Paulien Hagedoorn

Regional Inequalities in Lung Cancer Mortality in Belgium at the Beginning of the 21st Century: The Contribution of Individual and Area-Level Socioeconomic Status and Industrial Exposure.

Being a highly industrialized country with one of the highest male lung cancer mortality rates in Europe, Belgium is an interesting study area for lung cancer research. This study investigates geographical patterns in lung cancer mortality in Belgium. More specifically it probes into the contribution of individual as well as area-level characteristics to (sub-district patterns in) lung cancer mortality. Data from the 2001 census linked to register data from 2001–2011 are used, selecting all Belgian inhabitants aged 65+ at time of the census. Individual characteristics include education, housing status and home ownership. Urbanicity, unemployment rate, the percentage employed in mining and the percentage employed in other high-risk industries are included as sub-district characteristics. Regional variation in lung cancer mortality at sub-district level is estimated using directly age-standardized mortality rates. The association between lung cancer mortality and individual and area characteristics, and their impact on the variation of sub-district level is estimated using multilevel Poisson models. Significant sub-district variations in lung cancer mortality are observed. Individual characteristics explain a small share of this variation, while a large share is explained by sub-district characteristics. Individuals with a low socioeconomic status experience a higher lung cancer mortality risk. Among women, an association with lung cancer mortality is found for the sub-district characteristics urbanicity and unemployment rate, while for men lung cancer mortality was associated with the percentage employed in mining. Not just individual characteristics, but also area characteristics are thus important determinants of (regional differences in) lung cancer mortality.

Trends in site- and sex-specific cancer mortality between 1979 and 2010 in Belgium compared with Europe using WHO data

BACKGROUND Cancer mortality constitutes a major health burden in Europe. Trends are different for men and women, and across Europe. This study aims to map out Belgian cancer mortality trends for the most common cancer types in both sexes between 1979 and 2010, and to link these with trends in cancer mortality and smoking prevalence across Europe. METHODS Mortality and population data were obtained from the World Health Organization Mortality Database. Age-standardized mortality rates were calculated by direct standardization using the European Standard Population. RESULTS Belgian mortality decreased for the most common cancer sites between 1979 and 2010, except for female lung cancer. Yet, Belgian male lung and female breast cancer rates remain high compared with the remainder of Western Europe. For some cancer sites, mortality trends are similar among the European Regions (e.g. stomach cancer), yet for others trends are divergent (e.g. colorectal cancer). CONCLUSIONS Generally, cancer mortality shows a favorable trend in Belgium and Europe. Yet, female lung cancer mortality rates are increasing in Belgium. Furthermore, Belgium still has higher male lung and female breast cancer mortality rates compared with the European regional averages. Considering this and the current smoking prevalence, enduring tobacco control efforts should be made.

A cohort study into head and neck cancer mortality in Belgium (2001–11): Are individual socioeconomic differences conditional on area deprivation?

OBJECTIVE The aim of this study is to assess to what extent individual and area-level socioeconomic position (SEP) are associated to head and neck cancer (HNC) mortality and to what extent they contribute to regional variation in HNC mortality in Belgium. MATERIALS AND METHODS Data on men aged 40-64 are collected from a population based dataset based on the 2001 Belgian census linked to register data on emigration and mortality for 2001-2011. Individual SEP is measured using education, employment status and housing conditions. Deprivation at municipal level is measured by a deprivation index. Absolute mortality differences are estimated by age standardised mortality rates. Multilevel Poisson models are used to estimate the association and interaction between HNC mortality and individual and area-level SEP, and to estimate the regional variation in HNC mortality. RESULTS HNC mortality rates are significantly higher for men with a low SEP and men living in deprived areas. Cross-level interactions indicate that the association between individual SEP and HNC mortality is conditional on area deprivation. HNC mortality in deprived areas is especially high among high-SEP men. As a result, social disparities appear to be smaller in more deprived areas. Regional variation in HNC mortality was significant. Population composition partially explains this regional variation, while area deprivation and cross-level interactions explains little. CONCLUSION Both individual and area-level deprivation are important determinants of HNC mortality. Underlying trends in incidence and survival, and risk factors, such as alcohol and tobacco use, should be explored further.

