Siegfried Geyer

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.

Some conceptual considerations on the sense of coherence

Aaron Antonovskys sense of coherence (SOC) [(1987) Unraveling the Mystery of Health, How People Manage Stress and Stay Well, Jossey-Bass, San Francisco] ought to explain why some people manage stress and stay well while others break down. According to Antonovskys formulation, SOC is strongly developed if a person sees the world as comprehensible (i.e. rational, understandable, consistent and predictable), as manageable, and as meaningful (i.e. challenging and that things are worth making commitments for). Sense of coherence has gained widespread attention and has been used as an explanatory variable in many studies. This paper discusses some aspects that have not sufficiently been considered in the SOC literature. First, an outline of the construct is given. Next, overlaps and differences with other concepts in the same domain are discussed. Little empirical evidence concerning the stability of SOC is available. Therefore, findings from experimental social psychological studies on self-esteem are applied to SOC. Third, it can be assumed that SOC is an attitude of people who are well educated, are in rather privileged societal positions, and with opportunities for decision-making. Finally, the empirical basis is reviewed. Statistical relationships between SOC and symptoms/disease are in the predicted direction, but due to the simultaneous assessment of variables it is open to debate whether a low SOC has some effect on the probability of falling ill or whether it is the other way around. Very high negative correlations between SOC and depression/anxiety suggest that the instruments used may assess the same phenomenon, but with inverse signs. Based on these considerations, directions for further research are proposed.

Income, occupational position, qualification and health inequalities—competing risks? (Comparing indicators of social status)

STUDY OBJECTIVE The debate on health inequalities has shifted from the consequences of occupational position, as expressed in the Registrar Generals classification, to consequences of material living conditions. This change in interest occurred without comparative analyses of different sources of health inequalities. Thus this study investigated the relative contribution of “material resources” (income), “qualification” and “occupational position” for explaining social differentials in mortality. DESIGN AND SETTING Analyses were performed with records from a statutory health insurance in West Germany. The analyses were performed with data of 84 814 employed men and women between 25 and 65 years of age who were insured between 1987 and 1995 for at least 150 days. RESULTS The three indicators were statistically associated, but not strong enough to warrant the conclusion that they share the same empirical content. The relative risk (hazard rate) for income by controlling for occupational position and gender for the highest as compared with the lowest category was 1.99 (95% CI 1.66, 2.39). The corresponding relative risk for income by controlling for qualification and gender was 2.03 (95% CI 1.68, 2.46). In both multivariate analyses, the effects of occupational position and qualification were no longer interpretable because of large confidence intervals. In sum, income related relative mortality risks were the comparably highest, while qualification and occupational position were no longer substantial. CONCLUSIONS The results emphasise the present discussion on the consequences of material living conditions. Income on the one hand and qualification and occupational position on the other are largely independent. Mortality related effects of income override those of the other socioeconomic status indicators. However, seen in a time perspective, qualification may still have a placement function at least for the first occupational position.

Social gradients and cumulative effects of income and education on dental health in the Fourth German Oral Health Study

OBJECTIVE To consider differential effects of income and education on oral health for each indicator separately and in combination. Finally the combined effects of the lowest income level and the lowest level of education were examined. METHODS Data were drawn from the Fourth German Oral Health Study. They were collected using proportional random sampling in order to obtain information also for less densely populated regions. The subjects included in the study were between 35 and 44 years of age (n = 925). It included a clinical dental examination and a sociological survey. Social differentiation was depicted by education and income (divided into categories), oral health was measured using the DMFT-index. RESULTS Social gradients emerged for both indicators of social differentiation. The effects derived from single analyses were somewhat higher than those obtained by simultaneous estimations. The odds ratio of the lowest as compared with the highest income category was OR = 3.74 and OR = 2.34 in the analysis with both indicators. For education the respective effects were OR = 3.75 and OR = 2.95. The cumulative effect of the lowest income and the lowest educational level combined was OR = 6.06. CONCLUSION Education and income are shaping social inequalities in oral health independently from each other, and they are only moderately correlated. They refer to different dimensions of disadvantage thus making preventive measures more complicated.

