Dissertations / Theses on the topic 'Health; socioecomic position'

Background: The National Health Service (NHS) aims to achieve maximum health gains with its limited resources, while also ensuring that it provides services according to need, irrespective of factors such as socioeconomic position (SEP). Aim: The aim of this thesis is to explore the relationships between SEP and various aspects of the NHS orthodontic service, including need, demand, supply, and outcomes. Methods: Three main data sources were used: two population-based surveys (the 2003 United Kingdom (UK) Children’s Dental Health Survey (CDHS) and the 2008-2009 NHS Dental Epidemiology Programme for England Oral Health Survey (OHS) in the North West) and an administrative data set (containing 2008-2012 North West NHS orthodontic activity data). The data were used to investigate levels of need and willingness to have orthodontic treatment, treatment utilisation, assessment procedures, and treatment outcomes, and the costs associated with the service. Subsequently, regression analyses were carried out to explore the associations between SEP and the various orthodontic variables. Results: Over a third of 12-year-olds had normative need for orthodontic treatment and over half had patient-defined need. Those in the most deprived groups in the North West tended to have lower levels of treatment compared to those in the least deprived group (despite the fact that normative need was not shown to vary by SEP), and they were more likely to discontinue treatment and have residual post-treatment need (RPTN). There was a great deal of variation among practices/orthodontic clinicians in terms of the percentages of patients with repeated assessments, treatment discontinuations, and RPTN. The major sources of potential inefficiency costs in the NHS orthodontic service in the North West are treatments that result in discontinuations (which cost £2.4 million per year), RPTN (which cost £1.8 million per year), and unreported treatment outcomes (which cost £13.0 million per year). Discussion: The NHS is not delivering orthodontic care equitably between SEP groups in the North West, as those from more deprived groups are more likely to fail to receive treatment, and to have poor outcomes if they do receive treatment. In addition, the wide range of process and outcome indicators between practices/orthodontic clinicians raises issues about quality of the overall service. In particular, treatment outcomes are frequently unreported, which highlights the need to improve the outcome monitoring systems in the NHS orthodontic service.

Background: In Russia, the educational gradient in mortality increased during the 1990s. However, there have been few comparisons of gradients using different socioeconomic indicators. Aims: These were to study the association of different measures of socioeconomic position with each other and with health, together with possible explanations. Data: The Russia Longitudinal Monitoring Survey is a large, nationally representative panel study. Data from 7 rounds (1994-2001) were used to study 11,482 adults aged over 18. Social and economic measures, self-rated health and deaths (reported by a household member) were recorded. Methods: Correlations between income, education, occupation and subjective social status were measured. Their associations with self-rated health and mortality were studied using logistic regression and Cox proportional hazards analysis respectively, including multivariate analyses. Results: Education and occupation were strongly correlated (R=0.52). Both were weakly associated with income (R=0.08 and 0.13 respectively). Education (3 categories) was strongly protective against mortality 0.66 (0.59-0.74) men, 0.66 (0.59-0.74) women , and education explained the weaker associations between income, occupation and mortality. Although alcohol consumption and smoking predicted mortality, they did not explain its association with socioeconomic position. Income, occupation and education were all moderately associated with self-rated health. Subjective social status strongly predicted self-rated health, but not mortality. Ownership of consumer goods, satisfaction and optimism predicted self-rated health, but did not fully explain its association with socioeconomic position. Unemployment and insecure employment were associated with health, although inconsistently. Discussion: Income was weakly associated with education and occupation compared to the West. Socioeconomic gradients in self-rated health and mortality were demonstrated, and were not fully explained by alcohol, smoking, material and psychosocial measures. The strong association between education and mortality could perhaps be because it reflects lifetime socioeconomic position. Associations between education, smoking and mortality were comparable to other studies, supporting the reliability of the data.

The mechanisms by which life course socioeconomic position (SEP) may influence cardiovascular disease (CVD) are not well explored. Objectives were to investigate the association between cumulative life course SEP and an indicator of subclinical atherosclerosis: ankle-brachial index (ABI). Participants (n=1454) were from the Framingham Heart Study Offspring Cohort. Cumulative SEP was calculated by summing scores for childhood SEP (father's education), early adulthood SEP (own education), and active professional life SEP (own occupation). ABI was dichotomized as low (≤1.1) and normal (>1.1 to 1.4). In logistic regression analyses, cumulative SEP was associated with low ABI in men (odds ratio [OR]=2.09, 95% confidence interval [CI]: 1.24,3.51 for low vs. high cumulative SEP score) but not in women (OR=0.94, 95% CI: 0.63,1.38), after adjustment for age and CVD risk markers. This effect was largely explained by the association of own education with low ABI in men and not in women. Father's education and own occupation were not significantly associated with low ABI in men or women. In conclusion, while cumulative SEP was inversely associated with ABI in men, this effect was primarily due to own education.<br>Les mécanismes par lesquels la situation socio-économique (SSE) pourrait influencer les maladies cardiovasculaires (MCV) ne sont pas bien définis. Les objectifs de cette étude sont d'examiner la relation entre la SSE au cours d'une vie et l'athérosclérose sous-clinique, telle que mesurée par le "Indice de Pression Cheville Brachial ABPI", aussi connu sous le nom de "index ABPI''. Les participants (n=1454) provenaient de l'étude de cohortes Framingham Heart Study Offspring. La SSE cumulative a été calculée en additionnant les résultats pour la SSE durant l'enfance (scolarité du père), la SSE durant la period le jeune et l'adolescence (sa propre scolarité) et la SSE durant la vie professionnelle active (sa propre profession). L'index ABPI a été divisé en deux fractions, notamment la fraction basse (≤1.1) et normale (>1.1 à 1.4). Dans des analyses de régression logistique, la SSE cumulative a été associée à un index ABPI bas pour les hommes, mais pas pour les femmes, après l'ajustement pour le sexe et pour les facteurs risque de MCV. Ce résultat s'explique largement par l'association entre sa propre scolarité et un index ABPI bas dans le cas des hommes, mais pas dans les cas des femmes. Il n'y a pas eu d'association significative entre scolaritè du père ou sa propre profession et un index ABPI bas ni pour les hommes, ni pour les femmes. On peut donc conclure que si la SSE cumulative a été inversement proportionnelle à l'index ABPI pour les hommes, cela est principalement dû à sa propre scolarité.

This thesis aims to describe health inequalities among older people in Britain in the 1980s and 1990s and to assess whether various personal circumstances and experiences contribute towards this variation. Three sources of data are used: the Longitudinal Study; the first Whitehall cohort of male civil servants; and baseline quality of life information from the MRC Trial of the Assessment and Management of Older People in the Community (MRC Study). Housing tenure, car availability, and employment grade are the main socioeconomic measures used, but also social class and income. Findings: People disadvantaged in mid-life socioeconomic circumstances continue to experience increased risks of mortality, insitutionalisation, poor self-reported health and functioning 20-30 years later. Smoking and cardio-respiratory factors in middle age partially accounted for the differentials found in the Whitehall Study. The MRC Study revealed worse prospects for five dimensions of health-related quality of life among people in rented homes compared to owner-occupied ones, even among those who were deemed independent. Symptoms of ill health, and health behaviours accounted for over 40% of the housing tenure differentials in quality of life among these independent people. Being in a deprived or densely-populated area was not as strong a discriminator of quality of life as personal housing-tenure. Finally, people whose socioeconomic circumstances become worse in late middle age have greater risks of poor health outcomes than those who stay advantaged. The findings on benefits of improvements in socioeconomic circumstances are more mixed and complicated by ill health leading to apparent upward socioeconomic mobility. Conclusions: The three studies provide evidence of both long-term implications of socioeconomic position in mid-life and continuing relevance of socioeconomic position in old age. Although personal factors and health symptoms contribute to health inequalities in old age they are also seen as a possible product of socioeconomic position.

Early-life socioeconomic position (SEP) contributes to disease risk in adults, however, there is mixed evidence for the role of early-life SEP in adult depression. Using logistic regression analysis we explore whether parents' education influences the risk for major depressive episode (MDE) independent of other early-life and adult risk factors. Data are from the first seven waves of the Canadian National Population Health Survey (1994/95 to 2006/07), and include 1,267 participants that were aged 12 to 24 at wave one. Father's education has no effect. Respondents of mothers with less than secondary school are at increased risk for MDE (OR: 2.04, 95% CI: 1.25, 3.32) compared to respondents of more educated mothers. Adjusting for the respondent's adverse childhood experiences, SEP, psychosocial factors, and physical health does not reduce the impact of maternal education. These results suggest that maternal education may play a significant role in the aetiology of adult depression.<br>Les résultats concernant le rôle de la position socioéconomique d'origine sur la dépression à l'âge adulte sont contradictoires. A l'aide de modèles de régression logistique, nous avons évalué l'impact du niveau d'étude des parents sur les épisodes dépressifs majeurs (EDM). Les données proviennent des sept premières vagues de l'Enquête nationale sur la santé de la population (1994/95 à 2006/07). Nous avons retenu 1,267 participants âgés de 12 à 24 ans à l'inclusion. Le niveau d'étude du père n'avait pas d'effet. Le risque de déclarer un EDM était plus élevé chez les répondants dont la mère avait un faible niveau d'étude (OR: 2.04, IC 95%: 1.25, 3.32). L'impact du niveau d'éducation de la mère n'était pas diminué après ajustement sur les expériences difficiles durant l'enfance, la position socioéconomique, les facteurs psychosociaux et l'état de santé physique. Ces résultats suggèrent que le niveau d'étude de la mère joue un rôle important dans l'étiologie de la dépression à l'âge adulte.

The purpose of this study was to investigate the relationship between mental illness and socioeconomic factors such as education, age and gender among drug users. Descriptive and ANOVA analysis were performed to 68 structured interviews (Addiction Severity Index basic). Analysis addressed associations between drug usage and level of education, age and gender. Results showed gender differences in self-rated mental health with women drug users rating their mental health lower than men. In addition, there was no association between age, educational level and self-rated mental health. Further studies are warranted to investigate mental health among drug users.

This cross-sectional study of a 45 to 60 year old Brisbane population examined socioeconomic differences in campaign reach, understanding of health language, and effectiveness, of a recent mass media health promotion campaign. Lower socioeconomic groups were reached significantly less and understood significantly less of the health language than higher socioeconomic groups thus contributing to the widening of the health inequality gap.

