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1.  Is Occupation a Good Predictor of Self-Rated Health in China? 
PLoS ONE  2015;10(5):e0125274.
China’s rapidly changing economic landscape has led to widening social inequalities. Occupational status in terms of occupational type and prestige may reflect these socio-structural shifts of social position and be more predictive of self-rated health status than income and education, which may only reflect more gradual acquisitions of social status over time. The goals of this study were to understand the role of occupational status in predicting self-rated health, which is well known to be associated with long-term mortality, as well as compare the occupational status to the other major socioeconomic indicators of income and education.
Data from the 2010 baseline surveys of the China Family Panel Studies, which utilized multi-stage probability sampling with implicit stratification was used. Logistic regression was used to examine the relationship of various socioeconomic indicators (i.e. occupational status, income, and education) with self-rated health as the primary outcome of interest. A series of models considered the associations of occupational category or occupational prestige with self-rated health.
The final sample consisted of 14,367 employed adults aged 18–60, which was nationally representative of working adults in China. We found that occupation was not a major predictor of self-rated health in China when age, ethnicity, location, marital status, physical and mental health status were controlled for, with the exception of women working in lower grade management and professional jobs (OR = 1.82, 95% CI: 1.03–3.22). In comparison, income followed by education exhibited greater association with self-rated health. The highest income group had the least probability to report poor health (In men: OR = 0.30, 95% CI: 0.21–0.43. In women: OR = 0.44, 95% CI: 0.26–0.73). People educated with junior high school had better self-rated health than those with primary and below education level (In men: OR = 0.62, 95% CI: 0.50–0.75. In women: OR = 0.53, 95% CI: 0.42–0.68). Income, education and occupation were correlated with each other.
Within the context of rapid societal changes in China, income and its implications for greater healthcare access and benefits had the greatest association with self-rated health followed by education. Occupational status was not associated. Occupational categories and prestige should be better adapted to reflect China’s unique sociopolitical and historical context.
PMCID: PMC4423882  PMID: 25951087
2.  Health Behaviours, Socioeconomic Status, and Mortality: Further Analyses of the British Whitehall II and the French GAZEL Prospective Cohorts 
PLoS Medicine  2011;8(2):e1000419.
Further analysis of data from two prospective cohorts reveals differences in the extent to which health behaviors attenuate associations between socioeconomic position and mortality outcomes.
Differences in morbidity and mortality between socioeconomic groups constitute one of the most consistent findings of epidemiologic research. However, research on social inequalities in health has yet to provide a comprehensive understanding of the mechanisms underlying this association. In recent analysis, we showed health behaviours, assessed longitudinally over the follow-up, to explain a major proportion of the association of socioeconomic status (SES) with mortality in the British Whitehall II study. However, whether health behaviours are equally important mediators of the SES-mortality association in different cultural settings remains unknown. In the present paper, we examine this issue in Whitehall II and another prospective European cohort, the French GAZEL study.
Methods and Findings
We included 9,771 participants from the Whitehall II study and 17,760 from the GAZEL study. Over the follow-up (mean 19.5 y in Whitehall II and 16.5 y in GAZEL), health behaviours (smoking, alcohol consumption, diet, and physical activity), were assessed longitudinally. Occupation (in the main analysis), education, and income (supplementary analysis) were the markers of SES. The socioeconomic gradient in smoking was greater (p<0.001) in Whitehall II (odds ratio [OR]  = 3.68, 95% confidence interval [CI] 3.11–4.36) than in GAZEL (OR  = 1.33, 95% CI 1.18–1.49); this was also true for unhealthy diet (OR  = 7.42, 95% CI 5.19–10.60 in Whitehall II and OR  = 1.31, 95% CI 1.15–1.49 in GAZEL, p<0.001). Socioeconomic differences in mortality were similar in the two cohorts, a hazard ratio of 1.62 (95% CI 1.28–2.05) in Whitehall II and 1.94 in GAZEL (95% CI 1.58–2.39) for lowest versus highest occupational position. Health behaviours attenuated the association of SES with mortality by 75% (95% CI 44%–149%) in Whitehall II but only by 19% (95% CI 13%–29%) in GAZEL. Analysis using education and income yielded similar results.
Health behaviours were strong predictors of mortality in both cohorts but their association with SES was remarkably different. Thus, health behaviours are likely to be major contributors of socioeconomic differences in health only in contexts with a marked social characterisation of health behaviours.
Please see later in the article for the Editors' Summary
Editors' Summary
The influence of the socioeconomic environment on the health of individuals and populations is well known, giving rise to the so-called social determinants of health. The social determinants of health are the conditions in which people are born, grow, live, work, and age, including the health system. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels, which are themselves influenced by policy choices. The social determinants of health are mostly responsible for health inequities—the unfair and avoidable differences in health status seen within and between countries. In addition, health-damaging behaviors are often strongly socially patterned. For example, material constraints, lack of knowledge, and limited opportunities to follow health promoting messages often act as barriers that prevent those from lower socioeconomic groups to adopt a healthy lifestyle. Yet the extent to which health behaviors explain social inequalities in health remains unclear and can range from 12% to 72% according to some studies.
Why Was This Study Done?
In a recently published paper using data from the British Whitehall II cohort, the researchers showed that longitudinal assessment of health behaviors accounted for socioeconomic differences in mortality better than a single baseline assessment as used in most previous studies. (The Whitehall II study started in 1985 to examine the socioeconomic gradient in health among 10,308 London-based civil servants [6,895 men and 3,413 women] aged 35–55).
However, it is not clear whether health behaviors are equally important mediators of the socioeconomic-health association in different cultural settings. In this study, the researchers examine this issue by comparing their recent findings of the Whitehall II study with another European cohort, the French GAZEL study. (The GAZEL study started in 1989 among employees of the French national gas and electricity company totaling 20,625 employees [15,011 men and 5,614 women], aged 35–50.) The Whitehall II study and the GAZEL study have comparable designs in the way both assess socioeconomic status, health behaviors, and mortality and have a similar age range and follow-up period.
What Did the Researchers Do and Find?
The researchers included 9,771 participants from the Whitehall II study and 17,760 from the GAZEL study—mean follow up for Whitehall II was 19.5 years and for GAZEL was 16.5 years. The researchers used occupation as the main marker of socioeconomic status, and education and income as supplementary markers of socioeconomic status. Apart from a few exceptions, the researchers analyzed each cohort separately and used statistical techniques to calculate: the mortality rates per 1000 person-years for each socioeconomic group; the age- and sex-adjusted prevalence rates of smoking, heavy alcohol consumption, unhealthy diet, and physical inactivity, at the first and the last follow-up of the study for each socioeconomic group; and the differences in health behaviors prevalence between lowest and highest occupational position. Then the researchers used a statistical model to deduce the contribution of all health behaviors.
The researchers found that the socioeconomic gradient in smoking, unhealthy diet, and physical inactivity was greater in Whitehall II than in GAZEL. Socioeconomic differences in mortality were similar in the two cohorts, a hazard ratio of 1.62 in Whitehall II and 1.94 in GAZEL for lowest versus highest occupational position. Health behaviors weakened the association between socioeconomic status and mortality by 75% in Whitehall II but only by 19% in GAZEL. The supplementary analysis the researchers conducted using education and income as socioeconomic markers gave similar results.
What Do These Findings Mean?
These results suggest that the social patterning of unhealthy behaviors differs between countries. Although in both cohorts socioeconomic status and health behaviors were strong predictors of mortality, major differences in the social patterning of unhealthy behaviors in the two cohorts meant that the causal chains leading from socioeconomic status to health behaviors to mortality were different. Therefore it may be that health behaviors are likely to only be major contributors of socioeconomic differences in health in contexts with a marked social characterization of those behaviors. In order to identify the common and unique determinants of social inequalities in health in different populations, there needs to be further comparative research on the relative importance of different pathways linking socioeconomic status to health.
Additional Information
Please access these websites via the online version of this summary at
WHO provides information on social determinants of health
University College London provides information on the Whitehall study
The GAZEL study is available in an online open access format
PMCID: PMC3043001  PMID: 21364974
3.  A population-based case–control study on social factors and risk of testicular germ cell tumours 
BMJ Open  2013;3(9):e003833.
Incidence rates for testicular cancer have risen over the last few decades. Findings of an association between the risk of testicular cancer and social factors are controversial. The association of testicular cancer and different indicators of social factors were examined in this study.
Case–control study.
Population-based multicentre study in four German regions (city states Bremen and Hamburg, the Saarland region and the city of Essen).
