Culture, socioeconomic status, and physical and mental health in Brazil

The association of socioeconomic variables with poor health status has been widely observed, if not well understood, and cultural dimensions of socioeconomic differences have rarely been incorporated into research models. In this article, a cultural dimension of socioeconomic status is examined in a Brazilian city through the use of ethnographic and social survey techniques. It suggests that lifestyle, defined in terms of the relative ability to accumulate consumer goods and the adoption of associated behaviors, is an important component of socioeconomic differences. Further research using cultural consensus analysis, a structured ethnographic technique that may be used to study shared cultural knowledge, demonstrates significant consensus regarding the definition of the successful lifestyle. Then, using that culturally defined model of the successful lifestyle as the central tendency, an individual-level measure of approximation to that lifestyle was developed for a representative sample of 250 persons. This culturally defined measure of lifestyle was inversely associated with arterial blood pressure (beta = -.216, p < .01), depressive symptoms (beta = -.236, p < .01), and globally perceived stress (beta = -.358, p < .01); furthermore, it absorbed the explained variability in these outcomes that is associated with conventional socioeconomic variables (occupation, education, income). For arterial pressure, cultural consonance explained almost 10 percent of the differences in blood pressure between individuals; for the psychological outcome variables, cultural consonance explained between 10 percent and 20 percent of the differences between individuals. Finally, its statistical effects were independent of other socioeconomic, dietary, anthropometric, and psychosocial variables. These results suggest that an individual's approximation to the cultural ideal of lifestyle, his or her "cultural consonance," mediates the observed effects of socioeconomic variables on health status.     

Influence of paid work on the perceived health state in women

BACKGROUND: Several studies show that paid work has a positive effect on women's health, although few studies have shown this relationship in Southern-European countries. The aim of this paper was to analyze the self-perceived health status of women of Barcelona, Spain according to their type of work (homemaker or worker). PATIENTS AND METHODS: Cross sectional study using the 1992 Barcelona Health Interview Survey data. Subjects: 1194 women aged 25 to 64 years old. Bivariate analysis of women's perceived health status by all other variables. A logistic regression model was performed with the dependent variable being women's self-perceived health status and the independent variables: type of work (homemaker or worker), age, number of chronic diseases, medical care visits, children under 12 years and elderly over 65 years living at home and social class based on occupation. RESULTS: 15.8% of workers and 31.4% of homemakers reported poor self-perceived health status (p < 0.05). This same distribution was maintained when adjusting for all independent variables. Social class had an important relationship with health, with women from lower social classes reporting poorer self-perceived health status than homemakers from upper social classes. CONCLUSIONS: The 1992 Barcelona Health Interview Survey analysis confirms that in Barcelona as well, paid work has a positive relationship on women's self-perceived health status.     

Origins of health inequalities in a national population sample

BACKGROUND: Explanations for social inequalities in health are often explored but remain largely unresolved. To elucidate the origins of health inequalties, we investigated the extent to which adult-disease risk factors vary systematically according to social position over three decades of early life. METHODS: We used the 1958 birth cohort (all children born in England, Scotland, and Wales on March 3-9, 1958) with data up to age 33 years from parents, teachers, doctors, and cohort members (n = 11,407 for age 33 interview). FINDINGS: Social class of origin was associated with physical risk factors (birthweight, height, and adult body-mass index); economic circumstances, including household overcrowding, basic amenities, and low income; health behaviour of parents (breastfeeding and smoking) and of participants (smoking and diet); social and family functioning and structure, such as divorce or separation of participants or their parents, emotional adjustment in adolescence, social support in early adulthood; and educational achievement and working career, in particular no qualifications, unemployment, job strain, and insecurity. With few exceptions, there were strong significant trends of increasing risk from classes I and II to classes IV and V. Self-perceived health status and symptoms were worse in participants with lower class origins. INTERPRETATION: An individual's chance of encountering multiple adverse health risks throughout life is influenced powerfully by social position. Social trends in adult-disease risk factors do not emerge exclusively in mid-life, but accumulate over decades. Investment in educational and emotional development is needed in all social groups to strengthen prevention strategies relating to health behaviour, work-place environment, and income inequality.     