A prospective, randomized, double-blind, placebo controlled trial of beta-blockade in patients who have undergone surgical correction of tetralogy of Fallot

AIMS Our purpose was to evaluate the effect of a treatment over six months with bisoprolol on the surrogate parameters of N-Terminal-pro brain natriuretic peptide, subsequently to be described as brain natriuretic peptide, peak uptake of oxygen, and ventricular function assessed by magnetic resonance imaging in grown ups and adults who had undergone surgical correction of tetralogy of Fallot. METHODS AND RESULTS We designed a prospective, randomized, double-blind, placebo controlled trial. We enrolled 33 patients, aged 30.9 plus or minus 9.5 years in either class 1 or 2 of the grading of the New York Heart Association class with both levels of brain natriuretic peptide greater than 100 pg/ml and a reduced peak uptake of oxygen less than 25 ml/kg/min. During treatment with Bisoprolol, the levels of brain natriuretic peptide increased significantly from 206 plus or minus 95 to 341 plus or minus 250 pg/ml (p< 0.05), and those of atrial natriuretic peptide from 4117 plus or minus 1837 to 5340 plus or minus 2102 fmol/ml (p = 0.0005). These measures remained unchanged in the group of patients receiving the placebo. Peak uptake of oxygen did not differ significantly in either group, nor did treatment have any significant effect on right and left ventricular volumes and ejection fractions as determined by magnetic resonance imaging. The clinical state as judged within the grading system of the New York Heart Association was also unchanged by beta-blockade. CONCLUSION Beta blockade with Bisoprolol seems to have no beneficial effect on asymptomatic or mildly symptomatic patients with right ventricular dysfunction secondary to repaired tetralogy of Fallot with residual pulmonary regurgitation and/or stenosis.

Emotional support, education and self-rated health in 22 European countries

BackgroundThe analyses focus on three aims: (1) to explore the associations between education and emotional support in 22 European countries, (2) to explore the associations between emotional support and self-rated health in the European countries, and (3) to analyse whether the association between education and self-rated health can be partly explained by emotional support.MethodsThe study uses data from the European Social Survey 2003. Probability sampling from all private residents aged 15 years and older was applied in all countries. The European Social Survey includes 42,359 cases. Persons under age 25 were excluded to minimise the number of respondents whose education was not complete. Education was coded according to the International Standard Classification of Education. Perceived emotional support was assessed by the availability of a confidant with whom one can discuss intimate and personal matters with. Self-rated health was used as health indicator.ResultsResults of multiple logistic regression analyses show that emotional support is positively associated with education among women and men in most European countries. However, the magnitude of the association varies according to country and gender. Emotional support is positively associated with self-rated health. Again, gender and country differences in the association were observed. Emotional support explains little of the educational differences in self-rated health among women and men in most European countries.ConclusionResults indicate that it is important to consider socio-economic factors like education and country-specific contexts in studies on health effects of emotional support.

Depression- and anxiety-related sick leave and the risk of permanent disability and mortality in the working population in Germany: a cohort study