The study included 797 control participants and 266 participants newly diagnosed with testicular cancer of which 167 cases were classified as seminoma and 99 as non-seminoma. The age of study participants ranged from 15 to 69 years.
Social position was classified by educational attainment level, posteducational training, occupational sectors according to Erikson-Goldthorpe-Portocarrero (EGP) and the socioeconomic status (SES) on the basis of the International SocioEconomic Index of occupational status (ISEI). ORs and corresponding 95% CIs (95% CIs) were calculated for the whole study sample and for seminoma and non-seminoma separately.
Testicular cancer risk was modestly increased among participants with an apprenticeship (OR=1.7 (95% CI 1.0 to 2.8)) or a university degree (OR=1.6 (95% CI 0.9 to 2.8)) relative to those whose education was limited to school. Analysis of occupational sectors revealed an excess risk for farmers and farm-related occupations. No clear trend was observed for the analyses according to the ISEI-scale.
Social factors based on occupational measures were not a risk factor for testicular cancer in this study. The elevated risk in farmers and farm-related occupations warrants further research including analysis of occupational exposures.
PMCID: PMC3780297  PMID: 24056494
4.  AB 9. Health management of occupational diseases challenge for the bulgarian economy and public health 
Journal of Thoracic Disease  2012;4(Suppl 1):AB9.
In 2001 a National Registry of Occupational Diseases was founded in Bulgaria which introduced a new system of reporting and recording Occupational illness into practice. In 2009 more than 400,000 people in Bulgaria were recorded with permanent disability, a lot of them representing victims of Occupational illness or injury. The intention of our present study was to analyze the frequency and type of different Occupational diseases over the last decade, and to determine which types of employment represent the greatest Occupational hazards to the employees’ health and safety.
Patients and methods
A detailed and thorough record of patients with Occupational illnesses was collected by experts for the mentioned time frame. An analysis of the health information was conducted and the characteristics and hazards at the work place were identified. The type and frequency of different Occupational illnesses were investigated and the Occupational Hazards and their effects on employment were determined.
From 1998 until 2008 the number of Occupational diseases in Bulgaria increased especially in specific areas of employment. Musculoskeletal diseases and peripheral nerve-damage caused by exposure to hazardous substances at the workplace represent 55% of all cases. While respiratory diseases (like chronic bronchitis, COPD and bronchiectasis) and diseases caused by noise and vibrations comprise 22% and 12% of cases, accordingly.
The number of patients with permanent disability in Bulgaria is extremely high - which is unacceptable from the medical, social and economic point of view. This is the result of changes of Occupational dynamics (the aging work-population, immigration) and unfavorable work conditions at a time of economic transition. Contributory are also changes of law and practice of Occupational Medicine as well as insufficient training and information of employees about Occupational health and safety. It is important to improve the training of Occupational Physicians which will facilitate preventative and early diagnostic measures of Occupational illnesses and thus substantially contribute to the improvement of Occupational conditions especially regarding serious Occupational hazards. This process needs to be well coordinated and in collaboration with all the parties responsible for the Occupational Health and Safety of employees. (This study was sponsored by “Proekt GRANT” 2012, of the Medical University of Sofia - Bulgaria.)
PMCID: PMC3537354
5.  Social inequalities and correlates of psychotropic drug use among young adults: a population-based questionnaire study 
Use of psychotropic drugs is widespread in Europe, and is markedly more common in France than elsewhere. Young adults often fare less well than adolescents on health indicators (injury, homicide, and substance use). This population-based study assessed disparities in psychotropic drug use among people aged 18–29 from different socio-occupational groups and determined whether they were mediated by educational level, health status, income, health-related behaviours, family support, personality traits, or disability.
A total of 1,257 people aged 18–29, randomly selected in north-eastern France completed a post-mailed questionnaire covering sex, date of birth, height, weight, educational level, occupation, smoking habit, alcohol abuse, income, health-status, diseases, reported disabilities, self-reported personality traits, family support, and frequent psychotropic medication for tiredness, nervousness/anxiety or insomnia. The data were analyzed using the adjusted odds ratios (ORa) computed with logistic models.
Use of psychotropic drugs was common (33.2%). Compared with upper/intermediate professionals, markedly high odds ratios adjusted for sex were found for manual workers (2.57, 95% CI 1.02–6.44), employees (2.58, 1.11–5.98), farmers/craftsmen/tradesmen (4.97, 1.13–21.8), students (2.40, 1.06–5.40), and housewives (3.82, 1.39–10.5). Adjusting for all the confounders considered reduced the estimates to a pronounced degree for manual workers (adjusted OR 1.49, non-significant) but only slightly for the other socio-occupational groups. The odds ratio for unemployed people did not reach statistical significance. The significant confounders were: sex, not-good health status, musculoskeletal disorders and other diseases, being worried, nervous or sad, and lack of family support (adjusted odds ratios between 1.60 and 2.50).
There were marked disparities among young adults from different socio-occupational groups. Sex, health status, musculoskeletal diseases, family support, and personality traits were related to use of psychotropic drugs. These factors mediated the higher risk strongly among manual workers and slightly among the other groups.
PMCID: PMC2262083  PMID: 18205942
6.  Socioeconomic disparities in behavioral risk factors and health outcomes by gender in the Republic of Korea 
BMC Public Health  2010;10:195.
Few studies have examined socioeconomic disparities in health and behavioral risk factors by gender in Asian countries and in South Korea, specifically. We investigated the relationship between socioeconomic position (education, income, and occupation) and subjective and acute and chronic health outcomes and behavioral risk factors by gender, and compared results from 1998 and 2005, in the Republic of Korea.
We examined data from a nationally representative stratified random sample of 4213 men and 4618 women from the 1998 Korea National Health and Nutrition Examination Survey, and 8289 men and 8827 women from the 2005 Korea National Health and Nutrition Examination Survey using General Linear Modeling and multiple logistic regression methods.
Controlling for behavioral risk factors (smoking, drinking, obesity, exercise, and sleep), those in lower socioeconomic positions had poorer health outcomes in both self-reported acute and chronic disease and subjective measures; differences were especially pronounced among women. A socioeconomic gradient for education and income was found for both men and women for morbidity and self-reported health status, but the gradient was more pronounced in women. In 1998, the odds ratios (ORs) of higher morbidity for illiterate vs. college educated females was 5.4:1 and 1.9:1 for females in the lowest income quintile vs. the highest. The OR for education decreased in 2005 to 2.9:1 and that for income quintiles remained the same at 1.9:1. The OR of lower self-reported health status for illiterate vs. college educated females was 2.9:1 and 1.6:1 for females in the lowest income quintile vs. the highest in 1998, and 3.3:1 and 2.3:1 in 2005.
Among Korean adults, men and women in lower socioeconomic position, as denoted by education, income, and somewhat less by occupation, experience significantly higher levels of morbidity and lower self-reported health status, even after controlling for standard behavioral risk factors. Disparities were more pronounced for women than for men. Efforts to reduce health disparities in South Korea require attention to the root causes of socioeconomic inequality and gender differences in the impact of socioeconomic position on health.
PMCID: PMC2867999  PMID: 20398324
7.  Expectations for Recovery Important in the Prognosis of Whiplash Injuries 
PLoS Medicine  2008;5(5):e105.
Individuals' expectations on returning to work after an injury have been shown to predict the duration of time that a person with work-related low back pain will remain on benefits; individuals with lower recovery expectations received benefits for a longer time than those with higher expectations. The role of expectations in recovery from traumatic neck pain, in particular whiplash-associated disorders (WAD), has not been assessed to date to our knowledge. The aim of this study was to investigate if expectations for recovery are a prognostic factor after experiencing a WAD.
Methods and Findings
We used a prospective cohort study composed of insurance claimants in Sweden. The participants were car occupants who filed a neck injury claim (i.e., for WAD) to one of two insurance companies between 15 January 2004 and 12 January 2005 (n = 1,032). Postal questionnaires were completed shortly (average 23 d) after the collision and then again 6 mo later. Expectations for recovery were measured with a numerical rating scale (NRS) at baseline, where 0 corresponds to “unlikely to make a full recovery” and 10 to “very likely to make a full recovery.” The scale was reverse coded and trichotomised into NRS 0, 1–4, and 5–10. The main outcome measure was self-perceived disability at 6 mo postinjury, measured with the Pain Disability Index, and categorised into no/low, moderate, and high disability. Multivariable polytomous logistic regression was used for the analysis. There was a dose response relationship between recovery expectations and disability. After controlling for severity of physical and mental symptoms, individuals who stated that they were less likely to make a full recovery (NRS 5–10), were more likely to have a high disability compared to individuals who stated that they were very likely to make a full recovery (odds ratio [OR] 4.2 [95% confidence interval (CI) 2.1 to 8.5]. For the intermediate category (NRS 1–4), the OR was 2.1 (95% CI 1.2 to 3.2). Associations between expectations and disability were also found among individuals with moderate disability.
