern about underweight, paradoxically most often parents of children in the overweight or obesity categories. In 63%, parents of children in the overweight category marked proper weight'. The strongest predictor for accurate parental weight perception for children with overweight and obesity was BMI z-score (odds ratio [OR]=7.2, 95% confidence interval [CI] 6.18.7). Compared to Southern Europe, ORs for accurate parental weight perception were 4.4 (95% CI 3.36.0) in Northern Europe and 3.4 (95% CI 2.74.2) in Central Europe. Conclusion: Parents of children categorized as being overweight or obese systematically underestimated weight. Parents differed regionally regarding accurate weight perception and concern about overweight and underweight