Allostatic load (AL) is a measure of overall physiological wear-and-tear over the life course, which could partially be the consequence of early life exposures. AL could allow a better understanding ...of the potential biological pathways playing a role in the construction of the social gradient in adult health. To explore the biological embedding hypothesis, we examined whether adverse childhood experiences (ACEs) are associated with elevated AL in midlife. We used imputed data on 3,782 women and 3,753 men of the National Child Development Study in Britain followed up seven times. ACEs were measured using prospective data collected at ages 7, 11, and 16. AL was operationalized using data from the biomedical survey collected at age 44 on 14 parameters representing four biological systems. We examined the role of adult health behaviors, body mass index (BMI), and socioeconomic status as potential mediators using a path analysis. ACEs were associated with higher AL for both men and women after adjustment for early life factors and childhood pathologies. The path analysis showed that the association between ACEs and AL was largely explained by early adult factors at age 23 and 33. For men, the total mediated effect was 59% (for two or more ACEs) via health behaviors, education level, and wealth. For women, the mediated effect represented 76% (for two or more ACEs) via smoking, BMI, education level, and wealth. Our results indicate that early psychosocial stress has an indirect lasting impact on physiological wear-and-tear via health behaviors, BMI, and socioeconomic factors in adulthood.
Significance The role of early life experiences on health is of major concern to research. Recent studies have shown that chronic stress may “get under the skin” to alter human developmental processes and impact later health. Our findings suggest that early negative circumstances during childhood, collected prospectively in a British birth cohort, could be associated with physiological wear-and-tear in midlife as measured by allostatic load. This relationship was largely explained by health behaviors, body mass index, and socioeconomic status in adulthood, but not entirely. These results suggest that a biological link between adverse childhood exposures and adult health may be plausible. Our findings contribute to the development of more adapted public health interventions, both at a societal and individual level.
Socioeconomic inequalities in cancer mortality have been described for a range of cancers sites worldwide, using diverse measures of socioeconomic position (SEP). These studies have shown a negative ...social gradient where lower SEP was associated with greater odds of having cancer, particularly in men. However, there is a lack of information regarding low and middle‐income countries. The objective of our study was to analyze the relationship between the socioeconomic characteristics of patients' residential districts and mortality due to cancer in Costa Rica between 2011 and 2017. An ecological study at the level of the district of residence was conducted using the multilevel mixed‐effects Poisson regression. All cancer‐caused deaths between January 1, 2011 and December 31, 2017 were included (n = 32,117). Eleven cancer sites were analyzed independently. The 477 Costa Rican districts were divided by area (urban/mixed/rural) and wealth using census data. All‐cancer combined a significant association between cancer mortality and wealth was found. Cancer mortality was lower in the poorest as compared to the richest districts (IRRQ4 = 0.79 0.73–0.86). The majority of cancer sites followed a similar pattern, showing a positive social gradient. These results contradict the international literature mostly conducted in high‐income countries. These findings confirmed the importance of conducting studies in middle‐income countries, since the socioeconomic and cultural contexts are different from those in high‐income countries, which influence the social distribution of lifestyles and risk behaviors.
What's new?
While socioeconomic position (SEP) and cancer mortality are closely associated worldwide, where lower socioeconomic position was associated with greater odds of having cancer, all‐cancer combined. In this investigation of population‐based national registries specifically in Costa Rica, cancer mortality was found to follow a positive social gradient for the majority of cancer sites analyzed. The more socioeconomically deprived a district, the lower its cancer mortality. These findings are not consistent with international literature on SEP and cancer mortality and confirm the importance of conducting studies in middle‐income countries.
Highlights • Higher AL score was gradually associated with worse subjective health, after taking into account classic confounders. • Exposure to stressful events over life may leave a physiological ...stamp, partially captured by AL with consequences upon later health. • Due to the global physiological effect captured by the AL concept, it is particularly pertinent to examine its association with an integrative and holistic health measure.
Objectives
Low socioeconomic position (SEP) has been associated with higher incidences and mortality of lip, oral cavity and pharynx (LOP) cancers in the vast majority of countries with available ...data. The origins of health inequalities in cancer are socioeconomic, although they vary by time and country. Evidence from Low‐and Middle‐income Countries (LMICs) remains scarce. This study aims to identify and describe socioeconomic inequalities in LOP cancers incidence and mortality in Costa Rica. The hypothesis tested is that people leaving in low‐SEP districts in Costa Rica have greater incidence and mortality rates of lip, oral cavity and pharynx cancers.
Methods
The 10th revision of the International Classification of Diseases (ICD‐10) was used to define cancer sites. Data come from a national population‐based Cancer Registry with 100% completeness to study incidence. Incidence rate included all new cases of LOP cancer diagnosed from January 1, 2011, and December 31, 2015, for a total of 2 798 517 individuals, 13 832 524 years of follow‐up and 601 LOP cases. Mortality rate was extracted from the National Death Index, including 2 739 733 individuals, 23 950 240 person‐years of follow‐up and 586 LOP cancer deaths, from January 1, 2010, to December 31, 2018. The 2011 Census (with 94% of Costa Rican inhabitants) was used to characterize the urbanicity and wealth of 477 districts. Survival models were performed for both incidence and mortality, allowing to consider existing competitive risks. Cox models were used for incidence, and parametric survival models based on a Gompertz distribution for mortality.
