Örjan Hemström

Education, income, and occupational class cannot be used interchangeably in social epidemiology. Empirical evidence against a common practice

Study objective: Education, income, and occupational class are often used interchangeably in studies showing social inequalities in health. This procedure implies that all three characteristics measure the same underlying phenomena. This paper questions this practice. The study looked for any independent effects of education, income, and occupational class on four health outcomes: diabetes prevalence, myocardial infarction incidence and mortality, and finally all cause mortality in populations from Sweden and Germany. Design: Sweden: follow up of myocardial infarction mortality and all cause mortality in the entire population, based on census linkage to the Cause of Death Registry. Germany: follow up of myocardial infarction morbidity and all cause mortality in statutory health insurance data, plus analysis of prevalence data on diabetes. Multiple regression analyses were performed to calculate the effects of education, income, and occupational class before and after mutual adjustments. Setting and participants: Sweden (all residents aged 25–64) and Germany (Mettman district, Nordrhein-Westfalen, all insured persons aged 25–64). Main results: Correlations between education, income, and occupational class were low to moderate. Which of these yielded the strongest effects on health depended on type of health outcome in question. For diabetes, education was the strongest predictor and for all cause mortality it was income. Myocardial infarction morbidity and mortality showed a more mixed picture. In mutually adjusted analyses each social dimension had an independent effect on each health outcome in both countries. Conclusions: Education, income, and occupational class cannot be used interchangeably as indicators of a hypothetical latent social dimension. Although correlated, they measure different phenomena and tap into different causal mechanisms.

The societal cost of alcohol consumption: an estimation of the economic and human cost including health effects in Sweden, 2002

This article estimates the societal cost of alcohol consumption in Sweden in 2002, as well as the effects on health and quality of life. The estimation includes direct costs, indirect costs and intangible costs. Relevant cost-of-illness methods are applied using the human capital method and prevalence-based estimates, as suggested in existing international guidelines, allowing cautious comparison with prior studies. The results show that the net cost (i.e. including protective effects of alcohol consumption) is 20.3 billion Swedish kronor (SEK) and the gross cost (counting only detrimental effects) is 29.4 billon (0.9 and 1.3% of GDP). Alcohol consumption is estimated to cause a net loss of 121,800 QALYs. The results are within the range found in prior studies, although at the low end. A large number of sensitivity analyses are performed, indicating a sensitivity range of 50%.

Is the Impact of Job Control on Stroke Independent From Socioeconomic Status? A Large-Scale Study of the Swedish Working Population

Background and Purpose— The main purpose of this study was to test whether the impact of job control on stroke mortality is independent of socioeconomic factors. Methods— This was a register-based cohort study of nearly 3.5 million working people (25 to 64 years of age in the 1990 Swedish Census) with a 5-year follow-up for stroke mortality. Job control was aggregated to the data from a secondary data source (job exposure matrix). Gender-specific Poisson regressions were performed. Results— Compared with high job control occupations, low job control was significantly related to hemorrhagic (relative risk, 1.54; 95% CI, 1.10 to 2.17) and all-stroke mortality (relative risk, 1.50; 95% CI, 1.11 to 2.03) in women but not in men. The significance of job control in women was independent of all confounders included (marital status, education level, and occupational class). Class-specific analyses indicated a consistent effect of job control for most classes (significant for female lower nonmanuals). However, low job control did not increase the risk of stroke mortality in upper nonmanuals. Conclusions— Job control was significantly related to hemorrhagic and all-stroke mortality in women but not in men.

Does intergenerational social mobility among men affect cardiovascular mortality? A population-based register study from Sweden

Background: Socioeconomic inequalities in cardiovascular mortality are well documented. The aim here is to examine the relation between childhood and adulthood class as well as the role of unique intergenerational social mobility trajectories in such mortality. Methods: Data were obtained from Swedish registries. Childhood and adulthood information were from the 1960 and 1990 censuses. Men born 1945—59 (809,199) were followed-up for four cardiovascular mortality outcomes 1990— 2002 (5533 deaths) by means of Cox regressions. Three different approaches were applied to study mobility between four main classes. Results: In mutually adjusted models, the effect of a manual adulthood class (compared with non-manuals) was clearly larger (hazard ratios (HR) were 1.56 for MI, 1.70 for stroke, 1.64 for other cardiovascular disease (CVD), 1.62 for all CVD) as for a manual childhood class (1.38, 1.17, 1.24 and 1.28, respectively). This also applied to unclassifiable, while there were few systematic findings for self-employed. When adjusting for education level, childhood class was still significant for MI, other and all CVD, but adulthood class was significant for all outcomes. Trajectory-specific analyses revealed that mobile men from non-manual to manual had significantly higher mortality than mobile from manual to non-manual and stable non-manuals, but not significantly lower than stable manuals. Conclusions: Cardiovascular mortality was clearly structured by adulthood class, but not as consistently structured by childhood class. The mediating role of education suggests that a major part of life-course disadvantages or advantages in relation to CVD was due to achieved education.

