Shirley Harper

Trends in socioeconomic inequalities in adult health behaviors among U.S. states, 1990-2004

Objective. The purpose of this study was to measure state trends in educational inequalities in smoking, binge alcohol use, physical inactivity, obesity, and seatbelt use. Methods. The authors calculated the Relative Concentration Index of educational inequality for five health behaviors on adults from all 50 states and the District of Columbia using data from 1990 to 2004 in the Behavioral Risk Factor Surveillance System (n=2,118,562). Linear regression was used to measure changes and trends in the Relative Concentration Index of health inequality across education groups in each state. Results. Except for binge alcohol use, poorer health behaviors were concentrated among the less educated. The largest educational inequalities were for physical inactivity. From 1990 to 2004, significant increases in relative educational inequalities occurred in 40 states for smoking and 31 states for physical inactivity. For binge alcohol use, 27 states showed significant declining inequality trends, but educational inequalities reversed direction and binge alcohol use is now more prevalent among the less educated in 19 states. Significant decreases in educational inequalities occurred in 36 states for obesity and 24 states for seat belt use. Changes in educational inequalities across the different health behaviors were not associated, except for a modest correlation between changes in inequality in smoking and binge alcohol use (r=0.40; p=0.004). Similarly, there was little association between changes in the population prevalence of health behaviors and changes in educational inequality in health behaviors, with substantial heterogeneity among states. Conclusions. State trends in relative educational inequality among health behaviors were mixed, increasing for smoking and physical inactivity and decreasing for obesity and seat belt use. The factors influencing relative inequality trends may differ from those affecting overall prevalence trends.

Socioeconomic inequalities in risk factors for non communicable diseases in low-income and middle-income countries: results from the World Health Survey

BackgroundMonitoring inequalities in non communicable disease risk factor prevalence can help to inform and target effective interventions. The prevalence of current daily smoking, low fruit and vegetable consumption, physical inactivity, and heavy episodic alcohol drinking were quantified and compared across wealth and education levels in low- and middle-income country groups.MethodsThis study included self-reported data from 232,056 adult participants in 48 countries, derived from the 2002–2004 World Health Survey. Data were stratified by sex and low- or middle-income country status. The main outcome measurements were risk factor prevalence rates reported by wealth quintile and five levels of educational attainment. Socioeconomic inequalities were measured using the slope index of inequality, reflecting differences in prevalence rates, and the relative index of inequality, reflecting the prevalence ratio between the two extremes of wealth or education accounting for the entire distribution. Data were adjusted for confounding factors: sex, age, marital status, area of residence, and country of residence.ResultsSmoking and low fruit and vegetable consumption were significantly higher among lower socioeconomic groups. The highest wealth-related absolute inequality was seen in smoking among men of low- income country group (slope index of inequality 23.0 percentage points; 95% confidence interval 19.6, 26.4). The slope index of inequality for low fruit and vegetable consumption across the entire distribution of education was around 8 percentage points in both sexes and both country income groups. Physical inactivity was less prevalent in populations of low socioeconomic status, especially in low-income countries (relative index of inequality: (men) 0.46, 95% confidence interval 0.33, 0.64; (women) 0.52, 95% confidence interval 0.42, 0.65). Mixed patterns were found for heavy drinking.ConclusionsDisaggregated analysis of the prevalence of non-communicable disease risk factors demonstrated different patterns and varying degrees of socioeconomic inequalities across low- and middle-income settings. Interventions should aim to reach and achieve sustained benefits for high-risk populations.

Economic conditions and health behaviours during the ‘Great Recession’

Background The adoption of healthier behaviours has been hypothesised as a mechanism to explain empirical findings of population health improvements during some economic downturns. Methods We estimated the effect of the local unemployment rate on health behaviours using pooled annual surveys from the 2003–2010 Behavioral Risk Factor Surveillance Surveys, as well as population-based telephone surveys of the US adult general population. Analyses were based on approximately 1 million respondents aged 25 years or older living in 90 Metropolitan Statistical Areas and Metropolitan Divisions (MMSAs). The primary exposure was the quarterly MMSA-specific unemployment rate. Outcomes included alcohol consumption, smoking status, attempts to quit smoking, body mass index, overweight/obesity and past-month physical activity or exercise. Results The average unemployment rate across MMSAs increased from a low of 4.5% in 2007 to a high of 9.3% in 2010. In multivariable models accounting for individual-level sociodemographic characteristics and MMSA and quarter fixed effects, a one percentage-point increase in the unemployment rate was associated with 0.15 (95% CI −0.31 to 0.01) fewer drinks consumed in the past month and a 0.14 (95% CI −0.28 to 0.00) percentage-point decrease in the prevalence of past-month heavy drinking; these effects were driven primarily by men. Changes in the unemployment rate were not consistently associated with other health behaviours. Although individual-level unemployment status was associated with higher levels of alcohol consumption, smoking and obesity, the MMSA-level effects of the recession were largely invariant across employment groups. Conclusions Our results do not support the hypothesis that health behaviours mediate the effects of local-area economic conditions on mortality.