Individuals' expectations for recovery are important in prognosis, even after controlling for symptom severity. Interventions designed to increase patients' expectations may be beneficial and should be examined further in controlled studies.
Lena Holm and colleagues show that in people who had a whiplash injury after a car crash there was an association between expectation of disability and actual disability six months later.
Editors' Summary
The disability associated with injury is a major source of distress for patients, and can be costly to the health care system and employers when persons fail to recover quickly and are unable to return to work. Finding ways to help people recover quickly and get back to optimal health is important. Some of the most common injuries causing disability and time off work result from whiplash—the sudden hyperextension or “whipping” of the neck, which can occur from a motor vehicle crash. It has long been recognized that psychological factors (such as the ability to cope, how “in control” one feels about one's life) are as important as physical symptoms in how disabling an injury can be. There is now growing evidence that a person's feelings about their ability to recover from injury plays a part in actual recovery. Studies from Europe and North America have shown with conditions like low back pain and minor head injury that a patient's feelings about the possibility of getting better are related to how well they do. Less is known about how important these psychological factors are in recovery from disorders due to whiplash associated disorders.
Why Was This Study Done?
The authors wanted to find out whether there was a relationship between people's expectations for their recovery from whiplash associated disorders and their actual recovery six months later. So, for example, they wondered if a person with whiplash who felt they were very unlikely to recover from their injury, actually did not recover (and vice versa).
What Did the Researchers Do and Find?
The authors had access to an unusual set of health information—insurance claims by people who had been involved in car collisions to two insurance companies in Sweden. They identified about 1,000 adult insurance claimants over one year and mailed them a questionnaire that asked for details about the collision as well as information about the claimant: their demographic profile, health history, and the types of pain and symptoms experienced since the crash. The questionnaire also asked the claimant how likely they thought they were to make a full recovery from their injuries.
For those who said they had whiplash associated disorders, the authors followed up with another questionnaire six months later, which asked for information about any disability, pain, or other symptoms that the claimant was still experiencing because of the injury. Of those who had completed the first questionnaire, 82% were followed up.
Only about a quarter of claimants with whiplash associated disorders said they expected to make a full recovery. Perhaps not surprisingly, those with only mild pain, compared to those with intense pain, were more likely to think so. Persons who said they were less likely to make a full recovery were four times more likely to report high levels of disability six months later. Even for persons (or individuals) people with moderate levels of disability six months after injury, their expectations for recovery were similarly linked to how well they did: the lower the expectations for recovery, the higher the disability. These findings were true even after taking into account how severe signs and symptoms the person had, and how well the person was coping psychologically.
What Do These Findings Mean?
The findings indicate that those with the lowest expectations for recovery after their whiplash injury will have the poorest recovery, and those with the highest expectations will have the best recovery. They also suggest that a patient's expectations about getting better are as important as his or her physical symptoms. The authors say that the more we can influence patients to believe they will make a full recovery, the better chance they will have to recover completely. This means that it may be beneficial for healthcare providers to give support and/or education to patients with whiplash associated disorders that increases their positive feelings toward recovery. The authors call for more studies into whether these types of targeted interventions would be of benefit.
Additional Information
Please access these Web sites via the online version of this summary at
Information about research on injuries and rehabilitation can be found at the Web sites of organisations devoted to studying the health of workers, such as the Institute for Work and Health in Canada, the Finnish Institute of Occupational Health, and the US National Institute for Occupational Safety and Health
The Wikipedia entry for medical aspects of whiplash describes the four grades of whiplash disorder, but does not cover the debate about the credibility of whiplash disorder (please note that Wikipedia is an online encyclopedia that anyone can edit)
The Sjukvardsradgivningen Web site provides information about whiplash-related disorders, common signs and symptoms, recovery and prognosis, and treatments (in Swedish)
PMCID: PMC2375948  PMID: 18479182
8.  Socio-economic position and mental disorders in a working-age Finnish population: the health 2000 study 
Background: Mental disorders are more common in people with lower socio-economic position (SEP) but it is not known which specific SEP component is most strongly linked to poor mental health. We compared the strength of associations of three SEP components—occupation, income and education—with common mental disorders in a Finnish population. Methods: Cross-sectional analysis of a nationally representative sample of 4561 men and women aged 30–65 years. Mental disorders were assessed using the Composite International Diagnostic Interview resulting in 12-month DSM-IV diagnoses of depressive, anxiety and alcohol use disorders. Participants were classified as having low SEP if they worked in a manual occupation, lacked secondary-level education or had income below the Organisation for Economic Co-operation and Development (OECD) definition of relative poverty. Results: In models comparing the simultaneous association of all three socio-economic indicators with mental disorders, low income was associated with increased risk for depressive disorder [odds ratio (OR)=1.73, 95% confidence interval (CI) =1.31–2.29] and anxiety disorder (OR=1.56, 95% CI 1.14–2.12). Manual occupational class was modestly associated with risk for alcohol use disorder (OR=1.44, 95% CI 1.06–1.95). Low income was the only socio-economic component associated with psychiatric comorbidity, that is, a combination of various disorders within the same individual (OR 2.26, 95% CI 1.52–3.37 for any combination). Conclusion: Low income seems to be a more important correlate of mental disorders than education or occupation in a high-income country such as Finland.
PMCID: PMC3358631  PMID: 21953062
9.  An additional dimension to health inequalities: disease severity and socioeconomic position 
OBJECTIVE: To investigate the association between the severity of hip pain and disability, and a number of measures of socioeconomic position, using a range of individual and ecological socioeconomic indicators. DESIGN: Interviewer administered and self completed questionnaires on symptoms of pain and disability, general health and socioeconomic indicators, completed by people reporting hip pain in a cross sectional, postal, screening questionnaire. SETTING: 40 general practices from inner city, suburban and rural areas of south west England. PARTICIPANTS: 954 study participants who had reported hip pain in a postal questionnaire survey of 26,046 people aged 35 and over, selected using an age/sex stratified random probability sample. DATA: Individual indicators of socioeconomic position: social class based on occupation, maximum educational attainment, car ownership, gross household income, manual or non-manual occupation and living alone. Area level measures of socioeconomic position: Townsend scores for material deprivation at enumeration district level; urban or rural location based on the postcode of residence. Severity of hip disease, measured by the pain, disability and independence components of the New Zealand score for major joint replacement. Self reported comorbidity validated using general practice case notes and summary measures of general health. MAIN RESULTS: Increasing disease severity was strongly associated with increasing age and a variety of measures of general health, including comorbidity. The data provide considerable evidence for the systematic association of increased severity of hip disease with decreasing socioeconomic position. Measures of socioeconomic position that were systematically associated with increasing disease severity, standardised for age and sex, included educational attainment (relative index of inequality 1.95 (95% confidence intervals 1.29 to 2.62) and income (relative index of inequality 4.03 (95% confidence intervals 3.43 to 4.64). Those with access to a car (mean disease severity 15.5) had statistically significant lower severity of hip disease than those without (mean 17.5, p < 0.01). Similar results were found for access to higher or further education and living with others. For a given level of income, people with greater comorbidity had more severe hip pain and disability. The gradient in disease severity between rich and poor was steepest among those with the most comorbidity. CONCLUSIONS: People with lower socioeconomic position experience a greater severity of hip disease. The poorest sector of the population seem to be in double jeopardy: they not only experience a greater burden of chronic morbidity but also a greater severity of hip disease. This study has implications for health care provision, if the National Health Service is to live up to its principle of equal treatment for equal medical need.
PMCID: PMC1756792  PMID: 10616672
10.  Distribution of lipid parameters according to different socio-economic indicators- the EPIC-Norfolk prospective population study 
BMC Public Health  2014;14:782.
Data on the relationship between plasma levels of cholesterol and triglycerides and social class have been inconsistent. Most previous studies have used one classification of social class.
This was a cross-sectional population based study with data on occupational social class, educational level obtained using a detailed health and lifestyle questionnaire. A total of 10,147 men and 12,304 women aged 45–80 years living in Norfolk, United Kingdom, were recruited using general practice age-sex registers as part of the European Prospective Investigation into Cancer (EPIC-Norfolk). Plasma levels of cholesterol and triglycerides were measured in baseline samples. Social class was classified according to three classifications: occupation, educational level, and area deprivation score according to Townsend deprivation index. Differences in lipid levels by socio-economic status indices were quantified by analysis of variance (ANOVA) and multiple linear regression after adjusting for body mass index and alcohol consumption.