Intergenerational class mobility and cardiovascular mortality among Swedish women: A population-based register study☆

Class inequalities in cardiovascular disease (CVD) mortality are well documented, but the impact of intergenerational class mobility on CVD mortality among women has not been studied thoroughly. We examined whether womens mobility trajectories might contribute to CVD mortality beyond what could be expected from their childhood and adult social class position. The Swedish Work and Mortality Data Base provided childhood (1960) and adulthood (1990) social indicators. Women born 1945-59 (N=791 846) were followed up for CVD mortality 1990-2002 (2019 deaths) by means of logistic regression analysis. CVD mortality risks were estimated for 16 mobility trajectories. Gross and net impact of four childhood and four adult classes, based on occupation, were analysed for mortality in ischemic heart disease (IHD), stroke, other CVD, - and all CVD. Differences between the two most extreme trajectories were 10-fold, but the common trajectory of moving from manual to non-manual position was linked to only a slight excess mortality (OR=1.26) compared to the equally common trajectory of maintaining a stable non-manual position (reference category). Moving into adult manual class resulted in an elevated CVD mortality whatever the childhood position (ORs varied between 1.42 and 2.24). After adjustment for adult class, childhood class had some effect, in particular there was a low risk of coming from a self-employed childhood class on all outcomes (all ORs around=0.80). A womans own education had a stronger influence on the mortality estimates than did household income. Social mobility trajectories among Swedish women are linked to their CVD mortality risk. Educational achievement seems to be a key factor for intergenerational continuity and discontinuity in class-related risk of CVD mortality among Swedish women. However, on mutual adjustment, adult class was much more closely related to CVD mortality than was class in childhood.

The contribution of maternal working conditions to socio-economic inequalities in birth outcome

The aims of this study were to examine the association between maternal working conditions and birth outcomes, and to determine the extent to which these contributed to class inequalities in six birth outcomes. We used an existing job exposure matrix developed from survey data collected in 1977 and 1979 to apply occupational-level information on working conditions to the national Swedish Registry, including approximately 280,000 mothers and 360,000 births during the period 1980--1985. Data were analysed using multivariate logistic regressions. Low levels of job control, high levels of physical demands and job hazards were more common in manual compared to non-manual classes. The self-employed had intermediate levels of such exposures. Job exposures, particularly low levels of job control, were generally and significantly associated with higher risks for low birthweight, very low birthweight, small for gestational age, all preterm, very preterm and extremely preterm births, but not with mortality. Compared to middle non-manuals (the reference group), lower non-manual and manual classes had higher risks for all birth outcomes, and these risks were nearly all significant. The highest odds ratios were found for skilled and unskilled manual workers in the manufacturing sector, with ratios between 1.35 and 2.66 (all significant). Job control explained a considerable proportion of inequalities in all birth outcomes. Job hazards contributed particularly to very low birthweight and extremely preterm birth, and physical demands to low birthweight and all preterm births. In conclusion, class differences in maternal working conditions clearly contributed to class differences in low birthweight (explained fraction 14-38%), all preterm births (20-46%), very (14-46%) and extremely (12-100%) preterm births. For very low birthweight and small for gestational age, there was a similar contribution in the manufacturing sector only. For all birth outcomes, class differences could still be detected after working conditions were taken into consideration.

Attitudes toward Alcohol Policy in Six EU Countries

This study explores differences between Sweden, Finland, the United Kingdom, Germany, France and Italy regarding public attitudes toward alcohol control policy (measured by a statement that the government has a responsibility to keep down how much people drink). Cross-national representative samples of around 1,000 respondents 18–64 years old in each country were analyzed. A large majority of people in Italy and Sweden (about 75%) supported governmental responsibility for alcohol control. This was the case for 60% in France and for 48% in the UK, whereas in Finland and Germany those who were supportive constituted a minority (38% and 29%). After controlling for social factors in logistic regressions, this pattern was unaltered and clearly significant. The attitude was strongly related to alcohol consumption: in all six countries, non-drinkers and low consumers were most supportive and high consumers least supportive. Limitations of the data and potential explanations of the findings are discussed.

Informal Alcohol Control in Six EU Countries

This article describes differences between Finland, Sweden, Germany, the United Kingdom, France and Italy regarding having influenced someone to drink less alcohol. Representative samples of around 1,000 respondents 18–64 years old in each country were analyzed. Informal alcohol control was measured by questions on whether the respondent reported having influenced someone in any of eight categories of family members and friends to drink less. People in Italy significantly more often reported having pressured someone to drink less (38%) compared with the average rate (32%). In multivariate logistic regressions, people in France and Sweden were significantly less likely to report this. The higher rate in Italy was due to Italian mens high likelihood of trying to persuade both friends and family members to drink less compared with men in other countries. Differences among these six European countries regarding informal control of alcohol appear to be greater among men than among women.

More detailed data does not always raise the costs : Experience from a Swedish cost of alcohol study

The aim is to investigate the effect of availability and level of detail of data on cost estimates of alcohol consumption. Using the recent Swedish cost of alcohol study as baseline, limitations on data are applied, forming two models. The costs of alcohol in Sweden are re-estimated in the two models and compared to the baseline, to establish the magnitude and direction of the bias resulting from limited data, and which results are the most sensitive to variations in data availability and level of detail. Almost all differences between the baseline and the two limited models stem from reduced availability and not the level of detail of data. However, the level of detail plays an important role for the prevalence of consumption and the alcohol-attributable fractions (AAFs) for injuries. The conclusion is that it is more important to estimate more cost components than to improve existing estimates, as differences between cost estimates are mainly driven by the availability rather than the level of detail of data. However, the level of detail in the prevalence rates of consumption and in the AAFs for injuries is likely to considerably affect the cost estimates and obtaining the best possible data in these areas should therefore be prioritized.