Economic downturns and suicide mortality in the USA, 1980–2010: observational study

BACKGROUND Several studies have suggested strong associations between economic downturns and suicide mortality, but are at risk of bias due to unmeasured confounding. The rationale for our study was to provide more robust evidence by using a quasi-experimental design. METHODS We analysed 955,561 suicides occurring in the USA from 1980 to 2010 and used a broad index of economic activity in each US state to measure economic conditions. We used a quasi-experimental, fixed-effects design and we also assessed whether the effects were heterogeneous by demographic group and during periods of official recession. RESULTS After accounting for secular trends, seasonality and unmeasured fixed characteristics of states, we found that an economic downturn similar in magnitude to the 2007 Great Recession increased suicide mortality by 0.14 deaths per 100,000 population [95% confidence interval (CI) 0.00, 0.28] or around 350 deaths. Effects were stronger for men (0.28, 95% CI 0.07, 0.49) than women and for those with less than 12 years of education (1.22 95% CI 0.83, 1.60) compared with more than 12 years of education. The overall effect did not differ for recessionary (0.11, 95% CI -0.02, 0.25) vs non-recessionary periods (0.15, 95% CI 0.01, 0.29). The main study limitation is the potential for misclassified death certificates and we cannot definitively rule out unmeasured confounding. CONCLUSIONS We found limited evidence of a strong, population-wide detrimental effect of economic downturns on suicide mortality. The overall effect hides considerable heterogeneity by gender, socioeconomic position and time period.

Trends in Socioeconomic Inequalities in Motor Vehicle Accident Deaths in the United States, 1995–2010

Motor vehicle accident (MVA) mortality has been declining overall, but little is known about trends by socioeconomic position. We examined trends in education-related inequalities in US MVA death rates from 1995 to 2010. We used mortality data from the National Center for Health Statistics and population estimates from the Current Population Survey, and we calculated vehicle- and person-miles traveled using data from the National Household Travel Survey. We used negative binomial regression to estimate crude and age-, sex-, and race-adjusted mortality rates among adults aged 25 years or more. We found larger mortality decreases among the more highly educated and some evidence of mortality increases among the least educated. Adjusted death rates were 15.3 per 100,000 population (95% confidence interval (CI): 10.7, 19.9) higher at the bottom of the education distribution than at the top of the education distribution in 1995, increasing to 17.9 per 100,000 population (95% CI: 14.8, 21.0) by 2010. In relative terms, adjusted death rates were 2.4 (95% CI: 1.7, 3.0) times higher at the bottom of the education distribution than at the top in 1995, increasing to 4.3 times higher (95% CI: 3.4, 5.3) by 2010. Inequality increases were larger in terms of vehicle-miles traveled. Although overall MVA death rates declined during this period, socioeconomic differences in MVA mortality have persisted or worsened over time.

The effect of metropolitan-area mortgage delinquency on health behaviors, access to health services, and self-rated health in the United States, 2003–2010

The recent housing crisis offers the opportunity to understand the effects of unique indicators of macroeconomic conditions on health. We linked data on the proportion of mortgage borrowers per US metropolitan-area who were at least 90 days delinquent on their payments with individual-level outcomes from a representative sample of 1,021,341 adults surveyed through the Behavioral Risk Factor Surveillance System (BRFSS) between 2003 and 2010. We estimated the effects of metropolitan-area mortgage delinquency on individual health behaviors, medical coverage, and health status, as well as whether effects varied by race/ethnicity. Results showed that increases in the metropolitan-area delinquency rate resulted in decreases in heavy alcohol consumption and increases in exercise and health insurance coverage. However, the delinquency rate was also associated with increases in smoking and obesity in some population groups, suggesting the housing crisis may have induced stress-related behavioral change. Overall, the effects of metropolitan-area mortgage delinquency on population health were relatively modest.

Trends in Educational Inequalities in Drug Poisoning Mortality: United States, 1994–2010

OBJECTIVES We estimated trends in drug poisoning death rates by educational attainment and investigated educational inequalities in drug poisoning mortality by race, gender, and region. METHODS We linked drug poisoning death counts from the National Vital Statistics System to population denominators from the Current Population Survey to estimate drug poisoning rates by gender, race, region, and educational attainment (less than high school degree, high school degree, some college, college degree) from 1994 to 2010. RESULTS There were 372,485 drug poisoning deaths. Education-related inequalities increased during the study among all demographic groups and varied by region. Absolute increases in educational inequalities were higher among Whites than Blacks and men than women. The age-adjusted rate difference between White men with less than a high school degree increased from 8.7 per 100,000 in 1994 to 27.4 in 2010 (change = 18.7). Among Black men, the corresponding increases were 11.7 and 18.3, respectively (change = 6.6). CONCLUSIONS We found strong educational patterning in drug poisoning rates, chiefly by region and race. Rates are highest and increasing the fastest among groups with less education.