In Australia, and other Western countries, there are marked socioeconomic inequalities in mortality from chronic, diet-related diseases. Research in these countries has shown that adults from low socioeconomic backgrounds experience greater morbidity and mortality from these conditions compared to their higher-status counterparts. In recent decades, much research has focused on factors that may contribute to these inequalities. Dietary intakes are thought to account for a large proportion of the socioeconomic variability in health, and there is some evidence suggesting that the psychosocial foundations laid down in adolescence are important influences on these dietary intakes. In Australia, however, existing research examining socioeconomic differences in dietary intakes is limited. Most previous research has looked at dietary intakes in adulthood, and have not considered examining for socioeconomic differences in adolescence. Furthermore, not much is known about the health and nutrition-related beliefs, attitudes and perceptions of adolescents that may contribute to socioeconomic differences in dietary intakes. This study examined these issues by analysing for socioeconomic differences in food and nutrient intakes among both adolescents and adults. It also investigated some health and nutrition-related beliefs, attitudes and perceptions of adolescents from different socioeconomic backgrounds. Data from a national cross-sectional survey, the 1995 Australian National Nutrition Survey, were analysed to determine socioeconomic differences in food and nutrient intakes. Qualitative interviews were undertaken with adolescents to investigate their health and nutrition-related beliefs, attitudes and perceptions. The results show that compared to adults, there is less socioeconomic inequality in food and nutrient intakes among adolescents. Intakes of some anti-oxidant vitamins and folate were directly related with socioeconomic position among adults. Adults from low socioeconomic backgrounds were less likely to consume fruits or vegetables. They consumed a lower variety of fruits and vegetables and were less likely to choose fruits and vegetables high in vitamin A, folate and vitamin C. The results showed that these differences may be due to adults from low socioeconomic backgrounds being less likely to want to increase their fruit and vegetable intakes, and perceiving price and storage as barriers to doing so. There were a small number of socioeconomic differences in adolescents' beliefs, attitudes and perceptions about nutrition and health that may contribute to dietary intake inequalities in adulthood. Adolescents from lower socioeconomic backgrounds were less likely to see health as being important for achieving goals, and identified nutrients and sleep as influencing their health less frequently. These adolescents also referred to dietary recommendations, nutrient intakes, dairy foods and avoiding school canteen foods less frequently when describing a healthy diet. A number of recommendations about the design and targeting of nutrition-promotion campaigns and interventions are discussed, as well as future directions for research on socioeconomic differences in dietary intakes.

In Australia, and other Western countries, there are marked socioeconomic inequalities in mortality from chronic, diet-related diseases. Research in these countries has shown that adults from low socioeconomic backgrounds experience greater morbidity and mortality from these conditions compared to their higher-status counterparts. In recent decades, much research has focused on factors that may contribute to these inequalities. Dietary intakes are thought to account for a large proportion of the socioeconomic variability in health, and there is some evidence suggesting that the psychosocial foundations laid down in adolescence are important influences on these dietary intakes. In Australia, however, existing research examining socioeconomic differences in dietary intakes is limited. Most previous research has looked at dietary intakes in adulthood, and have not considered examining for socioeconomic differences in adolescence. Furthermore, not much is known about the health and nutrition-related beliefs, attitudes and perceptions of adolescents that may contribute to socioeconomic differences in dietary intakes. This study examined these issues by analysing for socioeconomic differences in food and nutrient intakes among both adolescents and adults. It also investigated some health and nutrition-related beliefs, attitudes and perceptions of adolescents from different socioeconomic backgrounds. Data from a national cross-sectional survey, the 1995 Australian National Nutrition Survey, were analysed to determine socioeconomic differences in food and nutrient intakes. Qualitative interviews were undertaken with adolescents to investigate their health and nutrition-related beliefs, attitudes and perceptions. The results show that compared to adults, there is less socioeconomic inequality in food and nutrient intakes among adolescents. Intakes of some anti-oxidant vitamins and folate were directly related with socioeconomic position among adults. Adults from low socioeconomic backgrounds were less likely to consume fruits or vegetables. They consumed a lower variety of fruits and vegetables and were less likely to choose fruits and vegetables high in vitamin A, folate and vitamin C. The results showed that these differences may be due to adults from low socioeconomic backgrounds being less likely to want to increase their fruit and vegetable intakes, and perceiving price and storage as barriers to doing so. There were a small number of socioeconomic differences in adolescents' beliefs, attitudes and perceptions about nutrition and health that may contribute to dietary intake inequalities in adulthood. Adolescents from lower socioeconomic backgrounds were less likely to see health as being important for achieving goals, and identified nutrients and sleep as influencing their health less frequently. These adolescents also referred to dietary recommendations, nutrient intakes, dairy foods and avoiding school canteen foods less frequently when describing a healthy diet. A number of recommendations about the design and targeting of nutrition-promotion campaigns and interventions are discussed, as well as future directions for research on socioeconomic differences in dietary intakes.

Background: International research has shown that socioeconomically disadvantaged groups experience significantly higher mortality and morbidity rates than other groups. Both cardiovascular disease (CVD) and diabetes are major contributors to Australia's burden of disease, and individuals from lower socioeconomic groups are more likely to be affected by both, and to have worse prognoses and outcomes. There is substantial research evidence that a range of preventive activities can reduce the morbidity and mortality associated with these conditions. Research in countries with good access to primary health care services has demonstrated that socioeconomically disadvantaged groups tend to have higher levels of medical consultations, but make less use of preventive care and screening services. This fact contributes to their poorer health outcomes, as diagnosis will typically occur later than for more advantaged individuals, thus leading to a poorer prognosis. However, to date, there has been little research on the differential utilisation of preventive health services for CVD and diabetes by different socioeconomic groups in Australia. To understand socioeconomic influences on the use of preventive health services, a comprehensive review of the literature of determinants of health service utilisation was conducted and a number of explanations for this relationship considered. It was proposed that the following factors are likely to be important in this relationship: differences in the perception of the availability of, and accessibility to health care, attitudes and beliefs toward preventive health care, having a regular source of care, perception of interpersonal care from general practitioners, and social support. A number of theoretical models were also reviewed; in particular, the Andersen Behavioural Model of Health Service Research Utilisation. Aims: This doctoral research program has described the relationship between socioeconomic position (SEP) and utilisation of preventive health services in relation to CVD and diabetes. It aims to improve the understanding of the determinants of uptake and utilisation of preventive health services in general practice by different socioeconomic groups in Australia. Methods: The study was conducted in Brisbane Australia, in 2004, using a cross-sectional design and a self-administered mailed survey for data collection. A sample of adults aged 25-64 years was selected randomly from the Brisbane Electoral Roll. A conceptual model incorporating a range of relevant socio-demographic, risk-factor and behavioural variables in the relationship between SEP and GP-based use of preventive health services was used to develop a self-administered questionnaire. The questionnaire was pilot-tested and then reviewed by a panel of international experts. A new self-administered questionnaire, the Health Service Utilisation Questionnaire (HSUQ), was developed. It included 79 items: 12 socio-demographic items; 10 items assessing health status, disease conditions and smoking status; 20 items assessing use of health services; and 37 items assessing the factors that might affect use of health services utilisation. The HSUQ was then mailed to 800 randomly selected survey participants. The survey response rate was 65.6 per cent. After exclusion of those patients with cardiovascular diseases and diabetes, the final sample size was 381, consisting of 155 males and 226 females. Socioeconomic indicators were individual education level and family income. Blood pressure, blood cholesterol and blood glucose check-ups by general practitioners (GPs) were used as the major outcome variables. Nine scales and two dichotomous variables that measure those potential factors were derived following Principal Component Analysis and reliability testing. The data were analysed separately by gender, and adjusted for age and each of the socioeconomic indicators. Statistical description, bivariate analysis and multivariable modelling in SPSS were applied for the data analysis. Results: The survey results were suggestive of socioeconomically disadvantaged people being less likely than more advantaged people to utilise preventive health services for CVD and diabetes. For males, the low socioeconomic groups recorded the least use of preventive health services among the three education and income groups, including blood cholesterol and blood glucose check-ups, while the high socioeconomic group recorded the greatest use of preventive health services. There was no apparent relationship between education level and blood pressure check-up, while individuals from low-income families were less likely to go for a blood pressure check-up. For females, most of the results suggested that the low socioeconomic groups were less likely than the high socioeconomic groups to have blood cholesterol and blood glucose check-ups. However, this was not the case for blood pressure check-ups. The results showed that the low and middle socioeconomic groups were more likely than the high socioeconomic groups to have BP check-ups. However, the low socioeconomic groups were still less likely than the middle socioeconomic groups to have a blood pressure check-up. Overall, there was a similar pattern between education and income and the use of GP-based preventive health services among both males and females. The findings from the examination of the mediating factors between SEP and the GP-based use of preventive health services suggested that socioeconomically disadvantaged adults (both low level of education and low income) are more concerned about transport and travel time to health care, and accessibility to health care in terms of finding a GP who bulk bills, the cost of seeing a GP and having a choice of GP. They are also less likely to have a regular place of care and social support. These potential factors are likely to result in a lesser use of preventive health services than their high-SEP counterparts. In addition, the findings also suggested that respondents with a low level of education have less-positive attitudes towards health care, and that those from low-income families do not have a regular care provider and are less likely to visit their GP for a preventive check-up in relation to CVD and diabetes in Australia. Conclusions: Strategies for reducing socioeconomic health inequalities are partly associated with changing social and economic policies, empowering individuals, strengthening social and family networks, and improving the equity of the health care system. Strategies have been recommended for implementation in general practice that are directed at targeting the needs of disadvantaged groups; for example, providing longer consultation time and actively offering information on preventive care. Implementation of health promotion programs is needed in disadvantaged areas to keep the community informed about the availability of health services and to make health services more accessible. The health care system needs to be geographically accessible through improvements to the transport system. In addition, improving access to a regular source of primary health care is likely to be an important step in encouraging low-SEP individuals to use preventive health services.

Background: International research has shown that socioeconomically disadvantaged groups experience significantly higher mortality and morbidity rates than other groups. Both cardiovascular disease (CVD) and diabetes are major contributors to Australia's burden of disease, and individuals from lower socioeconomic groups are more likely to be affected by both, and to have worse prognoses and outcomes. There is substantial research evidence that a range of preventive activities can reduce the morbidity and mortality associated with these conditions. Research in countries with good access to primary health care services has demonstrated that socioeconomically disadvantaged groups tend to have higher levels of medical consultations, but make less use of preventive care and screening services. This fact contributes to their poorer health outcomes, as diagnosis will typically occur later than for more advantaged individuals, thus leading to a poorer prognosis. However, to date, there has been little research on the differential utilisation of preventive health services for CVD and diabetes by different socioeconomic groups in Australia. To understand socioeconomic influences on the use of preventive health services, a comprehensive review of the literature of determinants of health service utilisation was conducted and a number of explanations for this relationship considered. It was proposed that the following factors are likely to be important in this relationship: differences in the perception of the availability of, and accessibility to health care, attitudes and beliefs toward preventive health care, having a regular source of care, perception of interpersonal care from general practitioners, and social support. A number of theoretical models were also reviewed; in particular, the Andersen Behavioural Model of Health Service Research Utilisation. Aims: This doctoral research program has described the relationship between socioeconomic position (SEP) and utilisation of preventive health services in relation to CVD and diabetes. It aims to improve the understanding of the determinants of uptake and utilisation of preventive health services in general practice by different socioeconomic groups in Australia. Methods: The study was conducted in Brisbane Australia, in 2004, using a cross-sectional design and a self-administered mailed survey for data collection. A sample of adults aged 25-64 years was selected randomly from the Brisbane Electoral Roll. A conceptual model incorporating a range of relevant socio-demographic, risk-factor and behavioural variables in the relationship between SEP and GP-based use of preventive health services was used to develop a self-administered questionnaire. The questionnaire was pilot-tested and then reviewed by a panel of international experts. A new self-administered questionnaire, the Health Service Utilisation Questionnaire (HSUQ), was developed. It included 79 items: 12 socio-demographic items; 10 items assessing health status, disease conditions and smoking status; 20 items assessing use of health services; and 37 items assessing the factors that might affect use of health services utilisation. The HSUQ was then mailed to 800 randomly selected survey participants. The survey response rate was 65.6 per cent. After exclusion of those patients with cardiovascular diseases and diabetes, the final sample size was 381, consisting of 155 males and 226 females. Socioeconomic indicators were individual education level and family income. Blood pressure, blood cholesterol and blood glucose check-ups by general practitioners (GPs) were used as the major outcome variables. Nine scales and two dichotomous variables that measure those potential factors were derived following Principal Component Analysis and reliability testing. The data were analysed separately by gender, and adjusted for age and each of the socioeconomic indicators. Statistical description, bivariate analysis and multivariable modelling in SPSS were applied for the data analysis. Results: The survey results were suggestive of socioeconomically disadvantaged people being less likely than more advantaged people to utilise preventive health services for CVD and diabetes. For males, the low socioeconomic groups recorded the least use of preventive health services among the three education and income groups, including blood cholesterol and blood glucose check-ups, while the high socioeconomic group recorded the greatest use of preventive health services. There was no apparent relationship between education level and blood pressure check-up, while individuals from low-income families were less likely to go for a blood pressure check-up. For females, most of the results suggested that the low socioeconomic groups were less likely than the high socioeconomic groups to have blood cholesterol and blood glucose check-ups. However, this was not the case for blood pressure check-ups. The results showed that the low and middle socioeconomic groups were more likely than the high socioeconomic groups to have BP check-ups. However, the low socioeconomic groups were still less likely than the middle socioeconomic groups to have a blood pressure check-up. Overall, there was a similar pattern between education and income and the use of GP-based preventive health services among both males and females. The findings from the examination of the mediating factors between SEP and the GP-based use of preventive health services suggested that socioeconomically disadvantaged adults (both low level of education and low income) are more concerned about transport and travel time to health care, and accessibility to health care in terms of finding a GP who bulk bills, the cost of seeing a GP and having a choice of GP. They are also less likely to have a regular place of care and social support. These potential factors are likely to result in a lesser use of preventive health services than their high-SEP counterparts. In addition, the findings also suggested that respondents with a low level of education have less-positive attitudes towards health care, and that those from low-income families do not have a regular care provider and are less likely to visit their GP for a preventive check-up in relation to CVD and diabetes in Australia. Conclusions: Strategies for reducing socioeconomic health inequalities are partly associated with changing social and economic policies, empowering individuals, strengthening social and family networks, and improving the equity of the health care system. Strategies have been recommended for implementation in general practice that are directed at targeting the needs of disadvantaged groups; for example, providing longer consultation time and actively offering information on preventive care. Implementation of health promotion programs is needed in disadvantaged areas to keep the community informed about the availability of health services and to make health services more accessible. The health care system needs to be geographically accessible through improvements to the transport system. In addition, improving access to a regular source of primary health care is likely to be an important step in encouraging low-SEP individuals to use preventive health services.