Total cholesterol levels were associated with occupational level among men, and with educational level among women. Triglyceride levels were associated with educational level and occupational level among women, but the latter association was lost after adjustment for age and body mass index. HDL-cholesterol levels were associated with both educational level and educational level among men and women. The relationships with educational level were substantially attenuated by adjustment for age, body mass index and alcohol use, whereas the association with educational class was retained upon adjustment. LDL-cholesterol levels were not associated with social class indices among men, but a positive association was observed with educational class among women. This association was not affected by adjustment for age, body mass index and alcohol use.
The findings of this study suggest that there are sex differences in the association between socio-economic status and serum lipid levels. The variations in lipid profile with socio-economic status may be largely attributed to potentially modifiable factors such as obesity, physical activity and dietary intake.
PMCID: PMC4155077  PMID: 25179437
11.  Socioeconomic Factors and All Cause and Cause-Specific Mortality among Older People in Latin America, India, and China: A Population-Based Cohort Study 
PLoS Medicine  2012;9(2):e1001179.
Cleusa Ferri and colleagues studied mortality rates in over 12,000 people aged 65 years and over in Latin America, India, and China and showed that chronic diseases are the main causes of death and that education has an important effect on mortality.
Even in low and middle income countries most deaths occur in older adults. In Europe, the effects of better education and home ownership upon mortality seem to persist into old age, but these effects may not generalise to LMICs. Reliable data on causes and determinants of mortality are lacking.
Methods and Findings
The vital status of 12,373 people aged 65 y and over was determined 3–5 y after baseline survey in sites in Latin America, India, and China. We report crude and standardised mortality rates, standardized mortality ratios comparing mortality experience with that in the United States, and estimated associations with socioeconomic factors using Cox's proportional hazards regression. Cause-specific mortality fractions were estimated using the InterVA algorithm. Crude mortality rates varied from 27.3 to 70.0 per 1,000 person-years, a 3-fold variation persisting after standardisation for demographic and economic factors. Compared with the US, mortality was much higher in urban India and rural China, much lower in Peru, Venezuela, and urban Mexico, and similar in other sites. Mortality rates were higher among men, and increased with age. Adjusting for these effects, it was found that education, occupational attainment, assets, and pension receipt were all inversely associated with mortality, and food insecurity positively associated. Mutually adjusted, only education remained protective (pooled hazard ratio 0.93, 95% CI 0.89–0.98). Most deaths occurred at home, but, except in India, most individuals received medical attention during their final illness. Chronic diseases were the main causes of death, together with tuberculosis and liver disease, with stroke the leading cause in nearly all sites.
Education seems to have an important latent effect on mortality into late life. However, compositional differences in socioeconomic position do not explain differences in mortality between sites. Social protection for older people, and the effectiveness of health systems in preventing and treating chronic disease, may be as important as economic and human development.
Please see later in the article for the Editors' Summary
Editors' Summary
Worldwide, half of all deaths occur in people aged 60 or older. Yet mortality among older people is a neglected topic in global health. In high income countries, where 84% of people do not die until they are aged 65 years or older, the causes of death among older people and the factors (determinants) that affect their risk of dying are well documented. In Europe, for example, the leading causes of death among older people are heart disease, stroke, and other chronic (long-term) diseases. Moreover, as in younger age groups, having a better education and owning a house reduces the risk of death among older people. By contrast, in low and middle income countries (LMICs), where three-quarters of deaths of older people occur, reliable data on the causes and determinants of death among older people are lacking, in part because many LMICs have inadequate vital registration systems—official records of all births and deaths.
Why Was This Study Done?
In many LMICs, chronic diseases are replacing communicable (infectious) diseases as the leading causes of death and disability—health experts call this the epidemiological transition (epidemiology is the study of the distribution and causes of disease in populations)—and the average age of the population is increasing (the demographic transition). Faced with these changes, which occur when countries move from a pre-industrial to an industrial economy, policy makers in LMICs need to introduce measures to improve health and reduce deaths among older people. However, to do this, they need reliable data on the causes and determinants of death in this section of the population. In this longitudinal population-based cohort study (a type of study that follows a group of people from a defined population over time), researchers from the 10/66 Dementia Research Group, which is carrying out population-based research on dementia, aging, and non-communicable diseases in LMICs, investigate the patterns of mortality among older people living in Latin America, India, and China.
What Did the Researchers Do and Find?
Between 2003 and 2005, the researchers completed a baseline survey of people aged 65 years or older living in six Latin American LMICs, China, and India. Three to five years later, they determined the vital status of 12,373 of the study participants (that is, they determined whether the individual was alive or dead) and interviewed a key informant (usually a relative) about each death using a standardized “verbal autopsy” questionnaire that includes questions about date and place of death, and about medical help-seeking and signs and symptoms noted during the final illness. Finally, they used a tool called the InterVA algorithm to calculate the most likely causes of death from the verbal autopsies. Crude mortality rates varied from 27.3 per 1,000 person-years in urban Peru to 70.0 per 1,000 person-years in urban India, a three-fold difference in mortality rates that persisted even after allowing for differences in age, sex, education, occupational attainment, and number of assets among the study sites. Compared to the US, mortality rates were much higher in urban India and rural China; much lower in urban and rural Peru, Venezuela, and urban Mexico; but similar elsewhere. Although several socioeconomic factors were associated with mortality, only a higher education status provided consistent independent protection against death in statistical analyses. Finally, chronic diseases were the main causes of death; stroke was the leading cause of death at all the sites except those in rural Peru and Mexico.
What Do These Findings Mean?
These findings identify the main causes of death among older adults in a range of LMICs and suggest that there is an association of education with mortality that extends into later life. However, these findings may not be generalizable to other LMICs or even to other sites in the LMICs studied, and because some of the information provided by key informants may have been affected by recall error, the accuracy of the findings may be limited. Nevertheless, these findings suggest how health and mortality might be improved in elderly people in LMICs. Specifically, they suggest that efforts to ensure universal access to education should confer substantial health benefits and that interventions that target social and economic vulnerability in later life and promote access to effectively organized health care (particularly for stroke) should be considered.
Additional Information
Please access these websites via the online version of this summary at
The World Health Organization provides information on mortality around the world and projections of global mortality up to 2030
The 10/66 Dementia Research Group is building an evidence base to inform the development and implementation of policies for improving the health and social welfare of older people in LMICs, particularly people with dementia; its website includes background information about demographic and epidemiological aging in LMICs
Wikipedia has a page on the demographic transition (note: Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
Information about the InterVA tool for interpreting verbal autopsy data is available
The US Centers for Disease Control and Prevention has information about healthy aging
PMCID: PMC3289608  PMID: 22389633
12.  Contribution of smoking and air pollution exposure in urban areas to social differences in respiratory health 
BMC Public Health  2008;8:179.
Socio-economic status, smoking, and exposure to increased levels of environmental air pollution are associated with adverse effects on respiratory health. We assessed the contribution of occupational exposures, smoking and outdoor air pollution as competing factors for the association between socio-economic status and respiratory health indicators in a cohort of women from the Ruhr area aged 55 at the time of investigation between 1985 and 1990.
Data of 1251 women with spirometry and complete questionnaire information about respiratory diseases, smoking and potential confounders were used in the analyses. Exposure to large-scale air pollution was assessed with data from monitoring stations. Exposure to small-scale air pollution was assessed as traffic-related exposure by distance to the nearest major road. Socio-economic status was defined by educational level. Multiple regression models were used to estimate the contribution of occupational exposures, smoking and outdoor air pollution to social differences in respiratory health.
Women with less than 10 years of school education in comparison to more than 10 years of school education were more often occupationally exposed (16.4% vs. 10.1%), smoked more often (20.3% vs. 13.9%), and lived more often close to major roads (26.0% vs. 22.9%). Long-term exposure to increased levels of PM10 was significantly associated with lower school education. Women with low school education were more likely to suffer from respiratory symptoms and had reduced lung function. In the multivariate analysis the associations between education and respiratory health attenuated after adjusting for occupational exposure, smoking and outdoor air pollution. The crude odds ratio for the association between the lung function indicator FEV1 less than 80% of predicted value and educational level (<10 years vs. >10 years of school education) was 1.83 (95% CI: 1.22–2.74). This changed to 1.56 (95% CI: 1.03–2.37) after adjusting for occupational exposure, smoking and outdoor air pollution.