Use of health services by children and young people according to ethnicity and social class: secondary analysis of a national survey

OBJECTIVE: To assess whether equity is achieved in use of general practitioner, outpatient, and inpatient services by children and young people according to their ethnic group and socioeconomic background. DESIGN: Secondary analysis of the British general household survey, 1991-94. SUBJECTS: 20 473 children and young people aged between 0 and 19 years. MAIN OUTCOME MEASURES: Consultations with a general practitioner within a two week period, outpatient attendances within a three month period, and inpatient stays during the past year. RESULTS: There were no significant class differences in the use of health services by children and young people, and there was little evidence of variation in use of health services according to housing tenure and parental work status. South Asian children and young people used general practitioner services more than any other ethnic group after controlling for socioeconomic background and perceived health status, but the use of hospital outpatient and inpatient services was significantly lower for children and young people from all minority ethnic groups compared with the white population. CONCLUSIONS: Our results differ from previous studies, which have reported significant class differences in use of health services for other age groups. We found no evidence that children and young people's use of health services varied according to their socioeconomic status, suggesting that equity has been achieved. A child or young person's ethnic origin, however, was clearly associated with use of general practitioner and hospital services, which could imply that children and young people from minority ethnic groups receive a poorer quality of health care than other children and young people.     

The cultural construction of social support in Brazil: associations with health outcomes

The association of social support and health outcomes has received considerable attention in recent years, but the cultural dimension of social support has not been extensively investigated. In this paper, using data collected in a Brazilian city, we present results indicating that those individuals whose reported access to social support more closely approximates an ideal cultural model of access to social support have lower blood pressure and report fewer depressive symptoms and lower levels of perceived stress. The cultural model of social support is derived using a combination of participant observation, semi-structured interviews, and the systematic ethnographic technique of cultural consensus modelling. These results are then used to develop a measure of an individual's approximation to that model of social support in a survey of four diverse neighborhoods in the city (n = 250). We call this approximation to the ideal cultural model of social support "cultural consonance" in social support. The association of health outcomes with cultural consonance in social support is independent of individual differences in the reporting of social support, and of standard covariates. In the case of blood pressure and perceived stress, it is independent of diet, and other socioeconomic and psychosocial variables. The association with depressive symptoms is not independent of other psychosocial variables. The implications of these results are discussed with respect to research on cultural dimensions of the distribution of disease.     

Multicenter study of penile cancer

The objective was to examine the relationships between serum ferritin, alcohol intake, and socioeconomic factors (school education, occupational education, occupation, income, marital status, cohabitation status, housing, social class) in a population survey performed in Copenhagen County during 1982-1984. The participants were selected at random from the census register and comprised 2235 healthy Danish individuals, non-blood donors (1044 men, 1191 women) in cohorts being 30, 40, 50, and 60 years old. The participants gave a detailed social and medical history and had a clinical examination including blood samples. In all age-groups, men had significantly higher serum ferritin and alcohol intake than women. In men, there was no relationship between serum ferritin and social class. Significant relationships were observed between ferritin and occupation (unemployed and self-employed men had higher ferritin than those with other occupations) and ferritin and income (in younger men, ferritin displayed a steady increase with income). None of the social variables were related to the prevalence of iron deficiency or iron overload. Alcohol intake was related to occupation and income, but not to social class. In women, none of the social variables showed any significant relationship to ferritin levels or iron overload. The prevalence of small iron stores (serum ferritin < or = 30 micrograms/l) was lower and the intake of alcohol was higher in women from high social classes. In both men and women, serum ferritin displayed highly significant positive correlations with alcohol intake. Likewise, the prevalence of iron overload (serum ferritin > 90th percentile) was closely correlated to alcohol intake. In conclusion, socioeconomic factors per se had a minor influence on serum ferritin levels and iron status in Danes. The distinct association between alcohol intake and serum ferritin levels should be considered in future iron status surveys.     