Socioeconomic position, population density and site-specific cancer mortality: A multilevel analysis of Belgian adults, 2001-2011

Our study explores the association between individual and neighborhood socioeconomic position (SEP) and all‐cancer and site‐specific cancer mortality. Data on all Belgian residents are retrieved from a population‐based dataset constructed from the 2001 census linked to register data on emigration and mortality for 2001–2011. The study population contains all men and women aged 40 years or older during follow‐up. Individual SEP is measured using education, employment status and housing conditions. Neighborhood SEP is measured by a deprivation index (in quintiles). Directly age‐standardized mortality rates and multilevel Poisson models are used to estimate the association between individual SEP and neighborhood deprivation and mortality from all‐cancer and cancer of the lung, colon and rectum, pancreas, prostate and female breast. The potential confounding role of population density is assessed using multilevel models as well. Our findings show an increase in mortality from all‐cancer and site‐specific cancer by decreasing level of individual SEP for both men and women. In addition, individuals living in highly deprived neighborhoods experience significantly higher mortality from all‐cancer, lung cancer, pancreatic cancer and female colorectal cancer after controlling for individual SEP. Male colorectal and prostate cancer and female breast cancer are not associated with neighborhood deprivation. Population density acts as a confounder for female lung cancer only. Our study indicates that deprivation at both the individual and neighborhood level is associated with all‐cancer mortality and mortality from several cancer sites. More research into the role of life‐style related and clinical factors is necessary to gain more insight into causal pathway.

Socioeconomic disparities in lung cancer mortality in Belgian men and women (2001-2011): does it matter who you live with?

BackgroundAmple studies have observed an adverse association between individual socioeconomic position (SEP) and lung cancer mortality. Moreover, the presence of a partner has shown to be a crucial determinant of health. Yet, few studies have assessed whether partner’s SEP affects health in addition to individual SEP. This paper will study whether own SEP (education), partner’s SEP (partner’s education) and own and partner’s SEP combined (housing conditions), are associated with lung cancer mortality in Belgium.MethodsData consist of the Belgian 2001 census linked to register data on cause-specific mortality for 2001–2011. The study population includes all married or cohabiting Belgian inhabitants aged 40–84 years. Age-standardized lung cancer mortality rates (direct standardization) and mortality rate ratios (Poisson regression) were computed for the different SEP groups.ResultsIn men, we observed a clear inverse association between all SEP indicators (own and partner’s education, and housing conditions) and lung cancer mortality. Men benefit from having a higher educated partner in terms of lower lung cancer mortality rates. These observations hold for both middle-aged and older men.For women, the picture is less uniform. In middle-aged and older women, housing conditions is inversely associated with lung cancer mortality. As for partner’s education, for middle-aged women, the association is rather weak whereas for older women, there is no such association. Whereas the educational level of middle-aged women is inversely associated with lung cancer mortality, in older women this association disappears in the fully adjusted model.ConclusionsBoth men and women benefit from being in a relationship with a high-educated partner. It seems that for men, the educational level of their partner is of great importance while for women the housing conditions is more substantial. Both research and policy interventions should allow for the family level as well.

Employment status and mortality in the context of high and low regional unemployment levels in Belgium (2001–2011): A test of the social norm hypothesis across educational levels

Because of compositional effects (more highly educated unemployed) and differences in the vulnerability towards the health consequences of unemployment (i.e. disappointment paradox hypothesis and/or status inconsistency for highly educated unemployed), it is argued that indicators of educational attainment need to be included when investigating the social norm of unemployment. Data from the 2001 census linked to register data from 2001–2011 are used, selecting all Belgian employed and unemployed between 30 and 59-year-old at time of the census. Poisson multilevel modelling was used to account for clustering of respondents within sub-districts. For individuals with low education levels, the relative difference in mortality rate ratios between the unemployed and employed is smallest in those regions where aggregate unemployment levels are high. For highly educated, this social norm effect was not found. This study suggest that the social norm effect is stronger for workers with low education levels, while highly educated workers suffer from disappointment and status inconsistency.