We found an association between socio-economic status and respiratory health. This can partly be explained by living conditions indicated by occupational exposure, smoking behaviour and ambient air pollution. A relevant part of the social differences in respiratory health, however, remained unexplained.
PMCID: PMC2426697  PMID: 18505547
13.  Reinterpreting Ethnic Patterns among White and African American Men Who Inject Heroin: A Social Science of Medicine Approach 
PLoS Medicine  2006;3(10):e452.
Street-based heroin injectors represent an especially vulnerable population group subject to negative health outcomes and social stigma. Effective clinical treatment and public health intervention for this population requires an understanding of their cultural environment and experiences. Social science theory and methods offer tools to understand the reasons for economic and ethnic disparities that cause individual suffering and stress at the institutional level.
Methods and Findings
We used a cross-methodological approach that incorporated quantitative, clinical, and ethnographic data collected by two contemporaneous long-term San Francisco studies, one epidemiological and one ethnographic, to explore the impact of ethnicity on street-based heroin-injecting men 45 years of age or older who were self-identified as either African American or white. We triangulated our ethnographic findings by statistically examining 14 relevant epidemiological variables stratified by median age and ethnicity. We observed significant differences in social practices between self-identified African Americans and whites in our ethnographic social network sample with respect to patterns of (1) drug consumption; (2) income generation; (3) social and institutional relationships; and (4) personal health and hygiene. African Americans and whites tended to experience different structural relationships to their shared condition of addiction and poverty. Specifically, this generation of San Francisco injectors grew up as the children of poor rural to urban immigrants in an era (the late 1960s through 1970s) when industrial jobs disappeared and heroin became fashionable. This was also when violent segregated inner city youth gangs proliferated and the federal government initiated its “War on Drugs.” African Americans had earlier and more negative contact with law enforcement but maintained long-term ties with their extended families. Most of the whites were expelled from their families when they began engaging in drug-related crime. These historical-structural conditions generated distinct presentations of self. Whites styled themselves as outcasts, defeated by addiction. They professed to be injecting heroin to stave off “dopesickness” rather than to seek pleasure. African Americans, in contrast, cast their physical addiction as an oppositional pursuit of autonomy and pleasure. They considered themselves to be professional outlaws and rejected any appearance of abjection. Many, but not all, of these ethnographic findings were corroborated by our epidemiological data, highlighting the variability of behaviors within ethnic categories.
Bringing quantitative and qualitative methodologies and perspectives into a collaborative dialog among cross-disciplinary researchers highlights the fact that clinical practice must go beyond simple racial or cultural categories. A clinical social science approach provides insights into how sociocultural processes are mediated by historically rooted and institutionally enforced power relations. Recognizing the logical underpinnings of ethnically specific behavioral patterns of street-based injectors is the foundation for cultural competence and for successful clinical relationships. It reduces the risk of suboptimal medical care for an exceptionally vulnerable and challenging patient population. Social science approaches can also help explain larger-scale patterns of health disparities; inform new approaches to structural and institutional-level public health initiatives; and enable clinicians to take more leadership in changing public policies that have negative health consequences.
Bourgois and colleagues found that the African American and white men in their study had a different pattern of drug use and risk behaviors, adopted different strategies for survival, and had different personal histories.
Editors' Summary
There are stark differences in the health of different ethnic groups in America. For example, the life expectancy for white men is 75.4 years, but it is only 69.2 years for African-American men. The reasons behind these disparities are unclear, though there are several possible explanations. Perhaps, for example, different ethnic groups are treated differently by health professionals (with some groups receiving poorer quality health care). Or maybe the health disparities are due to differences across ethnic groups in income level (we know that richer people are healthier). These disparities are likely to persist unless we gain a better understanding of how they arise.
Why Was This Study Done?
The researchers wanted to study the health of a very vulnerable community of people: heroin users living on the streets in the San Francisco Bay Area. The health status of this community is extremely poor, and its members are highly stigmatized—including by health professionals themselves. The researchers wanted to know whether African American men and white men who live on the streets have a different pattern of drug use, whether they adopt varying strategies for survival, and whether they have different personal histories. Knowledge of such differences would help the health community to provide more tailored and culturally appropriate interventions. Physicians, nurses, and social workers often treat street-based drug users, especially in emergency rooms and free clinics. These health professionals regularly report that their interactions with street-based drug users are frustrating and confrontational. The researchers hoped that their study would help these professionals to have a better understanding of the cultural backgrounds and motivations of their drug-using patients.
What Did the Researchers Do and Find?
Over the course of six years, the researchers directly observed about 70 men living on the streets who injected heroin as they went about their usual lives (this type of research is called “participant observation”). The researchers specifically looked to see whether there were differences between the white and African American men. All the men gave their consent to be studied in this way and to be photographed. The researchers also studied a database of interviews with almost 7,000 injection drug users conducted over five years, drawing out the data on differences between white and African men. The researchers found that the white men were more likely to supplement their heroin use with inexpensive fortified wine, while African American men were more likely to supplement heroin with crack. Most of the white men were expelled from their families when they began engaging in drug-related crime, and these men tended to consider themselves as destitute outcasts. African American men had earlier and more negative contact with law enforcement but maintained long-term ties with their extended families, and these men tended to consider themselves as professional outlaws. The white men persevered less in attempting to find a vein in which to inject heroin, and so were more likely to inject the drug directly under the skin—this meant that they were more likely to suffer from skin abscesses. The white men generated most of their income from panhandling (begging for money), while the African American men generated most of their income through petty crime and/or through offering services such as washing car windows at gas stations.
What Do These Findings Mean?
Among street-based heroin users, there are important differences between white men and African American men in the type of drugs used, the method of drug use, their social backgrounds, the way in which they identify themselves, and the health risks that they take. By understanding these differences, health professionals should be better placed to provide tailored and appropriate care when these men present to clinics and emergency rooms. As the researchers say, “understanding of different ethnic populations of drug injectors may reduce difficult clinical interactions and resultant physician frustration while improving patient access and adherence to care.” One limitation of this study is that the researchers studied one specific community in one particular area of the US—so we should not assume that their findings would apply to street-based heroin users elsewhere.
Additional Information.
Please access these Web sites via the online version of this summary at
The US Centers for Disease Control (CDC) has a web page on HIV prevention among injection drug users
The World Health Organization has collected documents on reducing the risk of HIV in injection drug users and on harm reduction approaches
The International Harm Reduction Association has information relevant to a global audience on reducing drug-related harm among individuals and communities
US-focused information on harm reduction is available via the websites of the Harm Reduction Coalition and the Chicago Recovery Alliance
Canada-focused information can be found at the Street Works Web site
The Harm Reduction Journal publishes open-access articles
The CDC has a web page on eliminating racial and ethnic health disparities
The Drug Policy Alliance has a web page on drug policy in the United States
PMCID: PMC1621100  PMID: 17076569
14.  Prognostic Factors of Long Term Disability Due to Mental Disorders: A Systematic Review 
Introduction In the past few decades, mental health problems have increasingly contributed to sickness absence and long-term disability. However, little is known about prognostic factors of return to work (RTW) and disability of persons already on sick leave due to mental health problems. Understanding these factors may help to develop effective prevention and intervention strategies to shorten the duration of disability and facilitate RTW. Method We reviewed systematically current scientific evidence about prognostic factors for mental health related long term disability, RTW and symptom recovery. Searching PubMed, PsycINFO, Embase, Cinahl and Business Source Premier, we selected articles with a publication date from January 1990 to March 2009, describing longitudinal cohort studies with a follow-up period of at least 1 year. Participants were persons on sick leave or receiving disability benefit at baseline. We assessed the methodological quality of included studies using an established criteria list. Consistent findings in at least two high quality studies were defined as strong evidence and positive findings in one high quality study were defined as limited evidence. Results Out of 796 studies, we included seven articles, all of high methodological quality describing a range of prognostic factors, according to the ICF-model categorized as health-related, personal and external factors. We found strong evidence that older age (>50 years) is associated with continuing disability and longer time to RTW. There is limited evidence for the association of other personal factors (gender, education, history of previous sickness absence, negative recovery expectation, socio-economic status), health related (stress-related and shoulder/back pain, depression/anxiety disorder) and external i.e., job-related factors (unemployment, quality and continuity of occupational care, supervisor behavior) with disability and RTW. We found limited evidence for the association of personal/external factors (education, sole breadwinner, partial/full RTW, changing work tasks) with symptom recovery. Conclusion This systematic review identifies a number of prognostic factors, some more or less consistent with findings in related literature (mental health factors, age, history of previous sickness absence, negative recovery expectation, socio-economic status, unemployment, quality and continuity of occupational care), while other prognostic factors (gender, level of education, sole breadwinner, supervisor support) conflict with existing evidence. There is still great need for research on modifiable prognostic factors of continuing disability and RTW among benefit claimants with mental health problems. Recommendations are made as to directions and methodological quality of further research, i.e., prognostic cohort studies.