Background: Social inequalities in health represent one of the greatest challenges to public health today. Traditionally, studies investigating health inequalities have treated gender, ethnicity, and socioeconomic position as independent and additive explanatory variables. Consequently, important health inequalities that exist at the intersection of social groups remain invisible and unaccounted for. Aim: An intersectionality framework was employed to investigate the role of intersections of gender, ethnicity and socioeconomic position in explaining health inequalities among adults living in England. The objectives of the study were firstly, to establish whether intersections of gender, ethnicity, and socioeconomic position in health are present among adults in England, and secondly, to explore the contextual and explanatory factors perceived to underlie these intersections. Methods: A sequential explanatory mixed methods design comprising a quantitative phase followed by a qualitative phase was employed. In the quantitative phase, data from the Health Survey for England 2004 were analysed to test for significant interaction effects between gender, ethnicity, and socioeconomic indicators, with three measures of subjective health. In the qualitative phase, a subset of significant interactions relating to Pakistani and White English survey participants were explored using semi-structured interviews with 25 Pakistani and White English women recruited in South Yorkshire. Findings: The quantitative analysis identified 15 significant interaction effects (P<0.05). Each dimension of inequality (i.e. gender, ethnicity, socioeconomic position) was found to significantly interact with at least one other on one or more health outcome. The qualitative analysis revealed how overlapping systems of discrimination were perceived to underlie the burden of poor health experienced among Pakistani women living in England. Conclusions: This thesis demonstrates both quantitative and qualitative evidence for intersections of gender, ethnicity, and socioeconomic position in health inequalities in England. These findings highlight the need for policies seeking to reduce social inequalities in health to take account of intersectionality.

The global prevalence of diabetes has achieved epidemic proportions and is expected to continue to climb. Approximately 90-95% of diabetes cases are type 2 diabetes, a disease that disproportionally affects disadvantaged populations. To assess the associations of timing and duration of socioeconomic position (SEP) across the life course on incidence of type 2 diabetes, we conducted a prospective analysis of 1,895 participants from the Framingham Offspring Study. We used three life course epidemiology frameworks to conceptualize SEP: accumulation of risk, sensitive periods and social mobility. We found that cumulative exposure to low SEP across the life course increased risk for developing type 2 diabetes in women and not men. In addition, adulthood may be a sensitive period where if exposed to low SEP (education and/or occupation), women have increased risk for developing type 2 diabetes.<br>La prévalence du diabète à l'échelle planétaire atteint maintenant des proportions épidémiques. Environ 90-95% des cas de diabète sont de type 2 et cette maladie affecte de manière disproportionnée les populations défavorisées. Afin d'examiner l'association de facteurs biographiques reliés à la position socio-économique (PSE) et l'incidence du diabète de type 2, une étude prospective portant sur 1,895 participants de la 'Framingham Offspring Study' a été menée. Trois cadres conceptuels épidémiologiques ont été utilisés pour abstraire la PSE : l'accumulation du risque, les périodes critiques et la mobilité sociale. Les résultats démontrent que l'exposition cumulée à une basse PSE accroît le risque de développer un diabète de type 2 chez la femme mais non chez l'homme. De plus, l'âge adulte est une période critique chez la femme durant laquelle l'exposition a une basse PSE (éducation et/ou occupation) augmente le risque de développer un diabète de type 2.

Background: Oral cancer has high incidence and mortality rates in both the developed and developing world. Its main risk factors are tobacco and alcohol consumption and, in India, paan chewing habits. Although socioeconomic position (SEP) has been associated with oral cancer, no studies have assessed this association using life course SEP in an Indian population. Objective: To estimate the extent to which life course SEP is an independent risk factor for oral cancer and how much of this association is explained by behavioural habits and oral health related factors in a sample of Indian subjects. Methods: Data from 200 oral cancer cases and 150 controls were drawn from an ongoing hospital-based case-control study: HeNCe Life (Head and Neck Cancer Life course) study. Detailed information regarding SEP, behavioural and oral health factors over the life course was collected using a questionnaire and a life grid technique. Data analysis involved descriptive and logistic regression analysis. Results: Subjects who were in low SEP throughout their lives were at significant risk for oral cancer (OR=5.81, 95% CI: 2.90-11.64) when compared to those who spent their lives in high SEP. The addition of behavioural and oral health factors into the models attenuated this association (OR= 2.08, 95% CI: 0.89-4.89 for low SEP compared to high SEP). However, low lifetime SEP was still related to an increased risk of oral cancer. Conclusion: Low life course SEP is a significant risk factor for oral cancer in this population.<br>Introduction: Le cancer oral présente des taux d'incidence et de mortalité élevés, à la fois dans les pays développés et ceux en voie de développement. Ses facteurs de risque principaux sont la consommation de tabac et d'alcool et, en Inde, les habitudes de mâchage. Bien que la position socioéconomique (PSE) ait été associée avec le cancer oral, aucune étude n'a encore évalué cette association en utilisant la PSE tout au long de la vie chez une population indienne. Objectif: Estimer le degré auquel la PSE tout au long de la vie est un facteur de risque indépendant pour le cancer oral et à quel point cette association est expliquée par des habitudes comportementales et des facteurs reliés à la santé buccodentaire dans un échantillon de sujets indiens. Méthode: Des données portant sur 200 cas de cancer oral et 150 témoins ont été tirées d'une étude cas-témoins en cours dans les hôpitaux: l'étude HeNCe Life (Head and Neck Cancer Life course). De l'information détaillée concernant la PSE, des facteurs comportementaux et de santé buccodentaire tout au long de la vie a été recueillie à l'aide d'un questionnaire et de la technique de la grille de vie. L'analyse des données impliquait des analyses descriptives et de régression logistique. Résultats: Les sujets qui étaient dans une PSE faible tout au long de leur vie avaient un risque significativement plus élevé d'être diagnostiqué d'un cancer oral (RC=5.81, IC 95%: 2.90-11.64) comparativement à ceux qui ont vécu leur vie dans une PSE élevée. L'ajout de facteurs comportementaux et de santé buccodentaire aux modèles a atténué cette association (RC= 2.08, IC 95%: 0.89-4.89 pour une SEP faible comparativement à une PSE élevée). Cependant, la PSE au cours de la vie est demeurée reliée à un risque accru de cancer oral. Conclusion: Une PSE faible tout au long de la vie est un facteur de risque significatif de cancer oral dans cette population.

This meta-analysis investigated the association of gender and socioeconomic position with cardiorespiratory fitness in adolescents. Public health professionals know the importance of physical activity level as a modifiable behavior; however, the literature has revealed that more research is needed on the association of sociodemographic variables like gender and socioeconomic position with cardiorespiratory fitness in adolescents. Using the physical fitness and health outcomes conceptual model as a guide, the overall effect sizes across studies were assessed as well as the moderators of study design, sample size, age, and country. A systematic review of literature identified a total of 18 peer-reviewed studies meeting inclusion criteria, which yielded a total of 41 unique effect sizes. Meta-analysis utilizing a random effects model indicated that gender and socioeconomic position are associated with cardiorespiratory fitness and that age and country moderated these effects. The positive social change implication of this meta-analysis may provide evidence-based knowledge to public health officials, physical educators, and health educators who are considering changes in school health promotion policies and health promotion interventions geared toward different gender and socioeconomic groups. Long term results include increased physical activity, decreased clustered cardiovascular risk factors, and lowered all-cause and cardiovascular disease mortality as adolescents track into adulthood.

Low socioeconomic position is known to be associated with greater coronary heart disease (CHD) risk in most developed countries. However, studies have largely focused on the association between socioeconomic position and CHD in middle-aged populations and little is known about the extent to which socioeconomic position affects CHD risk in later life. This thesis uses the British Regional Heart Study, a populationbased cohort of British men to investigate the extent of socioeconomic inequalities in CHD in older age and the possible pathways to these inequalities. Issues addressed in detail include trends in socioeconomic inequalities in CHD with increasing age and over time, the extent of socioeconomic inequalities in CHD in older age (60-79 years), the contribution of established and novel coronary risk factors to these inequalities, and the influence of early life socioeconomic position on CHD risk in later life. Although CHD mortality declined over the last two decades in Britain, relative social class differences in CHD did not narrow between 1980 and 2005. With increasing age (from 40-59 years to 65-84 years), relative social class inequalities in CHD narrowed, although absolute differences widened with age. Marked socioeconomic differences in CHD were present in older age; CHD risk increased from the highest to the lowest social class group. Socioeconomic differences in behavioural coronary risk factors (particularly cigarette smoking) could explain at least a third of these inequalities; inflammatory markers made some additional contribution. Lower socioeconomic position in childhood was associated with increased CHD risk in older age; part of this association was due to the relationship of childhood socioeconomic position with adult behavioural factors. Appreciable socioeconomic inequalities were also present in disability among older men with CHD. The results suggest that important socioeconomic inequalities in CHD persist in older age; the implications for public health and further epidemiological research are discussed.