Parental and/or Personal Socioeconomic Circumstances: How to Explain Site-Specific Cancer Mortality Inequalities Among Young Belgian Adults

Both socioeconomic position (SEP) in childhood and adulthood are associated with adult mortality. Yet, the relative importance of childhood socioeconomic (SE) conditions is likely to vary depending on the cause of death. This paper will study: 1) whether SE conditions during both childhood and adulthood are associated with overall and site-specific cancer mortality among Belgian young adults; 2) the relative importance of all indicators of parental and personal SEP in explaining differences in cancer mortality. Data were derived from record linkage between the Belgian censuses of 1991 and 2001 and mortality follow-up data for 2001-2011. Parental educational attainment, parental occupational status, parental housing status, and childhood area deprivation were used as measures of parental SEP, and current education as indicator of personal SEP. SE differences were studied for overall and site-specific cancer mortality by calculating age-standardized mortality rates and mortality rate ratios using Poisson regression. Both low parental and personal SEP are associated with higher all-cancer mortality in young adulthood. Personal education seemed to be the strongest indicator of overall and site-specific cancer mortality in young adulthood, independent of parental SEP. Yet, for women, this was partly due to a health selection effect. In the full models, parental SEP was no longer associated with cancer mortality but deprived living conditions still were. Site-specific inequalities were generally more expressed among women than among men. Studies and policies focussing on SE inequalities in mortality in young adulthood should allow for both childhood and adulthood SE conditions.

Site-specific cancer mortality inequalities by employment and occupational groups: a cohort study among Belgian adults, 2001–2011

Objective This study probes into site-specific cancer mortality inequalities by employment and occupational group among Belgians, adjusted for other indicators of socioeconomic (SE) position. Design This cohort study is based on record linkage between the Belgian censuses of 1991 and 2001 and register data on emigration and mortality for 01/10/2001 to 31/12/2011. Setting Belgium. Participants The study population contains all Belgians within the economically active age (25–65 years) at the census of 1991. Outcome measures Both absolute and relative measures were calculated. First, age-standardised mortality rates have been calculated, directly standardised to the Belgian population. Second, mortality rate ratios were calculated using Poisson’s regression, adjusted for education, housing conditions, attained age, region and migrant background. Results This study highlights inequalities in site-specific cancer mortality, both related to being employed or not and to the occupational group of the employed population. Unemployed men and women show consistently higher overall and site-specific cancer mortality compared with the employed group. Also within the employed group, inequalities are observed by occupational group. Generally manual workers and service and sales workers have higher site-specific cancer mortality rates compared with white-collar workers and agricultural and fishery workers. These inequalities are manifest for almost all preventable cancer sites, especially those cancer sites related to alcohol and smoking such as cancers of the lung, oesophagus and head and neck. Overall, occupational inequalities were less pronounced among women compared with men. Conclusions Important SE inequalities in site-specific cancer mortality were observed by employment and occupational group. Ensuring financial security for the unemployed is a key issue in this regard. Future studies could also take a look at other working regimes, for instance temporary employment or part-time employment and their relation to health.

The effects of individual and area-level socioeconomic status on mortality from cancer of the head and neck in Belgium, 2001-2011

Multiple studies observed an independent effect of area characteristics on cancer mortality. Few focused on specific cancer types, although this might yield more information on cancer etiology, risk factors, and at-risk populations. Some research has been conducted on head and neck cancer, observing higher incidence and lower survival from head and neck cancer in deprived areas. Yet, the effect of area characteristics on (mortality from) head and neck cancer remains understudied. This study aims to determine the spatial pattern of head and neck cancer mortality in Belgium, to assess the effect of individual and area-level socioeconomic status on mortality from head and neck cancer, and to estimate the interaction between individual and area-level characteristics. Data are collected from a unique dataset linking census and register data on all Belgian inhabitants aged 40 and above from 2001-2011. Head and neck cancer mortality is defined according to the ICD-10 codes C00-C14 and C30-C32. The (indirectly) standardized mortality ratio (SMR) is calculated by sub-district using the age and sex-specific rates of Belgium as the standard. Multilevel Poisson models are used to estimate the (interaction) effects of individual and area-level socioeconomic status on head and neck cancer, and their contribution to regional variations. Analyses are stratified by age category (40-64; 65+) and by subtype with different etiologies and risk factors. Preliminary results show distinct spatial patterns in the SMR for cancer of the head and neck. A negative association with individual socioeconomic status is observed. The spatial pattern of housing quality and unemployment rate shows similarities to that of head and neck cancer mortality, indicating these area-level characteristics might be associated to mortality of head and neck cancer. The spatial pattern of head and neck cancer also closely resembles that of alcohol-related mortality, suggesting alcohol consumption might be a possible risk factor as well.