Socioeconomic status, standard of living, and neurotic disorder

BACKGROUND: Evidence on the association between socioeconomic status and the prevalence of neurotic disorder is contradictory. We studied the association between three elements of socioeconomic status and the prevalence of neurotic psychiatric disorder in a representative sample of adults aged 16-64 living in private households in the UK. METHODS: A cross-sectional survey of 10,108 adults aged 16-65 resident in private households in the UK was selected by a multi-stage, clustered, random-sampling design. Neurotic disorders were defined using a standardised interview, the revised clinical interview schedule (CIS-R). Data for 9570 people were available for this study. FINDINGS: We used housing tenure and access to cars as measures of standard of living; both were associated with the prevalence of neurotic disorder even after adjustment for other socioeconomic and demographic variables, including Registrar General's Social Class and educational attainment. Those people with no access to a car had an odds ratio for neurotic disorder of 1.4 (95% CI 1.1-1.7), compared with those who had access to two or more cars. People who rented their homes were also at increased risk (1.3 [1.1-1.5]). We estimated that about 10% of the neurotic disorder in the UK could be attributed to the increased prevalence of those without cars who rented their homes. There was a complex interaction between Registrar General's Social Class and sex, and there was no independent association with educational attainment. INTERPRETATION: There is an independent association between low standard of living and the prevalence of neurotic psychiatric disorder. The UK has experienced one of the largest increases in income inequality within western market economies over the past 20 years, and this inequality may have had adverse consequences for the mental health of the population.     

Low education, high GP consultation rates: the effect of psychosocial factors

The purpose of this study was to estimate the contribution of psychosocial factors to the increased use of a general practitioner (GP) among those with a lower level of education. The use of GP services was elicited from survey data from 2867 respondents from the Dutch Longitudinal Study on Socio-Economic Differences in the Utilization of Health Services (LS-SEDUHS) using a simple "Yes/ No" format. Psychosocial variables included long-term stressful conditions, social support, external locus of control, coping styles, and tendency to consult (a measure of people's propensity to go to a doctor with health problems). People with primary education used the GP services more than people with higher vocational training or a university degree (OR 1.87, p<0.05), adjusted for health status and health insurance. Only tendency to consult partially explained this difference (OR: 1.74, p>0.05). Most psychosocial factors do not seem very important in explaining high GP utilization rates among those with a low socioeconomic status. Alternative explanations are discussed.     

Passive smoking in children up to 5 years of age

Passive smoking is a major health risk in young children. We investigated the percentage of children with mothers and/or fathers who reported regular smoking. Data are the national and regional health surveys of the German Cardiovascular Prevention Study (GCP) conducted from 1984 to 1992 in West Germany. 2538 mothers aged 25-40 years were included. The prevalence of passive smoking in children due to smoking mothers was 33.6% 55.4% of the children up to 5 years lived in households with at least one smoking parent member. In 23.4% of these households both parents were smokers. If only one member of the parents smoked this was in two out of three cases the father. 28.2% of mothers with a child younger than one year were current smokers. This prevalence rate increased with the age of the youngest child up to 35.6% for mothers, whose youngest child was 5 years old. Multiple logistic regression analysis was performed to investigate the association between smoking behaviour and the following variables: mother's age, social class, family status, community size and year of the survey. It was found that lower social class members, unmarried or divorced mothers and inhabitants of large cities reported significantly more often regular current smoking. These results underscore the importance of special intervention programs to reduce smoking in parents with young children.     

Prosthodontic profiles relating to economic status, social network, and social support in an elderly population living independently in Canada

STATEMENT OF PROBLEM: Previous evaluations of life satisfaction and health have not completely explained the impact of social network, social support, and economics on the oral health-related behavior of elderly patients, particularly in relation to missing teeth. PURPOSE: This study measured the strength of associations between social network/support/class and the use of complete and removable partial dentures in elderly patients living independently. MATERIAL AND METHODS: A multiple stepwise logistic regression was used to contrast data from previous studies relating to the subject and to explore the influence of these social variables. RESULTS: The results substantiated the links observed in a previous study between some social features and oral fitness. More frequent use of complete dentures was identified among participants who reported higher incomes and among those who thought their incomes were sufficient for their needs. Unreplaced missing anterior teeth were associated more commonly with subjects less willing or able to leave their homes. CONCLUSIONS: Some salient features of prosthodontic care and oral health status were common to 2, comparable social environments. A minority within the elderly population may not see a need to make use of clinical dental services, regardless of how accessible these services are to them. Social network and social support issues may be important determinants in this perceived need to use clinical services.     