Although the incidence of breast cancer in women under 40 years of age is somewhat rare, young women tend to present with cancer that is more advanced and with poorer prognostic characteristics. This research will be important to providers, women and their families and those seeking to clarify screening guidelines. The purpose of this quantitative, retrospective, cohort study was to evaluate differences in prognostic characteristics by socioeconomic position (SIP). The cohort was comprised of females aged 18 to 39 with a primary diagnosis of breast cancer. Data were obtained from the Surveillance, Epidemiology and End Results registry for all primary breast cancers reported between 2001 and 2006 (n = 14,696). Hierarchical regression analysis was performed to assess to what extent SEP had an independent effect on tumor size and cancer summary stage upon diagnosis, and overall survival. SEP was found to be a significant predictor of tumor size and summary stage at the time of diagnosis. As cancer summary stage increases by 1 unit, women were .14 times as likely to have a tumor size of less than 2 cm versus a tumor size of greater than 5 cm. As SEP increases by 1 unit, the likelihood of having a tumor size of less than 2 cm versus greater than 5 cm increases by a factor of 1.14. SEP was not a significant predictor of survival time. The results of this study have the potential to promote positive social change by advancing the understanding of breast cancer in young women, as well as raise awareness of socioeconomic, racial and clinical inequalities. In addition, it may assist researchers and policy makers clearly defined formal screening guidelines for young women in higher-risk subgroups based on socioeconomic position.

Background: There are gradients in general and oral health by socioeconomic position (SEP). Psychosocial processes play an important role to explain those social gradients. One such process is Antonovsky’s Sense of Coherence (SOC) construct. However, the contribution of SOC in explaining social gradients in oral health has not been fully explored. SOC relates to how individuals make sense of the world, use required resources to respond to it and feel their responses are meaningful and make sense emotionally. Aim and Objectives: This thesis aimed to assess the role of SOC in the relationship between SEP and oral health in Finnish dentate adults. The objectives were to assess the role of SOC as a moderator of the relationship of adulthood SEP with behaviours and oral health; to assess the role of SOC as a mediator of the relationship of childhood SEP with adult behaviours and oral health; and to assess the contribution of SOC to oral health independently of socio-demographic and behavioural factors. Methods: Data were from the nationally representative Finnish Health 2000 Survey of adults aged 30 years and over. Childhood SEP was indicated by parental education and adulthood SEP by education and income. SOC was measured by the Orientation to Life questionnaire. Outcomes were behaviours, clinical oral health measures and self-rated oral health. Regression analysis and structural equation modelling were used. Results: Findings did not support a moderating role of SOC in the relationship of adulthood SEP with behaviours and oral health. SOC was a modest mediator of the relationship of childhood SEP with adult behaviours and oral health, compared to the role of adulthood SEP. Finally, SOC was independently associated with oral health. Conclusion: SOC appears to be an important psychosocial disposition for the development and maintenance of individuals’ oral health. The association between SOC and oral health was not explained away by socio-demographic or behavioural factors.

Aims: The aims of this thesis were to investigate the risk of severe maternal morbidity amongst women from different socioeconomic groups in the UK, explore why these differences exist and compare these findings to the setting in Australia. Methods: Three separate analyses were conducted. The first used UK Obstetric Surveillance System (UKOSS) data to assess the incidence and independent odds of severe maternal morbidity by socioeconomic group in the UK. The second analysis used quantitative and qualitative data from the 2010 UK National Maternity Survey (NMS) to explore the possible reasons for the difference in odds of morbidity between socioeconomic groups in the UK. The third analysis used data from the Victorian Perinatal Data Collection (VPDC) unit in Austra lia to assess the incidence and odds of severe maternal morbidity by socioeconomic group in Victoria. Results: The UKOSS analysis showed that compared with women from the highest socioeconomic group, women in the lowest 'unemployed' group had 1.22 (95%CI: 0.92 - 1.61) times greater odds associated with severe maternal morbidity. The NMS analysis demonstrated that independent of ethnicity, age and parity, women from the lowest socioeconomic quintiJe were 60% less likely to have had any antenatal care (aOR 0.40; 95%CI 0.18 - 0.87), 40% less likely to have been seen by a health professional prior to 12 weeks gestation (aOR 0.62; 95%CI 0.45 - 0.85) and 45% less likely to have had a postnatal check with their doctor (aOR 0.55; 95%CI 0.42 - 0.70) compared to women from the highest quintile. The Victorian analysis showed that women from the lowest socioeconomic group were 21% (aOR 1.21 ; 95% CI 1.00 - 1.47) more likely and that Aboriginal and Torres Strait Islander women were twice (aOR 2.02; 95%CI 1.32 - 3.09) as likely to experience severe morbidity. Discussion: The resu lts suggest that women from the lowest socioeconomic group in the UK and in Victoria have increased odds of severe maternal morbidity. Further research is needed into why these differences exist and efforts must be made to ensure that these women are appropriately prioritised in the future planning of maternity services provisio n in the UK and Australia.

<p>This thesis described socioeconomic inequalities in fruit and vegetable consumption in Stockholm County.<strong> </strong>A comparative descriptive analysis was carried out with the use of secondary data from the 2006 Stockholm County Public Health Survey. The data was analyzed through cross tabulations that were conducted in SPSS.<strong> </strong>The findings showed that people with high socioeconomic position consumed fruit and vegetables more frequently than those of low socioeconomic position. Differences in fruit and vegetable consumption were found for the three measures of socioeconomic position; education, occupation and income. These differences were pronounced to a larger extent across different education levels compared to levels of occupation and income. Further research is needed to investigate which factors may explain the observed differences.</p>

Thesis (Ph. D.)--University of North Carolina at Chapel Hill, 2008.<br>Title from electronic title page (viewed Feb. 17, 2009). "... in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the Department of Epidemiology from the School of Public Health." Discipline: Epidemiology; Department/School: Public Health.

Fat and lean mass have important implications for adult health and physical functioning, but few studies have examined their determinants. This thesis used a life course perspective to examine how explanatory factors across life relate to adult measures of fat and lean mass. The MRC National Survey of Health and Development was used—a British birth cohort study originally comprised of 5362 babies born in March 1946. At 60–64 years, 746 males and 812 females had fat and lean mass measures taken using dual energy X-ray absorptiometry. Linear regression was used to examine associations between prospectively ascertained explanatory variables (socioeconomic position, measures of growth, and physical activity) with these masses. Lower childhood and adult socioeconomic position, greater weight gains in childhood and adolescence (7-20 years), and lower current physical activity levels (measured objectively and by self-report) were all associated with higher fat mass, with evidence in females of cumulative benefits of leisure time physical activity across adulthood (36 to 60–64 years) in leading to lower fat mass. Higher childhood (females only) and adult (both sexes) socioeconomic position, higher birth weight, greater weight gain from birth to 20 years, and physical activity participation across adulthood were all associated with higher lean mass; associations with socioeconomic position and physical activity were found after adjustment for fat mass. Associations between lower childhood socioeconomic position and higher fat mass were partly mediated by weight gain from 7–20 years; associations with higher fat and lower lean mass were partly mediated by leisure time physical activity measures. Factors operating in both early and adult life were associated with adult fat and lean mass. These factors could be potential targets for public health strategies which seek to reduce fat mass and increase lean mass in the population.

Identifying risk factors associated with normal cognitive ageing is a prerequisite for understanding dementia. Potential modifiable risk factors include socioeconomic factors and health behaviours. This thesis investigated the importance of life course socioeconomic position (SEP) and two core health behaviours, alcohol consumption and smoking, for mid-late life cognitive function in four previously unstudied Central and Eastern European populations with historically smaller income inequalities and significant contributions of alcohol and smoking to the high premature mortality in these populations. The thesis used data from over 29,000 men and women aged 45-78 from random population samples in Novosibirsk (Russia), Krakow (Poland), Kaunas (Lithuania) and six Czech towns participating in the HAPIEE study. Cognitive function was measured using four tests of fluid cognition. SEP measures, alcohol consumption and smoking were self-reported using structured interviews. Structural equation analyses revealed significant associations between SEP measures from across the life course and cognition. Education consistently showed the strongest association with cognition and some accumulation of disadvantage across the life course was observed, similar to studies in Western countries. However, variation in magnitude of these associations across centres may partly reflect the influence of contextual factors. Regression analyses showed modest associations of cognitive function with alcohol and smoking, and neither of these behaviours appeared to significantly mediate the associations between life course SEP and cognition. An inverted U-shaped association indicated slightly worse cognitive performance among male heavy drinkers and lower scores in non-drinkers, compared to light drinkers. Binge drinking and alcohol type were not associated with cognitive performance. Smoking was associated with poorer mental speed in both genders but not with any other cognitive test. The findings suggest a pattern of associations between life course SEP and cognition similar to Western populations and modest associations of alcohol and smoking with mid-late life cognitive performance in these Central and Eastern European populations.

Background: Low socioeconomic position throughout the life course is associated with a number of adverse health outcomes in older people. However, whether life course socioeconomic position influences subjective outcomes in early old age, such as quality of life, is not well known. There is a lack of life course research that considers the wider structural determinants of health. In particular, it is not well understood if the association between life course socioeconomic position and quality of life is the same across European societies that have differing welfare state arrangements. This thesis addressed two key aims: (1) Investigate whether, and how, life course socioeconomic position influences the quality of life of Europeans in early old age. (2) Examine differences in this relationship by welfare regime. Methods: Two methodological approaches were taken to address the research objectives: (1) A systematic review of quantitative studies examining the influence of life course socioeconomic position on quality of life was conducted, with a narrative synthesis. (2) An empirical analysis was carried out examining the influence of life course socioeconomic position on the quality of life of individuals in early old age, as measured by CASP-12 and life satisfaction. This used secondary data from 13 European countries (representing Southern, Scandinavian, Post-communist, and Bismarckian welfare regimes) that were part of Wave 2 of the Survey of Health, Ageing, and Retirement in Europe (SHARE) and SHARELIFE, which collected retrospective life histories of respondents. Two statistical techniques were used to analyse the data: multilevel modelling and path analysis. Slope indices of inequality were calculated to enable measures of socioeconomic position to be compared. Results: The systematic review identified 12 relevant studies, which varied in terms of the outcomes examined, study quality, and populations. No studies were identified from Bismarckian or Post-communist welfare regimes, with most containing populations from the Scandinavian or Liberal regime types. Some supportive evidence was found for a latent effect of low childhood socioeconomic position on quality of life among women. Social mobility models were generally not supported. High quality studies addressing inter-generational mobility were lacking and few studies examined cumulative and pathway effects. Results from the analysis using SHARE suggested that the most proximal measures of socioeconomic position were the strongest predictors of quality of life. In most welfare regimes, inequalities in quality of life were largest by current wealth, but among women in the Southern and Post-communist regimes inequalities by education level were particularly large. In the Scandinavian regime there were very small differences in quality of life between the least and most educated. Generally, there was little difference in the magnitude of socioeconomic inequalities in quality of life between Scandinavian and Bismarckian regimes. Support for a latent effect on quality of life was lacking, using most measures of childhood socioeconomic position. The findings from both the multilevel models and path analysis supported the pathway theory whereby childhood socioeconomic position chiefly influenced quality of life through later socioeconomic experiences. However, the number of books in childhood exhibited a weak association with quality of life even when taking into account current measures of socioeconomic position, suggesting a small latent effect for this measure. When stratifying by welfare regime, the potential direct effect from the number of books in childhood was specific to particular welfare regimes and genders. A greater number of socioeconomically advantaged positions over the life course was associated with higher quality of life in early old age, but the results suggested this was mainly due to the influence of socioeconomic advantage during adulthood. The association between life course socioeconomic position (as measured by a cumulative socioeconomic advantage score) and quality of life was weaker in the Scandinavian regime and stronger in Southern and Post-communist regimes. Including a measure of current financial distress greatly attenuated these associations. There was generally a lack of supportive evidence for an effect of social mobility on quality of life. Conclusions: Socioeconomic inequalities in quality of life were apparent in all welfare regimes and were largest by more proximal measures of socioeconomic position. Overall, Scandinavian and Bismarckian welfare regimes exhibited both higher quality of life and narrower inequalities in quality of life, compared to Southern and Post-communist regimes. Interventions to reduce socioeconomic inequalities across the life course are needed, but those which buffer the effect of financial distress in early old age may be particularly beneficial for improving quality of life and producing a more equitable distribution.