PMCID: PMC3098343  PMID: 21057974
Mental health; Occupational health; Long-term disability; Return to work; Literature review
15.  Temporal changes in occupational sitting time in the Danish workforce and associations with all-cause mortality: results from the Danish work environment cohort study 
Prolonged sitting has been negatively associated with a range of non-communicably diseases. However, the role of occupational sitting is less clear, and little is known on the changes of occupational sitting in a working population over time. The present study aimed to determine 1) temporal changes in occupational sitting time between 1990 and 2010 in the Danish workforce; 2) the association and possible dose-response relationship between occupational sitting time and all-cause mortality.
This study analysed data from the Danish Work Environment Cohort Study (DWECS), which is a cohort study of the Danish working population conducted in five yearly intervals between 1990 and 2010. Occupational sitting time is self-reported in the DWECS. To determine the association with all-cause mortality, the DWECS was linked to the Danish Register of Causes of Death via the Central Person Register.
Between 1990 and 2010 the proportion of the Danish workforce who sat for at least three quarters of their work time gradually increased from 33.1 to 39.1 %. All-cause mortality analyses were performed with 149,773 person-years of observation and an average follow-up of 12.61 years, during which 533 deaths were registered. None of the presented analyses found a statistically significant association between occupational sitting time and all-cause mortality. The hazard ratio for all-cause mortality was 0.97 (95 % CI: 0.79; 1.18) when ≥24 hr/wk occupational sitting time was compared to <24 hr/wk for the 1990–2005 waves.
Occupational sitting time increased by 18 % in the Danish workforce, which seemed to be limited to people with high socio-economic status. If this increase is accompanied by increases in total sitting time, this development has serious public health implications, given the detrimental associations between total sitting time and mortality. The current study was inconclusive on the specific role that occupational sitting might play in the increased all-cause mortality risk associated with the total volume of sitting.
PMCID: PMC4453049  PMID: 26031453
Sitting; Mortality; Workforce; Prospective cohort
16.  The impact of social status inconsistency on cardiovascular risk factors, myocardial infarction and stroke in the EPIC-Heidelberg cohort 
BMC Public Health  2011;11:104.
Social inequalities in cardiovascular diseases are well documented. Yet, the relation of social status inconsistency (having different ranks in two or more status indicators like education, occupational position or income) and medical conditions of heart or vessels is not clear. Status inconsistency (SI) is assumed to be stressful, and the association of psychosocial distress and health is well known. Therefore, we aimed to analyze the relationship between cardiovascular diseases (CVD) and status inconsistency. Another target was to assess the influence of behaviour related risk factors on this association.
8960 men and 6070 women, aged 45-65 years, from the EPIC-Heidelberg cohort (European Prospective Investigation into Cancer and Nutrition) were included. Socio-economic status was assessed by education/vocational training and occupational position at recruitment. During a median follow-up of 8.7 years, information on CVD was collected.
Compared to status consistent subjects, men who were in a higher occupational position than could be expected given their educational attainment had a nearly two-fold increased incidence of CVD (Odds Ratio (OR) = 1.8, 95% Confidence Interval (CI) = 1.5; 2.4, adjusted for age). Smoking behaviour and BMI differed significantly between those who had adequate occupational positions and those who did not. Yet, these lifestyle factors, as opposed to age, did not contribute to the observed differences in CVD. No association of cardiovascular diseases and status inconsistency was found for women or in cases where education exceeded occupational position.
Status inconsistent men (occupational position > education) had a higher risk of cardiovascular diseases than status consistent men. However, harmful behaviour did not explain this relationship.
PMCID: PMC3045944  PMID: 21324154
17.  The role of social support on occupational stress among hospital nurses 
Stress is a nonspecific reaction to everything the body needs. Although occupational stress exists in every occupation, it is seen with more frequency and intensity amongst those occupations related to human health. In this study, we aimed to investigate the relationship between occupational stress and social support (SS) among hospital nurses. A cross-sectional survey was conducted among 1144 hospital nurse in China. They were investigated with a self-administered questionnaire about socio-demographic characteristics, occupational stress and social support. A validated version of the revised Occupational Stress Inventory (OSI-R) was applied to evaluate occupational stress; SS was measured by nine questions. Logistic regression analysis was used to study the association between occupational stress and SS and adjusted for income, gender, marital status, working years, educational level, and profession. Of 1144 nurses, the majority age group was less than 30 years, and the mean age across participants was 31.8 years. Further correlation analysis indicated that score of ORQ and PSQ had a significant negative correlation with score of SS (P<0.05), and a significant positive correlation was found between Score of PRQ and score of SS (P<0.05). The univariate analysis and multivariate analysis results also revealed that high SS increased significantly with decreasing ORQ score and increasing PRQ score after controlling for income, gender, marital status, working years, educational level and job title. SS significantly influences occupational stress in hospitals nurse. We also should pay more attention to occupational stress of married and long working years nurse.
PMCID: PMC4211824  PMID: 25356174
Social support; occupational stress; nurses
18.  Health and quality of life among older rural people in Purworejo District, Indonesia 
Global Health Action  2010;3:10.3402/gha.v3i0.2125.
Increasing life expectancy and longevity for people in many highly populated low- and middle-income countries has led to an increase in the number of older people. The population aged 60 years and over in Indonesia is projected to increase from 8.4% in 2005 to 25% in 2050. Understanding the determinants of healthy ageing is essential in targeting health-promotion programmes for older people in Indonesia.
To describe patterns of socio-economic and demographic factors associated with health status, and to identify any spatial clustering of poor health among older people in Indonesia.
In 2007, the WHO Study on global AGEing and adult health (SAGE) was conducted among 14,958 people aged 50 years and over in Purworejo District, Central Java, Indonesia. Three outcome measures were used in this analysis: self-reported quality of life (QoL), self-reported functioning and disability, and overall health score calculated from self-reported health over eight health domains. The factors associated with each health outcome were identified using multivariable logistic regression. Purely spatial analysis using Poisson regression was conducted to identify clusters of households with poor health outcomes.
Women, older age groups, people not in any marital relationship and low educational and socio-economic levels were associated with poor health outcomes, regardless of the health indices used. Older people with low educational and socio-economic status (SES) had 3.4 times higher odds of being in the worst QoL quintile (OR = 3.35; 95% CI = 2.73–4.11) as compared to people with high education and high SES. This disadvantaged group also had higher odds of being in the worst functioning and most disabled quintile (OR = 1.67; 95% CI = 1.35–2.06) and the lowest overall health score quintile (OR = 1.66; 95% CI = 1.36–2.03). Poor health and QoL are not randomly distributed among the population over 50 years old in Purworejo District, Indonesia. Spatial analysis showed that clusters of households with at least one member being in the worst quintiles of QoL, functioning and health score intersected in the central part of Purworejo District, which is a semi-urban area with more developed economic activities compared with other areas in the district.
Being female, old, unmarried and having low educational and socio-economic levels were significantly associated with poor self-reported QoL, health status and disability among older people in Purworejo District. This study showed the existence of geographical pockets of vulnerable older people in Purworejo District, and emphasized the need to take immediate action to address issues of older people's health and QoL.
PMCID: PMC2957148  PMID: 20959875
adult health; health status; clustering; quality of life; disability; ageing; Purworejo; Indonesia; INDEPTH WHO-SAGE
19.  Socio-demographic and behavioural correlates of physical activity perception in individuals with recently diagnosed diabetes: results from a cross-sectional study 
BMC Public Health  2013;13:678.
Physical activity (PA) levels in type 2 diabetes mellitus (T2DM) patients are generally low. Poor PA perception may impede healthy behaviour change in this high risk group. We describe (i) objective PA levels, (ii) the difference between objective and self-reported PA (‘PA disparity’) and the correlates of (iii) PA disparity and (iv) overestimation in recently diagnosed T2DM patients.