BackgroundAnxiety and depression are the most common psychiatric disorders and are the cause of a large and increasing amount of sick-leave in most developed countries. They are also implicated as an increasing mortality risk in community surveys. In this study we addressed, whether sick leave due to anxiety, depression or comorbid anxiety and depression was associated with increased risk of retirement due to permanent disability and increased mortality in a cohort of German workers.Methods128,001 German workers with statutory health insurance were followed for a mean of 6.4 years. We examined the associations between 1) depression/anxiety-related sick leave managed on an outpatient basis and 2) anxiety/depression-related psychiatric inpatient treatment, and later permanent disability/mortality using Cox proportional hazard regression models (stratified by sex and disorder) adjusted for age, education and job code classification.ResultsOutpatient-managed depression/anxiety-related sick leave was significantly associated with higher permanent disability (hazard ratio (95% confidence interval)) 1.48 (1.30, 1.69) for depression, 1.25 (1.07, 1.45) for anxiety, 1.91 (1.56, 2.35) for both). Among outpatients, comorbidly ill men (2.59 (1.97,3.41)) were more likely to retire early than women (1.42 (1.04,1.93)). Retirement rates were higher for depressive and comorbidly ill patients who needed inpatient treatment (depression 3.13 (2,51, 3,92), both 3.54 (2.80, 4.48)). Inpatient-treated depression was also associated with elevated mortality (2.50 (1.80, 3.48)). Anxiety (0.53 (0.38, 0.73)) and female outpatients with depression (0.61 (0.38, 0.97)) had reduced mortality compared to controls.ConclusionsDepression/anxiety diagnoses increase the risk of early retirement; comorbidity and severity further increase that risk, depression more strikingly than anxiety. Sickness-absence diagnoses of anxiety/depression identified a population at high risk of retiring early due to ill health, suggesting a target group for the development of interventions.

Socioeconomic status, status inconsistency and risk of ischaemic heart disease: a prospective study among members of a statutory health insurance company.

Background: Inconsistency in social status and its impact on health have been a focus of research 30–40 years ago. Yet, there is little recent information on it’s association with ischaemic heart disease (IHD) morbidity and IHD is still defined as one of the major health problems in socioeconomically developed societies. Methods: A secondary analysis of prospective historical data from 68 805 male and female members of a statutory German health insurance company aged 25–65 years was conducted. Data included information on sociodemographic variables, social status indicators (education, occupational grade and income) and hospital admissions because of IHD. Results: Findings from Cox regression analysis showed an increased risk for IHD in the group with the highest educational level, whereas the lowest occupational and income groups had the highest hazard ratio (HR). Further analysis revealed that after adjustment for income status inconsistency (defined by the combination of higher educational level with lower occupational status) accounts for increased risk of IHD (HR for men, 3.14 and for women, 3.63). An association of similar strength was observed regarding high education/low income in women (HR 3.53). The combination of low education with high income reduced the risk among men (HR 0.29). No respective findings were observed concerning occupational group and income. Conclusions: Status inconsistency is associated with the risk of IHD as well as single traditional indicators of socioeconomic position. Information on status inconsistency should be measured in addition to single indicators of socioeconomic status to achieve a more appropriate estimation of the risk of IHD.

Chances of employment in women and men after surgery of congenital heart disease: comparisons between patients and the general population.

OBJECTIVE It was examined whether women and men (17-45 years) with operated congenital heart disease differ with respect to chances of employment. Patients were compared with the general population. DESIGN Patients (n = 314) were classified by type of surgery (curative, reparative, palliative) as indicator of initial severity of disease. The second classification was performed according to a system proposed by the New York Heart Association in order to take reported impairments into account. Controls (n = 1165) consisted of a 10% random sample drawn from the German Socio-Economic Panel. RESULTS Chances of full-time employment decreased as disease severity increased. Chances of part-time and minor employment were higher in patients than among controls. These general effects were because of male patients, while the employment patterns of women did not differ from the control group. Independent of patient status, women were more likely to have lower rates of full-time employment, and the rates of part-time and minor employment were higher. CONCLUSION Long-term adaptation to impairments as a result of congenital heart disease differs between women and men with respect to employment status. While female patients do not differ from the general population, males may lower their engagement in paid work.

Soziale Ungleichheit in der gesundheitlichen Versorgung – Ein Plädoyer für systematische Forschung

Inequalities in health care are often discussed in an undifferentiated way in Germany. Against this background, this article presents an analysis scheme for a classification of relevant studies and an identification of research needs. To this aim, areas of health care are differentiated (ambulant and inpatient care, prevention and health promotion) and a difference is made between access, utilization and quality of care. According to this scheme, research regarding inequalities in health care can be conducted in nine fields. For each field, exemplary results of a recent study from Germany are summarized. It becomes apparent that there is a substantial lack of systematic research in inequalities in health care in Germany.