The aim of this thesis was to describe inequalities in the use of different health care services according to socioeconomic position (SEP) in Catalonia, Spain and Europe. In addition, we intended to assess whether the public coverage of the services, in particular dental health care, has an influence on the magnitude of inequalities in the use of such services. Finally, we aimed to determine the influence of population-based female cancer screening programmes on the prevalence of screening and on the extent of inequality. To accomplish these objectives four studies were carried out. The sources of information of the four studies were, respectively: several editions of the Catalan Health general practitioner (GP) services are equitable or manual classes use them to a greater extent. However, there are marked SEP inequalities in the use of outpatient specialist services, especially in dental care. Socioeconomic inequalities in use of dental care services exist throughout Europe, but they are larger in countries in which dental care is not covered at all by the public health care system than in countries in which dental care is partially covered. In Europe, socioeconomic inequalities in breast and cervical cancer screening are not found in countries with population-based screening programmes but they are found in those countries with only regional or pilot programmes and in those countries with opportunistic screening.<br>L'objectiu d'aquesta tesi era descriure les desigualtats en l'ús de diferents serveis sanitaris segons la posició socioeconòmica a Catalunya, Espanya i a Europa. A més a més, es volia avaluar si la cobertura pública dels serveis, en particular la dels serveis dentals, infuencia la magnitud de les desigualtats socioeconòmiques en l'ús d'aquests serveis. Finalment, es va voler determinar la influència dels programes poblacionals de cribratge dels càncers de mama i cèrvix en la prevalença de cribratge i en la magnitud de les desigualtats. Per tal d'assolir aquests objectius es van dur a terme 4 estudis. Les fonts d'informació d'aquests estudis van ser, respectivament: diferents edicions de l'Enquesta de Salut de Catalunya (ESCA), diferents edicions de l'Enquesta Nacional de Salut d'Espanya (ENS), l'Enquesta de Salut, Envelliment i Jubilació a Europa (SHARE) 2006 i dades dels països europeus que van participar a l'Enquesta Mundial de la Salut de l'OMS l'any 2002. Els dos primers estudis eren estudis de tendències mentre que els dos últims van ser transversals. En tots els estudis les desigualtats socioeconòmiques es van mesurar mitjançant índexos relatius (RII) i absoluts (SII) de desigualtat. Els resultats d'aquests estudis mostren que a Catalunya i a Espanya els serveis d'atenció primària són equitatius o fins i tot les persones de classes manuals en presenten una major proporció d'ús. Tanmateix, hi ha marcades desigualtats en visites a l'especialista, en especial en les visites al dentista. Les desigualtats socioeconòmiques en la utilització dels serveis dentals existeixen a tota Europa, però són més grans en aquells països on l'atenció dental no està coberta pel sistema públic de salut que en aquells països on aquesta està parcialment coberta. A Europa, no es troben desigualtats socioeconòmiques en el cribratge dels càncers de mama i cèrvix en aquells països amb programes poblacionals de cribratge, però sí que es troben en aquells països amb programes pilot o regionals o amb només cribratge oportunista.

Socioeconomic positions of individuals are clearly associated with the chances of living a healthy long life. In four empirical studies based on Swedish population registers, two topics are examined in this thesis: The relationships between different indicators of social position and mortality, and the importance of family members’ socioeconomic resources for the survival of the individual. The overall conclusion from the separate studies is that no single individual socioeconomic factor gives a complete picture of mortality inequalities. Further, the socioeconomic resources of partners and adult children are important in addition to the individual ones. The specific results from each study include that: I education, social class, social status and income are, to various extent, independently associated with mortality risk. Education and social status are related to women’s mortality, and education, social class, and income to men’s mortality. II one partner’s social position is related to the other partner’s survival, also when individual socioeconomic factors are statistically controlled for. In particular, men’s mortality is linked to their wives’ education and women’s mortality to their husbands’ social class. III adult children’s education is related to their parents’ risk of dying, also when both parents’ socioeconomic resources are taken into consideration. Further, the association between the offspring’s level of education and parental mortality cannot be explained by charac­teristics that parents share with their siblings. IV children’s social class and income are related to parental mortality, but not as strongly as the education of the children. There is no relationship between a mother’s own education and breast cancer mortality, while mothers seem to have better chances of surviving breast cancer if they have well-educated children.<br><p>At the time of doctoral defence the following paper was unpublished and had a status as follows: Paper 4: Manuscript</p>

Introduktion/Bakgrund: Enligt ett flertal vetenskapliga rapporter är misshandel och utnyttjande av äldre ett växande problem i Europa och övriga världen. Det kommer att ställas högre krav på vårdgivare både inom familjen och inom välfärden på grund av en åldrande europeisk befolkning. Det förutses att en tredjedel av den europeiska befolkningen kommer att vara 60 år eller äldre år 2050. Tillförlitliga data och forskning är dock en bristvara när det kommer till misshandel och utnyttjande av äldre. Syfte: Att granska den tillgängliga forskningen om vilken effekt olika socioekonomiska faktorer (utbildning, yrke och förmögenhet) har huruvida äldre människor (60 år eller äldre) riskerar att utsättas för fysisk och/eller psykisk misshandel. Metod: En litteraturstudie valdes som arbetsmetod. Vetenskapliga artiklar och relevant litteratur har granskats och valts ut via olika databaser. Resultat: Studien kom fram till att olika socioekonomiska faktorer (utbildning, yrke och förmögenhet) påverkar huruvida äldre människor riskerar att utsättas för fysisk och/eller psykisk misshandel. Av de studerade faktorerna var utbildning den socioekonomiska faktor som främst påverkade huruvida en äldre människa riskerade att bli utsatt för misshandel eller inte. De andra faktorerna, yrke och förmögenhet/inkomst, var inte representerade i samma utsträckning som utbildning i studiens resultat. En annan påverkande faktor som hänger ihop med socioekonomiska faktorer visade sig vara könstilhörighet. Majoriteten av den granskade litteraturen bekräftar att det finns ett mönster som innebär att äldre kvinnor löper en större risk än män att utsättas för psykisk och/eller fysisk misshandel. Det var svårt att identifiera likheter eller skillnader mellan olika europeiska regioner på grund av att studiemetod och studiedesign skiljde sig allt för mycket åt mellan de olika vetenskapliga artiklarna. Slutsats: Resultatet från litteraturgranskningen visade att utbildning har en större påverkan än yrke och förmögenhet huruvida en äldre människa riskerar att bli utsatt för psykisk och/eller fysisk misshandel eller inte. Studien fann även att könsskillnader var tydliga och innebär äldre kvinnor löper större risk än män att bli utsatta. Något som också måste tas i beaktning i framtida forskning. Bristen på forskning och litteratur inom ämnet vittnar om att det finns ett stort behov av mer forskning. En bättre förståelse för relationen mellan socioekonomisk position och misshandel av äldre är viktigt för framtiden.<br>Abstract Introduction: The issue of elder abuse is described as increasing in Europe and beyond according to several scientific reports. An ageing European population combined with longer life expectancy will increase demands on family caregivers and a well-functioning health and social care workforce. It is estimated that in year 2050 one third of the European population will be 60 years or older. However there is still a shortage of confident data across European countries regarding the extent, features, determinants and effects of elder abuse. Aim: To review existing knowledge of the impact of various measures of socioeconomic position (education, occupation and wealth) on physical and psychological abuse among elderly people (60 years of age and over) in Europe. Method: A literature study was chosen as working method. Scientific articles and relevant literature were examined using different databases. Results: The review found that socioeconomic position factors (education, occupation, wealth) have an impact on the likelihood of elderly individuals experiencing abuse. Of the assessed factors, education has shown to be the socioeconomic factor which has the most impact on the likelihood of elder abuse. Other factors such as occupation and wealth and income, were not represented in the results at the same extent as education. Another important factor related to elderly people’s socio-economic position was found to be gender. The majority of articles analysed in this thesis confirms that there is a pattern where elderly women are more likely to experience abuse than are men. Due to different study designs and measures in the analysed scientific articles and reports differences according to area context were hard to identify. Conclusion: Results of this thesis showed that education as measure of socioeconomic position had the biggest impact on elder abuse as compared to occupation and wealth. However, gender (a factor strictly linked to socioeconomic position) differentials were remarkable, a subject which needs to be taken into consideration in future research. Further, the lack of literature in the research subject points out to an urgent need for further studies. This is urgently needed, as both ageing and abuse are increasing across Europe. A better understanding of the relation between socioeconomic position and abuse among elderly will be of paramount importance for future interventions aimed to curb the ever growing trend.