Cross-sectional analysis of 425 recently diagnosed T2DM patients aged 42 to 71, participating in the ADDITION-Plus study in Eastern England, UK. We define ‘PA disparity’ as the non-negative value of the difference (in mathematical terms the absolute difference) between objective and self-reported physical activity energy expenditure (PAEE in kJ · kg-1 · day-1). ‘Overestimators’ comprised those whose self-reported- exceeded objective-PAEE by 4.91 kJ · kg-1 · day-1(the equivalent of 30 minutes moderate activity per day). Multivariable linear regression examined the association between PA disparity (continuous) and socio-demographic, clinical, health behaviour, quality of life and psychological characteristics. Logistic regression examined the association between PA overestimation and individual characteristics.
Mean objective and self-reported PAEE levels ± SD were 34.4 ± 17.0 and 22.6 ± 19.4 kJ · kg-1 · day-1, respectively (difference in means =11.8; 95% CI = 9.7 to 13.9 kJ · kg-1 · day-1). Higher PA disparity was associated with male sex, younger age, lower socio-economic status and lower BMI. PA overestimators comprised 19% (n = 80), with those in routine/manual occupations more likely to be overestimators than those in managerial/professional occupations.
T2DM patients with poor physical activity perception are more likely to be male, younger, from a lower socio-economic class and to have a lower BMI. PA overestimators were more likely to be in lower socio-economic categories. Self-monitoring and targeted feedback, particularly to those in lower socio-economic categories, may improve PA perceptions and optimise interventions in T2DM patients. Our findings suggest that strategies for enabling realistic assessment of physical activity levels, through self-monitoring or feedback, warrant further investigation and may help refine and improve physical activity interventions.
PMCID: PMC3729669  PMID: 23883169
Type 2 diabetes mellitus; Physical activity; Overestimation; Awareness; Perception; Health behaviour; Lifestyle behaviour; Social correlates of health; Health promotion intervention
20.  Communication between Dutch rheumatologists and occupational physicians in the occupational rehabilitation of patients with rheumatic diseases 
Objective: To assess the quality and quantity of communication and cooperation between Dutch rheumatologists and occupational physicians.
Methods: A postal survey among 187 Dutch rheumatologists.
Results: 153/187 rheumatologists (82%) returned the questionnaire. They considered reducing pain and fatigue to be their major responsibility in the process of occupational rehabilitation, followed by improving work participation (68/153 (44%)) and quality of work (55/153 (36%)). Although 112/153 (73%) of the rheumatologists judged the communication and cooperation with occupational physicians as reasonable to good, 119/153 (78%) of them were willing to improve the collaboration. Perceived bottlenecks mentioned were a lack of clarity about the occupational physician's position and activities, and the absence of practice guidelines. The most important prerequisites for improvement were found to be guarantees about the occupational physician's professional independence and more clarity about the competence of the occupational physicians and how they used the information provided.
Conclusion: Dutch rheumatologists are willing to improve cooperation and communication with occupational physicians. The perceived lack of clarity about their mutual tasks appears to be a major obstacle. Thus the development of a joint education programme and a guideline for occupational rehabilitation in rheumatic diseases may be appropriate first steps towards improvement.
PMCID: PMC1753888  PMID: 11779762
21.  Association of Lifecourse Socioeconomic Status with Chronic Inflammation and Type 2 Diabetes Risk: The Whitehall II Prospective Cohort Study 
PLoS Medicine  2013;10(7):e1001479.
Silvia Stringhini and colleagues followed a group of British civil servants over 18 years to look for links between socioeconomic status and health.
Please see later in the article for the Editors' Summary
Socioeconomic adversity in early life has been hypothesized to “program” a vulnerable phenotype with exaggerated inflammatory responses, so increasing the risk of developing type 2 diabetes in adulthood. The aim of this study is to test this hypothesis by assessing the extent to which the association between lifecourse socioeconomic status and type 2 diabetes incidence is explained by chronic inflammation.
Methods and Findings
We use data from the British Whitehall II study, a prospective occupational cohort of adults established in 1985. The inflammatory markers C-reactive protein and interleukin-6 were measured repeatedly and type 2 diabetes incidence (new cases) was monitored over an 18-year follow-up (from 1991–1993 until 2007–2009). Our analytical sample consisted of 6,387 non-diabetic participants (1,818 women), of whom 731 (207 women) developed type 2 diabetes over the follow-up. Cumulative exposure to low socioeconomic status from childhood to middle age was associated with an increased risk of developing type 2 diabetes in adulthood (hazard ratio [HR] = 1.96, 95% confidence interval: 1.48–2.58 for low cumulative lifecourse socioeconomic score and HR = 1.55, 95% confidence interval: 1.26–1.91 for low-low socioeconomic trajectory). 25% of the excess risk associated with cumulative socioeconomic adversity across the lifecourse and 32% of the excess risk associated with low-low socioeconomic trajectory was attributable to chronically elevated inflammation (95% confidence intervals 16%–58%).
In the present study, chronic inflammation explained a substantial part of the association between lifecourse socioeconomic disadvantage and type 2 diabetes. Further studies should be performed to confirm these findings in population-based samples, as the Whitehall II cohort is not representative of the general population, and to examine the extent to which social inequalities attributable to chronic inflammation are reversible.
Please see later in the article for the Editors' Summary
Editors' Summary
Worldwide, more than 350 million people have diabetes, a metabolic disorder characterized by high amounts of glucose (sugar) in the blood. Blood sugar levels are normally controlled by insulin, a hormone released by the pancreas after meals (digestion of food produces glucose). In people with type 2 diabetes (the commonest form of diabetes) blood sugar control fails because the fat and muscle cells that normally respond to insulin by removing sugar from the blood become insulin resistant. Type 2 diabetes, which was previously called adult-onset diabetes, can be controlled with diet and exercise, and with drugs that help the pancreas make more insulin or that make cells more sensitive to insulin. However, as the disease progresses, the pancreatic beta cells, which make insulin, become impaired and patients may eventually need insulin injections. Long-term complications, which include an increased risk of heart disease and stroke, reduce the life expectancy of people with diabetes by about 10 years compared to people without diabetes.
Why Was This Study Done?
Socioeconomic adversity in childhood seems to increase the risk of developing type 2 diabetes but why? One possibility is that chronic inflammation mediates the association between socioeconomic adversity and type 2 diabetes. Inflammation, which is the body's normal response to injury and disease, affects insulin signaling and increases beta-cell death, and markers of inflammation such as raised blood levels of C-reactive protein and interleukin 6 are associated with future diabetes risk. Notably, socioeconomic adversity in early life leads to exaggerated inflammatory responses later in life and people exposed to social adversity in adulthood show greater levels of inflammation than people with a higher socioeconomic status. In this prospective cohort study (an investigation that records the baseline characteristics of a group of people and then follows them to see who develops specific conditions), the researchers test the hypothesis that chronically increased inflammatory activity in individuals exposed to socioeconomic adversity over their lifetime may partly mediate the association between socioeconomic status over the lifecourse and future type 2 diabetes risk.
What Did the Researchers Do and Find?
To assess the extent to which chronic inflammation explains the association between lifecourse socioeconomic status and type 2 diabetes incidence (new cases), the researchers used data from the Whitehall II study, a prospective occupational cohort study initiated in 1985 to investigate the mechanisms underlying previously observed socioeconomic inequalities in disease. Whitehall II enrolled more than 10,000 London-based government employees ranging from clerical/support staff to administrative officials and monitored inflammatory marker levels and type 2 diabetes incidence in the study participants from 1991–1993 until 2007–2009. Of 6,387 participants who were not diabetic in 1991–1993, 731 developed diabetes during the 18-year follow-up. Compared to participants with the highest cumulative lifecourse socioeconomic score (calculated using information on father's occupational position and the participant's educational attainment and occupational position), participants with the lowest score had almost double the risk of developing diabetes during follow-up. Low lifetime socioeconomic status trajectories (being socially downwardly mobile or starting and ending with a low socioeconomic status) were also associated with an increased risk of developing diabetes in adulthood. A quarter of the excess risk associated with cumulative socioeconomic adversity and nearly a third of the excess risk associated with low socioeconomic trajectory was attributable to chronically increased inflammation.
What Do These Findings Mean?
These findings show a robust association between adverse socioeconomic circumstances over the lifecourse of the Whitehall II study participants and the risk of type 2 diabetes and suggest that chronic inflammation explains up to a third of this association. The accuracy of these findings may be affected by the measures of socioeconomic status used in the study. Moreover, because the study participants were from an occupational cohort, these findings need to be confirmed in a general population. Studies are also needed to examine the extent to which social inequalities in diabetes risk that are attributable to chronic inflammation are reversible. Importantly, if future studies confirm and extend the findings reported here, it might be possible to reduce the social inequalities in type 2 diabetes by promoting interventions designed to reduce inflammation, including weight management, physical activity, and smoking cessation programs and the use of anti-inflammatory drugs, among socially disadvantaged groups.