Outcomes following acute hospital care for stroke or hip fracture: how useful is an assessment of anxiety or depression for older people?

OBJECTIVE: To investigate the association between severe life events and mental health outcomes following acute hospital care for older patients with acute stroke or fractured neck of femur. DESIGN: Prospective longitudinal survey of stroke and hip fracture patients admitted to hospital from admission to 6-month follow-up. SETTING: Six district general hospitals, three in the North and three in the South of England. PARTICIPANTS: 642 patients admitted to hospital with an acute stroke (268) or hip fracture (374) resident in a private household at 6 months follow-up. MAIN OUTCOME MEASURES: Hospital Anxiety and Depression Scale, cognitive items of the Survey Psychiatric Assessment Scale, Clackmannan Disability Scale, Severe Life Events Inventory, Wenger Social Support Network Typology. RESULTS: 47% of 6-month survivors of stroke or hip fracture resident in private households had a possible psychiatric illness: dementia (13%), anxiety or depression (41%). 57% had severe or very severe disability and 48% experienced additional life events (17% two or more) after hospital admission. Severe disability was strongly associated with a higher prevalence of anxiety (p < 0.0005) or depression (p < 0.0001). Social contact was associated with a lower prevalence of anxiety (p < 0.01) or depression (p < 0.0001) and social support network type was strongly associated with depression (p < 0.001) but not anxiety (p = 0.096). Number of severe life events was associated with anxiety (p < 0.001) but not depression (p = 0.058). CONCLUSION: Disability is probably a more robust outcome measure than assessments of mental health for older people in uncontrolled studies.     

Inequality in men's mortality: the socioeconomic status gradient and geographic context

Lower mortality for older rural Americans, compared to urban residents, runs counter to rural-urban disparities in health care services and residents' socioeconomic resources. This paradox calls into question the ways in which community conditions influence mortality and contextualize the relationship between individuals' socioeconomic status and health. Drawing on 24 years of data from the National Longitudinal Survey of Older Men, we observe that rural older men's life expectancy advantages occur even after controlling for residential differences in social class and lifestyle factors. Our results also show that rural advantages in mortality coincide with a more equitable distribution of life chances across the social classes. The association between social class and mortality is strongest among urban men, arising from socioeconomic conditions throughout the life cycle.     

Drinking patterns within households: the estimation and interpretation of individual and group variables

Levels of alcohol consumption tend to be similar for individuals living in the same household. This may be because: (a) individuals with similar characteristics collect in households (correlated effects); (b) individuals in the same household are influenced by common factors (exogenous effects); and/or (c) the consumption levels of an individual directly influences the consumption levels of other individuals in the same household (endogenous effects). Whichever of these three possibilities is the principal reason underlying household clustering of consumption levels has important policy implications. In this paper we propose a testing strategy to distinguish between the three types of effect in a cross-sectional data-set. Allowing for exogenous or endogenous effects shows that the significant socio-economic gradient in a model containing only individual variables arises because of misspecification. However, because we find significant evidence of correlated effects, we cannot identify whether it is endogenous or exogenous effects which give rise to statistically significant group level variables. The results indicate the possible pitfalls of omitting group level influences.     