In developed countries the relationship between socioeconomic position (SEP) and health is unequivocal. Those who are socioeconomically disadvantaged are known to experience higher morbidity and mortality from a range of chronic diet-related conditions compared to those of higher SEP. Socioeconomic inequalities in diet are well established. Compared to their more advantaged counterparts, those of low SEP are consistently found to consume diets less consistent with dietary guidelines (i.e. higher in fat, salt and sugar and lower in fibre, fruit and vegetables). Although the reasons for dietary inequalities remain unclear, understanding how such differences arise is important for the development of strategies to reduce health inequalities. Both environmental (e.g. proximity of supermarkets, price, and availability of foods) and psychosocial (e.g. taste preference, nutrition knowledge) influences are proposed to account for inequalities in food choices. Although in the United States (US), United Kingdom (UK), and parts of Australia, environmental factors are associated with socioeconomic differences in food choices, these factors do not completely account for the observed inequalities. Internationally, this context has prompted calls for further exploration of the role of psychological and social factors in relation to inequalities in food choices. It is this task that forms the primary goal of this PhD research. In the small body of research examining the contribution of psychosocial factors to inequalities in food choices, studies have focussed on food cost concerns, nutrition knowledge or health concerns. These factors are generally found to be influential. However, since a range of psychosocial factors are known determinants of food choices in the general population, it is likely that a range of factors also contribute to inequalities in food choices. Identification of additional psychosocial factors of relevance to inequalities in food choices would provide new opportunities for health promotion, including the adaption of existing strategies. The methodological features of previous research have also hindered the advancement of knowledge in this area and a lack of qualitative studies has resulted in a dearth of descriptive information on this topic. This PhD investigation extends previous research by assessing a range of psychosocial factors in relation to inequalities in food choices using both quantitative and qualitative techniques. Secondary data analyses were undertaken using data obtained from two Brisbane-based studies, the Brisbane Food Study (N=1003, conducted in 2000), and the Sixty Families Study (N=60, conducted in 1998). Both studies involved main household food purchasers completing an interviewer-administered survey within their own home. Data pertaining to food-purchasing, and psychosocial, socioeconomic and demographic characteristics were collected in each study. The mutual goals of both the qualitative and quantitative phases of this investigation were to assess socioeconomic differences in food purchasing and to identify psychosocial factors relevant to any observed differences. The quantitative methods then additionally considered whether the associations examined differed according to the socioeconomic indicator used (i.e. income or education). The qualitative analyses made a unique contribution to this project by generating detailed descriptions of socioeconomic differences in psychosocial factors. Those with lower levels of income and education were found to make food purchasing choices less consistent with dietary guidelines compared to those of high SEP. The psychosocial factors identified as relevant to food-purchasing inequalities were: taste preferences, health concerns, health beliefs, nutrition knowledge, nutrition concerns, weight concerns, nutrition label use, and several other values and beliefs unique to particular socioeconomic groups. Factors more tenuously or inconsistently related to socioeconomic differences in food purchasing were cost concerns, and perceived adequacy of the family diet. Evidence was displayed in both the quantitative and qualitative analyses to suggest that psychosocial factors contribute to inequalities in food purchasing in a collective manner. The quantitative analyses revealed that considerable overlap in the socioeconomic variation in food purchasing was accounted for by key psychosocial factors of importance, including taste preference, nutrition concerns, nutrition knowledge, and health concerns. Consistent with these findings, the qualitative transcripts demonstrated the interplay between such influential psychosocial factors in determining food-purchasing choices. The qualitative analyses found socioeconomic differences in the prioritisation of psychosocial factors in relation to food choices. This is suggestive of complex cultural factors that distinguish advantaged and disadvantaged groups and result in socioeconomically distinct schemas related to health and food choices. Compared to those of high SEP, those of lower SEP were less likely to indicate that health concerns, nutrition concerns, or food labels influenced food choices, and exhibited lower levels of nutrition knowledge. In the absence of health or nutrition-related concerns, taste preferences tended to dominate the food purchasing choices of those of low SEP. Overall, while cost concerns did not appear to be a main determinant of socioeconomic differences in food purchasing, this factor had a dominant influence on the food choices of some of the most disadvantaged respondents included in this research. The findings of this study have several implications for health promotion. The integrated operation of psychosocial factors on food purchasing inequalities indicates that multiple psychosocial factors may be appropriate to target in health promotion. It also seems possible that the inter-relatedness of psychosocial factors would allow health promotion targeting a single psychosocial factor to have a flow-on affect in terms of altering other influential psychosocial factors. This research also suggests that current mass marketing approaches to health promotion may not be effective across all socioeconomic groups due to differences in the priorities and main factors of influence in food purchasing decisions across groups. In addition to the practical recommendations for health promotion, this investigation, through the critique of previous research, and through the substantive study findings, has highlighted important methodological considerations for future research. Of particular note are the recommendations pertaining to the selection of socioeconomic indicators, measurement of relevant constructs, consideration of confounders, and development of an analytical approach. Addressing inequalities in health has been noted as a main objective by many health authorities and governments internationally. It is envisaged that the substantive and methodological findings of this thesis will make a useful contribution towards this important goal.

Background: Supervised exercise and delivered education are first step treatment for knee, hip and hand osteoarthritis (OA) according to international guidelines. It is uncertain whether OA outcomes from participation in the Swedish self-management program “Better management of Osteoarthritis (BOA)” differs for participants with different sociodemographic background. The aim of this master thesis was thus to assess to what extent there were differences by level of education and immigration status among participants in the self-management program in terms of Health, Health-related quality of life, Mobility, Health-related behaviours and Adherence to the self-management program, measured at baseline, three and 12 months. Methods: Analysis of covariance (ANCOVA), logistic and multinomial regression was used to analyse outcomes for 22 741 participants. Results: For most adjusted outcomes, there were sociodemographic inequalities at all measurement points. However, there were no educational differences in mobility and attitude to physical activity at baseline, but at the follow-ups such inequalities emerged. Conversely, the willingness to undergo joint surgery differed by immigration status at baseline, but not at the follow-ups, and immigrants were more adherent towards the self-management program than domestic born participants. Conclusion: These results are pioneer findings showing that it exists sociodemographic differences related to OA treatment.

BACKGROUND: Previous studies show a positive association between household wealth and overweight in sub-Saharan African (SSA) countries; however, the manner in which this relationship differs in the presence of educational attainment has not been well-established. This study examined the multiplicative effect modification of educational attainment on the association between middle-income and rich household wealth and overweight status among adult females in 22 SSA countries. We hypothesized that household wealth was associated with a greater likelihood of being overweight among middle income and rich women with lower levels of educational attainment compared to those with higher levels of educational attainment. METHODS: Demographic and Health Survey (DHS) data from 2006 to 2016 for women aged 18-49 years in SSA countries were used for the study. Overweight was defined as a body mass index (BMI) ≥ 25 kg/m2. Household wealth index tertile was the exposure and educational attainment, the effect modifier. Potential confounders included age, ethnicity, place of residence, and parity. Descriptive analysis was conducted, and separate logistic regression models were fitted for each of the 22 SSA countries to compute measures of effect modification and 95% confidence intervals. Analysis of credibility (AnCred) methods were applied to assess the intrinsic credibility of the study findings and guide statistical inference. RESULTS: The prevalence of overweight ranged from 12.6% in Chad to 56.6% in Swaziland. Eighteen of the 22 SSA countries had measures of effect modification below one in at least one wealth tertile. This included eight of the 12 low-income countries and all 10 middle income countries. This implied that the odds of overweight were greater among middle-income and rich women with lower levels of educational attainment than those with higher educational attainment. On the basis of the AnCred analysis, it was found that the majority of the study findings across the region provided some support for the study hypothesis. CONCLUSIONS: Women in higher wealth strata and with lower levels of educational attainment appear to be more vulnerable to overweight compared to those in the same wealth strata but with higher levels of educational attainment in most low- and middle- income SSA countries.

Introduction. La notion d'" embodiment " propose que chaque humain est à la fois un être social ainsi que biologique, intégrant le monde dans lequel il/elle vit. Nous faisons l'hypothèse que la position socioéconomique pendant l'enfance peut être biologiquement incorporée, conduisant à la production des inégalités sociales de santé entre les sous-groupes de population. La charge allostatique (CA) est un concept qui tente de capturer l'usure physiologique globale du corps liée à l'activation répétée des mécanismes physiologiques compensatoires en cas d'exposition à des stress chroniques. La CA pourrait permettre une meilleure compréhension des voies biologiques qui jouent un rôle potentiel dans la construction du gradient social de santé des adultes. Objectif. Pour explorer l'hypothèse d'incorporation biologique, nous avons examiné les voies de médiation entre les adversités psychosociales et la position socioéconomique précoces et la CA à 44 ans. Nous avons également confronté l'indice de CA à une mesure multidimensionnelle de santé latente à 50 ans. Méthodes. Les données sont issues de la cohorte Britannique de naissance de 1958 (n=18 000). La CA a été construite avec les données de l'enquête biomédicale conduite à 44 ans, comme une mesure physiologique synthétique, multi-système, à l'aide de 14 biomarqueurs représentant les systèmes neuroendocrinien, métabolique, immunitaire / inflammatoire et cardiorespiratoire. Résultats. L'ensemble de nos résultats suggèrent que la CA pourrait être un indice approprié pour capturer partiellement la dimension biologique des processus d'embodiment. Discussion. Comprendre comment l'environnement affecte notre santé en se " glissant sous la peau " et pénétrant dans les cellules, les organes et les systèmes physiologiques de notre corps est un principe clé dans la recherche en santé publique. Promouvoir le recueil de marqueurs biologiques dans des grandes études prospectives et représentatives est crucial pour continuer la recherche sur ce sujet. Les études de réplication pourraient faire partie des futures perspectives de recherche, pour comparer entre populations avec des contextes culturels différents pour observer si un index de CA peut être considéré comme "universel "<br>Introduction. The notion of embodiment proposes that every human being is both a social and a biological organism that incorporates the world in which (s)he lives. It has been hypothesized that early life socioeconomic position (SEP) can be biologically embedded, potentially leading to the production of health inequalities across population groups. Allostatic load (AL) is a concept that intends to capture the overall physiological wear-and-tear of the body triggered by the repeated activation of compensatory physiological mechanisms as a response to chronic stress. AL could allow a better understanding of the potential biological pathways playing a role in the construction of the social gradient in adult health. Objective. To explore the biological embedding hypothesis, we examined the mediating pathways between early SEP and early adverse psychosocial experiences and higher AL at 44 years. We also confronted an AL index with a latent multidimensional and integrative measure of health status at 50y. Methods. Data are from the 1958 British birth cohort (n=18 000) follow-up to age 50. AL was operationalized using data from the biomedical survey collected at age 44 on 14 parameters representing the neuroendocrine, metabolic, immune-inflammatory and cardiovascular systems. Results. Overall, our results suggest that AL could be a suitable index to partially capture the biological dimensions of embodiment processes. Discussion. Understanding how human environments affect our health by 'getting under the skin' and penetrating the cells, organs and physiological systems of our bodies is a key tenet in public health research. Promoting the collection of biological markers in large representative and prospective studies is crucial to continue to investigate on this topic. Replication studies could be part of the future research perspectives, to compare with other cultural context and to observe if an AL index can be 'universal'

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior<br>Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro<br>Esta dissertação buscou uma apreciação crítica e pragmática da relação entre desigualdade socioeconômica e obesidade abdominal, em resposta a proposição internacional de monitoramento das desigualdades em saúde e a escassez de estudos desta natureza relativos à obesidade abdominal. Dois artigos foram elaborados a fim de estimar o grau de desigualdade educacional na ocorrência de obesidade abdominal e revisar os estudos de associação entre posição socioeconômica e obesidade abdominal. O primeiro artigo utilizou o índice angular de desigualdade e o índice relativo de desigualdade em dados seccionais de 3.117 participantes da linha de base do Estudo Pró-Saúde, 1999-2001, e o segundo artigo abarcou os resultados de estudos conduzidos em população adulta no Brasil. Os índices de desigualdade resumiram a tendência monotônica e inversa observada entre escolaridade e obesidade abdominal na população feminina, proporcionando estimativas quantitativas desta desigualdade (artigo 1). Em concordância, observou-se que a associação entre indicadores de posição socioeconômica e obesidade abdominal foi majoritariamente inversa entre as mulheres, principalmente com relação à escolaridade, e estatisticamente não significativa entre os homens (artigo 2). Tal cenário epidemiológico evidencia que a obesidade abdominal tem afetado desproporcionalmente as mulheres de posição socioeconômica mais baixa e que a desigualdade de gênero na prevalência de obesidade abdominal tende a aumentar com menor posição socioeconômica. Em suma, a presente dissertação visou à produção de conhecimento epidemiológico relevante ao enfrentamento das desigualdades em saúde, com o objetivo premente de subsidiar políticas públicas de fato realizáveis e individualmente aceitáveis.<br>This dissertation sought to a critical and pragmatic assessment of the relationship between socioeconomic inequality and abdominal obesity in response to international proposition of health inequalities monitoring and to lack of studies of this nature relating to abdominal obesity. Two articles were prepared to -estimate the level of educational inequality in the occurrence of abdominal obesity, and review the association studies between socioeconomic position and abdominal obesity. The first article used the slope index of inequality and the relative index of inequality in the sectional data of 3.117 participants in the baseline of the Pró-Saúde Study, 1999-2001; and the second article encompassed the results of the studies conducted in the adult population in Brazil. The inequality indexes summarized strictly monotonic and inverse trend between educational achievement and abdominal obesity in the female population, providing quantitative estimates of this inequality (Article 1). Accordingly, we found that the association between socioeconomic position indicators and abdominal obesity was mostly reversed among women, especially regarding education, and statistically not significant among men (Article 2). This epidemiological scenario shows that abdominal obesity has disproportionately affected women of the lower socioeconomic position, and gender inequality in the prevalence of abdominal obesity tends to increase with lower socioeconomic position. In short, this dissertation aimed at the production of relevant epidemiological knowledge to addressing health inequalities, with the targeted of subsidize public policies feasible and individually acceptable.