Additional Information
Please access these Web sites via the online version of this summary at
The US National Diabetes Information Clearinghouse provides information about diabetes for patients, health-care professionals, and the general public, including information on diabetes prevention (in English and Spanish)
The UK National Health Service Choices website provides information for patients and carers about type 2 diabetes; it includes peoples stories about diabetes
The nonprofit Diabetes UK also provides detailed information about diabetes for patients and carers, including information on healthy lifestyles for people with diabetes, and has a further selection of stories from people with diabetes; the nonprofit Healthtalkonline has interviews with people about their experiences of diabetes
MedlinePlus provides links to further resources and advice about diabetes (in English and Spanish)
Information about the Whitehall II study is available
PMCID: PMC3699448  PMID: 23843750
22.  Health Status, Intention to Seek Health Examination, and Participation in Health Education Among Taxi Drivers in Jinan, China 
Taxi drivers are exposed to various risk factors such as work overload, stress, an irregular diet, and a sedentary lifestyle, which make these individuals vulnerable to many diseases. This study was designed to assess the health status of this occupational group.
The objective was to explore the health status, the intention to seek health examination, and participation in health education among taxi drivers in Jinan, China.
Patients and Methods:
The sample-size was determined scientifically. The systematic sampling procedure was used for selecting the sample. Four hundred taxi drivers were randomly selected from several taxi companies in Jinan. In total, 396 valid questionnaires (from 370 males and 26 females) were returned. Health status, intention to seek health examination, and participation in health education were assessed by a self-designed questionnaire. Other personal information including sex, age, ethnicity, marital status, years of employment as a taxi driver, education level, and habits were also collected.
This survey revealed that 54.8% of taxi drivers reported illness in the last two weeks and 44.7% of participants reported chronic diseases. The prevalence rates of hypertension, diabetes mellitus, gastroenteritis, arthritis, and heart disease were 18.2%, 8.8%, 26%, 18.4%, and 4.8% of questioned taxi drivers, respectively. Significant self-reported symptoms included fatigue, waist and back pain, headache, dyspepsia, and dry throat affecting 49.7%, 26.2%, 23.5%, 26%, and 27% of participants, respectively. In total, 90.1% of subjects thought that it was necessary to receive a regular health examination. Only 17.9% of subjects had been given information about health education, and significantly, more than 87% of subjects who had been given information about health education reported that the information had been helpful.
Taxi drivers’ health was poor in our survey. Thus, using health education interventions to improve knowledge and change in behaviors are necessary and effective programs that improve the health of individuals in this special occupational group are needed.
PMCID: PMC4028770  PMID: 24910797
Health Status; Health Surveys; Occupational Disease; Health Education; Health Services Needs and Demand
23.  Health and the 2008 Economic Recession: Evidence from the United Kingdom 
PLoS ONE  2013;8(2):e56674.
The economic recession which began in 2008 has resulted in a substantial increase in unemployment across many countries, including the United Kingdom. Strong association between unemployment and poor health status among individuals is widely recognised. We investigated whether the prevalence of poor health at a population level increased concurrent to the rise in unemployment during the economic recession, and whether the impact on health varied by geographical and socioeconomic circumstances.
Health, demographic and socioeconomic measures on 1.36 million survey responses aged 16–64 were extracted from the Quarterly Labour Force Survey of the United Kingdom, collected every three months, from January 2006 to December 2010. The likelihood of self-reporting poor health status and specific types of health problems (depression, mental illness, cardiovascular and respiratory) across time were estimated separately using logistic regression. Explanatory variables included economic status (International Labour Organization definition), occupational class, age, gender, country of birth, ethnicity, educational qualifications, couple status, household tenure, number of dependents, and geographical region.
Unemployment (age-gender adjusted) rose from 4.5% in January 2008 to 7.1% by September 2009. The reporting of poor health status increased from 25.7% in July 2009 to 29.5% by December 2010. Similar increases were found for cardiovascular and respiratory health problems; not depression or mental illness. The prevalence of poor health status among the unemployed decreased from 28.8% in July 2008, to 24.9% by March 2009; but this was followed by an increase in poor health experienced across all regions and by all socioeconomic groups, including those who remained employed, regardless of their occupational class.
Although our study found no exacerbation of pre-recession health inequalities, the rise in poor health status not only for the unemployed, but also among people who remained employed, regardless of their occupational class, justifies concern voiced among many public health commentators.
PMCID: PMC3577686  PMID: 23437208
24.  Health-related quality of life after serious occupational injury in Egyptian workers: a cross-sectional study 
BMJ Open  2012;2(6):e000413.
Occupational injuries can have severe socioeconomic consequences; however, little research has examined the health-related quality of life (HRQoL) of workers following occupational injuries, especially in developing countries. This study was to employ the European Quality of Life Five Dimensions (EQ-5D) tool to measure HRQoL 6 months following serious occupational injury sustained by insured workers in the East Delta Region of Egypt.
This cross-sectional study was conducted from July to December 2008 among workers injured severely enough to be off work for at least 6 months after an occupational injury.
The Nile Insurance Hospital in Qalyubia, Egypt.
Adult workers returning for follow-up evaluation after being given 6 months off work by a physician for an occupational injury.
The workers described their health and quality of life using the EQ-5D instrument.
Most study participants were male (n=118 (90%)), with mean age of 41.5 years. Fractures were the most common type of injury (n=96 (73%)), mostly involving the lower limbs (n=70 (53%)). Participants identified persistent problems related to mobility (n=78 (60%)), self-care (n=69 (53%)), performing usual activities (n=109 (83%)), pain/discomfort (n=119 (91%)) and anxiety/depression (n=51 (40%)). The perceived HRQoL estimated by the mean (±SD) visual analogue scale (VAS) score among injured workers was 61.6±17.9. Multivariate linear regression showed an association between poor VAS score and amputations, mobility limitation, self-care problems, pain/discomfort and anxiety/depression.
Some people with occupational injuries experience significant problems such as pain/discomfort, functional limitations and anxiety/depression, long after the injury. Improvement in pain management strategies and physical and psychological rehabilitation may improve their health-related quality of life.
PMCID: PMC3533107  PMID: 23187968
Occupational & Industrial Medicine; Rehabilitation Medicine
25.  Lifetime Socioeconomic Position and Twins' Health: An Analysis of 308 Pairs of United States Women Twins 
PLoS Medicine  2005;2(7):e162.
Important controversies exist about the extent to which people's health status as adults is shaped by their living conditions in early life compared to adulthood. These debates have important policy implications, and one obstacle to resolving them is the relative lack of sufficient high-quality data on childhood and adult socioeconomic position and adult health status. We accordingly compared the health status among monozygotic and dizygotic women twin pairs who lived together through childhood (until at least age 14) and subsequently were discordant or concordant on adult socioeconomic position. This comparison permitted us to ascertain the additional impact of adult experiences on adult health in a population matched on early life experiences.
Methods and Findings
Our study employed data from a cross-sectional survey and physical examinations of twins in a population-based twin registry, the Kaiser Permanente Women Twins Study Examination II, conducted in 1989 to 1990 in Oakland, California, United States. The study population was composed of 308 women twin pairs (58% monozygotic, 42% dizygotic); data were obtained on childhood and adult socioeconomic position and on blood pressure, cholesterol, post-load glucose, body mass index, waist-to-hip ratio, physical activity, and self-rated health. Health outcomes among adult women twin pairs who lived together through childhood varied by their subsequent adult occupational class. Cardiovascular factors overall differed more among monozygotic twin pairs that were discordant compared to concordant on occupational class. Moreover, among the monozygotic twins discordant on adult occupational class, the working class twin fared worse and, compared to her professional twin, on average had significantly higher systolic blood pressure (mean matched difference = 4.54 mm Hg; 95% confidence interval [CI], 0.10–8.97), diastolic blood pressure (mean matched difference = 3.80 mm Hg; 95% CI, 0.44–7.17), and low-density lipoprotein cholesterol (mean matched difference = 7.82 mg/dl; 95% CI, 1.07–14.57). By contrast, no such differences were evident for analyses based on educational attainment, which does not capture post-education socioeconomic position.
These results provide novel evidence that lifetime socioeconomic position influences adult health and highlight the utility of studying social plus biological aspects of twinship.
Differing socioeconomic positions in adult life are associated with differences in the health of twins raised together.
PMCID: PMC1181870  PMID: 16033303

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