Costs of health services for the elderly and related factors in cities of Japan

OBJECTIVES: To estimate the costs of health services for the elderly in 1994 and to examine factors affecting them. METHODS: Questionnaires were sent to 631 cities and responses from 339 cities were received. Data obtained from questionnaires were total cost, proportion of labor sent to total cost, cost per user, cost per person eligible to receive Health services for the elderly. These variables were measured for health counseling service, health education, health examinations, functional training, and home-visit guidance. RESULTS: The proportion of labor cost was smaller for health examinations than for other services. Health examinations and home-visit guidance showed higher correlation coefficients between the number of users and the total cost than other services. In most services, cost per eligible person were negatively correlated with the number of residents in the city and positively correlated with the number of public health nurses per resident. However, costs per user did not show a correlation. The cities which established municipal health centers had lower costs per user of health education and functional training than the cities which did not. Standardized mortality ratios of cerebrovascular disease and stomach cancer were not correlated with total cost, proportion of labor cost, cost per user, cost per eligible person in most services. CONCLUSIONS: For the economic evaluation of health services for the elderly, it is necessary to examine the relationship between cost, both quantity and quality, and effectiveness of health services.     

Objective and subjective assessments of socioeconomic status and their relationship to self-rated health in an ethnically diverse sample of pregnant women.

A new measure of subjective socioeconomic status (SES) was examined in relation to self-rated physical health in pregnant women. Except among African Americans, subjective SES was significantly related to education, household income, and occupation. Subjective SES was significantly related to self-rated health among all groups. In multiple regression analyses, subjective SES was a significant predictor of self-rated health after the effects of objective indicators were accounted for among White and Chinese American women; among African American women and Latinas, household income was the only significant predictor of self-rated health. After accounting for the effects of subjective SES on health, objective indicators made no additional contribution to explaining health among White and Chinese American women; household income continued to predict health after accounting for subjective SES among Latinas and African American women. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Resources for health: Differential effects of optimistic self-beliefs and social support according to socioeconomic status.

Objective: This study examined whether socioeconomic status (SES) determines the degree to which psychological and social resources such as optimistic self-beliefs and social support affect health. Design: We used data from the representative German Ageing Survey (N = 2,454, aged 40–85 years). Structural equation modeling was employed to examine whether relationships between psychological (self-esteem, control beliefs, optimism) and social resources (perceived emotional and informational support, network size) and health differ between education and income groups. Main Outcome Measures: Self-reported physical health, functional health, and subjective health. Results: Psychological resources positively affected health in all groups but were stronger predictors of functional and subjective health in low compared to higher educated participants. A higher level of social resources was associated with better functional and subjective health mainly in the low-income group. Social resources were particularly important for financially disadvantaged older people. Conclusion: Our results provide evidence for differential effects of optimistic self-beliefs and social support on health depending on whether individuals are challenged by low incomes or low education. Future research, especially aimed at intervention, should consider that different aspects of SES have differential meanings and that the impact of health-protective factors may vary according to SES facet. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Advisory statements of the International Liaison Committee on Resuscitation (ILCOR) CPR in pregnancy

OBJECTIVE: To investigate the associations of individual and area-based socioeconomic indicators with cardiovascular disease risk factors and mortality. DESIGN: Prospective study. SETTING: The towns of Renfrew and Paisley in the west of Scotland. PARTICIPANTS: 6961 men and 7991 women included in a population-based cardiovascular disease screening study between 1972 and 1976. MAIN OUTCOME MEASURES: Cardiovascular disease risk factors and cardiorespiratory morbidity at the time of screening: 15 year mortality from all causes and cardiovascular disease. RESULTS: Both the area-based deprivation indicator and individual social class were associated with generally less favourable profiles of cardiovascular disease risk factors at the time of the baseline screening examinations. The exception was plasma cholesterol concentration, which was lower for men and women in manual social class groups. Independent contributions of area-based deprivation and individual social class were generally seen with respect to risk factors and morbidity. All cause and cardiovascular disease mortality rates were both inversely associated with socioeconomic position whether indexed by area-based deprivation or social class. The area-based and individual socioeconomic indicators made independent contributions to mortality risk. CONCLUSIONS: Individually assigned and area-based socioeconomic indicators make independent contributions to several important health outcomes. The degree of inequalities in health that exist will not be demonstrated in studies using only one category of indicator. Similarly, adjustment for confounding by socioeconomic position in aetiological epidemiological studies will be inadequate if only one level of indicator is used. Policies aimed at reducing socioeconomic differentials in health should pay attention to the characteristics of the areas in which people live as well as the characteristics of the people who live in these areas.