碩士<br>國立臺灣大學<br>衛生政策與管理研究所<br>96<br>Background: Substantial health disparities between Taiwan’s indigenous people and their non-indigenous counterparts have been observed, with socioeconomic position found to be one of the most important determinants. However, whether such disparities in health exist within the indigenous people remains unclear. This study aimed to examine the social gradient of health among the indigenous people in Taiwan. Methods: A representative sample of 20501 indigenous people aged 20 years and over were interviewed with a questionnaire in 2005. The survey data was further linked with the Death Registration Database in 2006. Socioeconomic characteristics to examine health disparities among the indigenous included educational attainment, individual income, and occupational class. Health outcome measures were self-report poor health and all-cause mortality in the year of 2006. Results: Overall, 13.5% reported poor health and 1.0% died in 2006. The results of multiple variables analysis showed that, after controlling for gender, age, and place of residence, self-reported poor health was significantly associated with educational attainment (OR=1.62-3.70, P<0.001), individual income (OR=2.09, P<0.001), and occupational class (OR=3.18, P<0.001). However, only employment status had a bearing on 1-year mortality (RR=5.83, P<0.001). Conclusion: Socioeconomic position is also an important determinant of health among the indigenous people in Taiwan. To improve the health of the indigenous people has to take the wider socioeconomic conditions into account.

碩士<br>國立臺灣大學<br>健康政策與管理研究所<br>101<br>Background: Workers’ absence due to health related problems has been an issue of concern in many European countries. Many studies indicated that, other than workers’ health status, factors that influence the extent of sickness absence include individual socio-demographic characteristics, work conditions, and social policy systems. Among individual factors, socioeconomic position (SEP) is important that influences not only worker’ health situation but also the accessibility to sickness absence benefit. Previous studies from other countries indicated that workers with lower SEP had poor health, but in contrast, those with higher SEP were more likely to have sickness absence. Up until now, few studies have been conducted in Taiwan to explore this issue. Objectives: This study aimed to investigate the prevalence of sickness absence and its association with health situation and socioeconomic position among employees in Taiwan. Methods: We analyzed data from a national survey of 9,503 male and 7,769 female employees aged 25~65 years in 2010. Information with regard to socioeconomic position (employment grade and education level), health situation, age, family workload, work conditions, psychosocial hazards at work and sickness absence was obtained by a standardized questionnaire. Results: The results showed that 26.72% male and 31.23% female employees had been absent from work due to health-related problems. Findings from regression models indicated that workers with poor health were more likely to have sickness absence, and the duration of sickness absence was also longer. In male workers, skilled manual workers had a higher risk for sickness absence (OR=1.21) than low-skilled manual workers, after controlling for health status and other factors. While in female workers, skilled non-manual workers had a higher risk for sickness absence (OR=1.19) than low-skilled manual workers. When using education as the indicator of SEP, we found that in men, as compared with workers with lowest education level, those with high school degree (OR=0.79) and college degree (OR=0.83) had lower risk and shorter duration of sickness absence; but no significant association was found in female employees. Conclusion and suggestion: Compare to non-skilled manual workers, skilled manual male workers and skilled non-manual female workers were at higher risk for sickness absence. This issue should be focused and managed. Future investigation should pay attention to the definition and measure of sickness absence, to aid in-depth evaluation and analyses on this topic.

碩士<br>中臺科技大學<br>醫護管理研究所<br>96<br>Background: International or cross-cultural marriages have become prevalent in Taiwan. In 2007, there were 398,720 transnational marriage couples registered in Taiwan; 90% of which were marriages to alien brides, mostly from Mainland China and the Southeastern Asian countries. The fertility rate of these registered alien brides from 1998 to 2007 was 10%. However, little is known about the health status of the children born to these women. For proper health planning, it is essential to have detailed information on the health status of this group of children as they constitute a significant portion of Taiwan’s future generation. Purpose: The purpose of this study was to examine the effects of parents’ socioeconomic position and local area deprivation on the health of children born to transnational married couples residing in Taiwan. Methods: This is a cross-sectional study using data from 2003 “The survey on Living Status of Immigrant Women” administered by the Ministry of the Interior. There were 287,059 new female immigrants included in this study. New female immigrants were classified as arriving from Mainland China, Hong Kong and Macao regions, Southeastern Asia, and other countries. Taiwan was divided into 25 administrative areas based on the 2003 “Taiwan-Fukien Demographic Fact Book.” Area deprivation was defined as a composite index of two items: (1) proportion of primary care occupational population; (2) prevalence of non-schooling among the population aged 15-17 years. A composite rank score from 1.25 (least deprived) to -1.30 (most deprived) was calculated and quintilised for the 25 areas in this analysis. Chi-square tests were used to examine the significance of bivariate relationships between parents’ socioeconomic position, area deprivation and children’s health. Multivariate logistic regression analyses were used to estimate odds ratios for the independent association of parents’ characteristics to their children’s health. Also, transformation of logistic models were used to report the marginal effects of the independent variables. Results: Logistic regression models, controlling for other maternal characteristics and socioeconomic factors, revealed that fathers’ job, education level, health status, income level as well as mothers’ job, migration status, and area deprivation were significant predictors of the children’s health. Families with lower socioeconomic positions and those residing in economically deprived areas were significantly more likely to have children with poorer health. Marginal effects showed that the children’s sex, fathers’ education, employment status, health status, and income level, as well as the mothers’ employment status, migration status, were the most important factors determining the health status of the children. Conclusion: Maternal nativity status was not associated with children’s health status. Alternatively, socioeconomic position of the family, health status of the parents, and local area deprivation were found to be determinants of the health status of children born to transnational couples. Policies focusing on the optimization of these determinants could benefit the health of a large portion of Taiwan’s children.

Measuring socioeconomic position (SEP) in population chronic disease and risk factor surveillance systems is essential for monitoring changes in socioeconomic inequities in health over time. A life course approach in epidemiology considers the long-term effects of physical and social exposures during gestation, childhood, adolescence, and later adult life on health. Previous studies provide evidence that socioeconomic factors at different stages of the life course influence current health status. Measures of SEP during early life to supplement existing indicators of current SEP are required to more adequately explain the contribution of socioeconomic factors to health status and monitor health inequities. The aim of this thesis was to examine how a life course perspective could enhance the monitoring of SEP in chronic disease and risk factor surveillance systems. The thesis reviewed indicators of early life SEP used in previous research, determined indicators of early life SEP that may be useful in South Australian surveillance systems, and examined the association of SEP over the life course and self-rated health in adulthood across different population groups to demonstrate that inclusion of indicators of early life SEP in surveillance systems could allow health inequities to be monitored among socially mobile and stable groups. A variety of indicators, such as parents’ education level and occupation, and financial circumstances and living conditions during childhood, have been used in different study designs in many countries. Indicators of early life SEP used to monitor trends in the health and SEP of populations over time, and to analyse long-term effects of policies on the changing health of populations, need to be feasible to measure retrospectively, and relevant to the historical, geographical and sociocultural context in which the surveillance system is operating. Retrospective recall of various indicators of early life SEP was examined in a telephone survey of a representative South Australian sample of adults. The highest proportions of missing data were observed for maternal grandfather’s occupation, and mother’s and father’s highest education level. Family structure, housing tenure, and family financial situation when the respondent was aged ten, and mother and father’s main occupation had lower item non-response. Respondents with missing data on early life SEP indicators were disadvantaged in terms of current SEP compared to those who provided this information. The differential response to early life SEP questions according to current circumstances has implications for chronic disease surveillance examining the life course impact of socioeconomic disadvantage. While face-to-face surveys are considered the gold standard of interviewing techniques, computer-assisted telephone interviewing is often preferred for cost and convenience. Recall of father’s and mother’s highest education level in the telephone survey was compared to that obtained in a face-to-face interview survey. The proportion of respondents who provided information about their father’s and mother’s highest education level was significantly higher in the face-to-face interview than in the telephone interview. Survey mode, however, did not influence the finding that respondents with missing data for parents’ education were more likely to be socioeconomically disadvantaged. Alternative indicators of early life SEP, such as material and financial circumstances, are likely to be more appropriate than parents’ education for life course analyses of health inequities using surveillance data. Questions about family financial situation and housing tenure during childhood and adulthood asked in the cross-sectional telephone survey were used to examine the association of SEP over the life course with self-rated health in adulthood. Disadvantaged SEP during both childhood and adulthood and upward social mobility in financial situation were associated with a reduced prevalence of excellent or very good health, although this relationship varied across gender, rurality, and country of birth groups. Trend data from a chronic disease and risk factor surveillance system indicated that socioeconomic disadvantage in adulthood was associated with poorer self-rated health. The surveillance system, however, does not currently contain any measures of early life SEP. Overlaying the social mobility variables on the surveillance data indicated how inequities in health could be differentiated in greater detail if early life SEP was measured in addition to current SEP. Inclusion of life course SEP measures in surveillance will enable monitoring of health inequities trends among socially mobile and stable groups. Life course measures are an innovative way to supplement other SEP indicators in surveillance systems. Considerable information can be gained with the addition of a few questions. This will provide further insight into the determinants of health and illness and enable improved monitoring of the effects of policies and interventions on health inequities and intergenerational disadvantage.<br>http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1367190<br>Thesis (Ph.D.) - University of Adelaide, School of Population Health and Clinical Practice, 2009

Background: Mental disorders present a pressing global health issue, and the disability associated with these conditions poses a challenge to persons’ wellPbeing, daily functioning, work performance, and social inclusion. Subsequently, a lower labour force participation of people with mental disorders has been found due to higher unemployment rates, sickness absence, and early retirement, leading to substantial personal and societal costs. In Portugal, the 2008 economic recession may have contributed to this pattern due to the deterioration of socioeconomic conditions, widening social inequalities in mental health across the population. Following three research phases, this doctoral thesis aimed to provide a better understanding of the consequences of mental disorders, in terms of disability and social inequalities, using both quantitative and qualitative approaches. In the 1st phase, the association between disability and mental disorders was characterized, along with the effect of socioeconomic position in the disability reported by people with mental disorders. Changes in socioeconomic position among people with mental disorders during the economic recession were evaluated in the 2nd phase. Primary health care users and professionals’ perspectives on the relationship between mental health and socioeconomic conditions during the economic recession, together with their proposed solutions to improve populations’ mental health, were explored in the 3rd phase. Methods: Data from the National Mental Health Survey (2008/09), a nationally representative crossPsectional survey (n=3849) were used in the 1st phase. Logistic regression models were performed to evaluate the association between disability and 12Pmonth mental disorders, adjusting for gender, age, education, resence of physical disorders and psychiatric comorbidity. Additionally, odds ratios were estimated at the specific values of the main effects and interaction terms between the presence of any 12P month mental disorder and indicators of socioeconomic position, adjusting for age, gender and presence of physical disorders. Data from the National Mental Health Survey FollowPup (2015/16) (n=911) were used in the 2nd phase. Multinomial and logistic recession models were performed to examine the association between the presence of any 12Pmonth mental disorder in 2008/2009 (T0) and selfPreported changes in indicators of socioeconomic position in 2015/2016 (T1), adjusting for age, gender, education and presence of physical disorders at T0. In the 3rd phase, a qualitative study was conducted in primary health care centres of the Lisbon Metropolitan Area during 2016/17. SemiP structured interviews and focus groups with users and professionals were audioP recorded, transcribed and thematic analysis was conducted. Results: In the 1st phase, disability was found to be significantly associated with both 12P month anxiety (OR: 1.88; 95% CI: 1.23P2.86) and mood disorders (OR: 3.94; 95% CI: 2.45P 6.34). Among people with 12Pmonth mental disorders (n=788) participants categorized as “retired or others” and those with financial deprivation had two times higher odds of reporting disability, when compared with those working (OR=2.19; 95%CI: 1.06P4.48) and nonPfinancially deprived (OR=2.36; 95%CI: 1.31P4.24), respectively. In the 2nd phase, participants with any 12Pmonth mental disorder in T0, when compared to those without these conditions, reported 2.20 (95%CI: 1.31P3.71; p<0.01) higher odds of financial hardship related to daily life in T1. In the 3rd phase, the narratives obtained by users and professionals on the relationship between socioeconomic conditions and mental health during the economic recession encompassed two themes. Poor mental health was perceived as a consequence of adverse socioeconomic conditions, whereas the experience of mental health problems was considered to lead to loss of socioeconomic position, due to disability, sickness absence and early retirement. Lastly, solutions to address the mental health consequences of the economic recession included increasing investment and reversing austerity measures in health and social sectors, enhancing coordination and integration of mental health care, and reducing social inequalities in mental health. Conclusions: The findings of this doctoral thesis contributed to a better understanding on the consequences of mental disorders, focusing on disability and pointing to the impact of the economic recession widening social inequalities in mental health. The cyclical nature of economic recessions urges the need to guarantee socioeconomic protection, access to appropriate healthcare and welfare benefits for people with mental disorders. Moreover, investing in mental health allow paving the way towards more just and equitable societies, a vision that should be promoted along with policy efforts integrating all relevant stakeholders.<br>Enquadramento: Os problemas de saúde mental representam um desafio urgente de saúde global, cuja incapacidade associada constitui dificuldades ao nível do bem-estar, atividades no dia a dia, desempenho no trabalho e inclusão social. Consequentemente existe uma menor participação no mercado de trabalho de pessoas com doença mental, devido a maiores níveis de desemprego, baixa medica e reforma antecipada, conduzindo a substanciais custos individuais e societais. Em Portugal, a recessão económica de 2008 poderá ter contribuído para agravar este padrão devido a deterioração de condições socioeconómicas, ampliando desigualdades sociais em saúde mental. Ao longo de três fases de investigação, a presente tese pretende proporcionar uma melhor compreensão relativamente as consequências das doenças mentais, em termos de incapacidade e desigualdades sociais, recorrendo a abordagens quantitativas e qualitativas. A associação entre incapacidade e doenças mentais nos últimos 12 meses foi caracterizada na 1a fase de investigação, assim como o efeito da posição socioeconómica na incapacidade reportada por pessoas com doença mental. As mudanças na posição socioeconómica reportadas por pessoas com doença mental nos últimos 12 meses durante a recessão económica foram avaliadas na 2a fase. As perspetivas de utentes e profissionais de cuidados de saúde primários face a relação entre saúde mental e condições socioeconómicas durante a recessão económica, bem como propostas para melhorar a saúde mental da população. Métodos: Dados do Estudo Epidemiológico Nacional de Saúde Mental (2008/09), um estudo transversal representativo da população Portuguesa (n=3849) foram usados na 1a fase. Modelos de regressão logística foram efetuados para avaliar a associação entre incapacidade e doenças mentais, ajustando por género, idade, doenças físicas e comorbidade psiquiátrica. Adicionalmente, odds ratios foram estimados considerando a presença de doenças mentais e indicadores de posição socioeconómica, ajustando por idade, género e doenças físicas. Dados do Follow-up do Estudo Epidemiológico Nacional de Saúde Mental (2015/16) (n=911) foram usados na 2a fase. Modelos de regressão multinominal e logística foram realizados para examinar a associação entre a presença de doença mental em 2008/09 (T0) e mudanças auto-reportadas na posição socioeconómicas em 2015/16 (T1), ajustando por idade, género, educação e doenças físicas em T0. Na 3a fase, um estudo qualitativo foi conduzido em centros de cuidados primários da Região Metropolitana de Lisboa em 2016/17. Entrevistas semiestruturadas e focus groups foram realizadas com utentes e profissionais de saúde, transcritas e analisadas tematicamente. Resultados: Na 1a fase, foi encontrada uma associação entre incapacidade e a presença de perturbações de ansiedade (OR: 1.88; 95% CI: 1.23P2.86) e humor (OR: 3.94; 95% CI: 2.45P6.34). Entre pessoas com doença mental (n=788), participantes na categoria de “reformados e outros”, bem como aqueles com privação financeira, reportaram aproximadamente 2 vezes maior probabilidade de incapacidade, em comparação com trabalhadores (OR=2.19; 95%CI: 1.06P4.48) e indivíduos sem privação financeira (OR=2.36; 95%CI: 1.31P4.24), respetivamente. Na 2a fase, participantes com doença mental em T0 tiveram 2.20 (95%CI: 1.31P3.71; p<0.01) maior probabilidade de reportar privação financeira no dia a dia em T1. Na 3a fase, as narrativas obtidas sobre a relação entre condições socioeconómicas e saúde mental durante a recessão foram organizadas em dois temas. Problemas de saúde mental foram percecionados como uma consequência de condições socioeconómicas adversas. Por outro lado, problemas de saúde mental foram considerados como conduzindo a perda de posição socioeconómica, devido a incapacidade, baixa medica e reforma antecipada. Por fim, as soluções propostas para lidar com as consequências da recessão económica incluíram o aumento de investimento e reversão de medidas de austeridade nos sectores da saúde e social, coordenação e integração de cuidados em saúde mental, bem como reduzir desigualdades sociais em saúde mental. Conclusões: Esta tese doutoral permite contribuir para um melhor conhecimento das consequências das doenças mentais, em termos de incapacidade e apontando para o impacto da recessão económica no aumento das desigualdades sociais em saúde mental. A natureza cíclica das recessões económicas apela a necessidade de garantir a proteção de pessoas com doença mental, assim como o acesso a cuidados de saúde e benefícios sociais. Investir em saúde mental significa abrir o caminho a sociedades mais justas e equitativas, uma visão que deve ser promovida em conjunto com o delineamento de políticas que envolvam todos os intervenientes relevantes.<br>European Social Fund (ESF)<br>Human Capital Operating Plan (HCOP)

L'activité physique améliore la santé, mais seulement 4.8% des Canadiens atteignent le niveau recommandé. La position socio-économique est un des déterminants de l'activité physique les plus importants. Elle est associée à l’activité physique de manière transversale à l’adolescence et à l’âge adulte. Cette thèse a tenté de déterminer s'il y a une association à long terme entre la position socio-économique au début du parcours de vie et l’activité physique à l’âge adulte. S'il y en avait une, un deuxième objectif était de déterminer quel modèle théorique en épidémiologie des parcours de vie décrivait le mieux sa forme. Cette thèse comprend trois articles: une recension systématique et deux recherches originales. Dans la recension systématique, des recherches ont été faites dans Medline et EMBASE pour trouver les études ayant mesuré la position socio-économique avant l'âge de 18 ans et l'activité physique à ≥18 ans. Dans les deux recherches originales, la modélisation par équations structurelles a été utilisée pour comparer trois modèles alternatifs en épidémiologie des parcours de vie: le modèle d’accumulation de risque avec effets additifs, le modèle d’accumulation de risque avec effet déclenché et le modèle de période critique. Ces modèles ont été comparés dans deux cohortes prospectives représentatives à l'échelle nationale: la 1970 British birth cohort (n=16,571; première recherche) et l’Enquête longitudinale nationale sur les enfants et les jeunes (n=16,903; deuxième recherche). Dans la recension systématique, 10 619 articles ont été passés en revue par deux chercheurs indépendants et 42 ont été retenus. Pour le résultat «activité physique» (tous types et mesures confondus), une association significative avec la position socio-économique durant l’enfance fut trouvée dans 26/42 études (61,9%). Quand seulement l’activité physique durant les loisirs a été considérée, une association significative fut trouvée dans 21/31 études (67,7%). Dans un sous-échantillon de 21 études ayant une méthodologie plus forte, les proportions d’études ayant trouvé une association furent plus hautes : 15/21 (71,4%) pour tous les types et toutes les mesures d’activité physique et 12/15 (80%) pour l’activité physique de loisir seulement. Dans notre première recherche originale sur les données de la British birth cohort, pour la classe sociale, nous avons trouvé que le modèle d’accumulation de risque avec effets additifs s’est ajusté le mieux chez les hommes et les femmes pour l’activité physique de loisir, au travail et durant les transports. Dans notre deuxième recherche originale sur les données canadiennes sur l'activité physique de loisir, nous avons trouvé que chez les hommes, le modèle de période critique s’est ajusté le mieux aux données pour le niveau d’éducation et le revenu, alors que chez les femmes, le modèle d’accumulation de risque avec effets additifs s’est ajusté le mieux pour le revenu, tandis que le niveau d’éducation ne s’est ajusté à aucun des modèles testés. En conclusion, notre recension systématique indique que la position socio-économique au début du parcours de vie est associée à la pratique d'activité physique à l'âge adulte. Les résultats de nos deux recherches originales suggèrent un patron d’associations le mieux représenté par le modèle d’accumulation de risque avec effets additifs.<br>Physical activity enhances health, yet only 4.8% of adults in Canada meet the recommended level. Among the determinants of physical activity, socioeconomic position shows some of the strongest and most consistent associations. Its association is found cross-sectionally during adolescence and cross-sectionally during adulthood. This thesis aimed to determine if there is a long-lasting, life course association between socioeconomic position early in life and physical activity during adulthood. If there was one, a second goal was to determine which theoretical model in life course epidemiology best described its pattern. This thesis comprises three papers: a systematic review and two original contributions. In the systematic review, Medline and EMBASE were searched for studies that assessed socioeconomic position before age 18 years and physical activity at age ≥18 years. In the two original research papers, structural equation modeling was used to compare three competing models in life course epidemiology: the accumulation of risk model with additive effects, the accumulation of risk model with trigger effect, and the critical period model. Each of the original research paper used data from a large, nationally representative prospective cohort. In the first paper, models were compared in the 1970 British birth cohort (n=16,571). Social class was used as an indicator of socioeconomic position, and physical activity was assessed during leisure time, during transports, and at work. In the second paper, models were compared in the Canadian National Longitudinal Survey of Children and Youth (n=16,903). Education and income were used as indicators of socioeconomic position and physical activity was assessed during leisure-time only. In the systematic review, 10,619 publications were reviewed by two independent investigators and 42 were retained. For outcome "physical activity" (all types and measures), a significant association with socioeconomic position before age 18 years was found in 26/42 studies (61.9%). When the only outcome considered was leisure-time physical activity, a significant association was found in 21/31 studies (67.7%). In a subset of 21 studies with more rigorous methodology, proportions of studies finding an association were higher: 15/21 (71.4%) for all types and measures of physical activity and 12/15 (80%) for leisure-time physical activity only. In our first original research paper, using British data on social class, we found that the accumulation of risk model with additive effects fit the data best in both men and women for all three domains of physical activity studied (leisure time, transports, and work). In our second original research paper, using Canadian data on leisure-time physical activity, we found that in men, the critical period model fit the data best for education and income, while in women, the accumulation of risk model with additive effects fit the data best for income, whereas education did not fit any model. To conclude, our systematic review suggests that socioeconomic position early in life is associated with physical activity during adulthood. Results from our two original research papers indicate that the pattern of its association may be best represented by the accumulation of risk model with additive effects.