Results
The study found that people who lived in the most socioeconomically disadvantaged areas had lower probabilities of developing LOP cancers than people in the richest districts. The same pattern for mortality, however, was not significant.
Conclusions
The hypothesis that incidence and mortality of LOP cancers will show a positive social gradient was not confirmed in this study, contradicting the existing literature. This could be explained by the social distribution of risky health behaviours, more frequent in socially advantaged populations.
To analyze health inequalities in cause-specific mortality in Costa Rica from 2010 to 2018, observing the main causes for inequality in the country.
The National Electoral Rolls were used to ...follow-up all Costa Rican adults aged 20 years or older from 2010 to 2018 (n = 2,739,733) in an ecological study. A parametric survival model based on the Gompertz distribution was performed and the event death was classified according to the ICD-10.
After adjustment for urbanicity, the poorest districts had a higher mortality than the wealthier districts for most causes of death except neoplasms, mental and behavioral disorders, and diseases of the nervous system. Urban districts showed significantly higher mortality than mixed and rural districts after adjustment for wealth for most causes except mental and behavioral disorders, diseases of the nervous system, and diseases of the respiratory system. Differences according to wealth were more frequent in women than men, whereas differences according to urbanicity were more frequent in men than in women.
The study's findings were consistent, but not fully similar, to the international literature.
Understanding how human environments affect our health by “getting under the skin” and penetrating the cells, organs and physiological systems of our bodies is a key tenet in public health research. ...Here, we examine the idea that early life socioeconomic position (SEP) can be biologically embodied, potentially leading to the production of health inequalities across population groups. Allostatic load (AL), a composite measure of overall physiological wear-and-tear, could allow for a better understanding of the potential biological pathways playing a role in the construction of the social gradient in adult health. We investigate the factors mediating the link between two components of parental SEP, maternal education (ME) and parental occupation (PO), and AL at 44 years. Data was used from 7573 members of the 1958 British birth cohort follow-up to age 44. AL was constructed using 14 biomarkers representing four physiological systems. We assessed the contribution of financial/materialist, psychological/psychosocial, educational, and health behaviors/BMI pathways over the life course, in mediating the associations between ME, PO and AL. ME and PO were mediated by three pathways: educational, material/financial, and health behaviors, for both men and women. A better understanding of embodiment processes leading to disease development may contribute to developing adapted public policies aiming to reduce health inequalities.
•Parental SEP at birth was linked with allostatic load at 44 years.•Parental SEP was mediated by an educational, material and health behaviors paths.•The educational path shows a major role in these relationships.•Allostatic load may allow a better understanding of social-to-biological transitions.
Objective
The uneven distribution of dental health services in a territory can cause an imbalance in accessibility, increasing health inequalities. This study aimed to describe the geographical ...distribution of dental health practitioners according to urbanicity and area‐level socio‐economic status in Costa Rica.
Methods
A National Dentist Survey was developed to identify employment status, number of working hours, address and list of the working clinics. Data was completed using information from the national College of Surgeons, including all Costa Rican dentists. The Minimal Geographic Units (MGU) allowed for aggregating the population's individual level socio‐economic position. Local Potential Accessibility (LPA) calculated the density of full‐time hour's equivalents around each MGU using floating sectors. Clinics were geocoded using Geographic Information Systems, creating 2853 clinical points. Distance between each MGU and the nearest accessible clinics considering full‐time working hours equivalents was estimated. MGU were divided into six categories: ‘No accessibility’, ‘Very low accessibility’, ‘Low accessibility’, ‘Good accessibility’ ‘High accessibility’ and ‘Very high accessibility’.
Results
Mean national LPA was 6.5 full‐time equivalents per 10 000 inhabitants, 3.4% of the Costa Rican population had no access to dentist; 12.9% had very low accessibility, 22.7% had low accessibility, 35.0% had good accessibility, 16.2% had high accessibility, and 9.8% had very high accessibility. Overall, 39% of the population has a rather low accessibility. LPA was higher in urban districts compared to rural districts and in wealthiest districts compared to most disadvantaged districts. Within districts, after adjustment for district's characteristics, LPA was higher in urban MGU compared to rural MGU and in wealthiest MGU compared to most disadvantaged MGU.
Conclusions
This study found that despite having a high number of dentists, their numbers are small in many areas, increasing inequalities in access to health care. The dentist's free establishment, where they can decide to provide private services within a community, creates zones with very high densities, in particular in the wealthiest urban areas, and others with very low densities, in particular the poorest rural areas. The lack of territorial planning has been one of the reasons that has encouraged an imbalance in the availability of dental human resources. To achieve effective universal health coverage, public institutions should focus their efforts on improving access to dental services in underserved areas.
Objectives
Although previous studies have shown that oral diseases can impact certain systemic conditions, dental care has been historically separated from medical healthcare organizations in ...middle‐income countries. There is a lack of research approaches which test the independent relationship between oral health and multidimensional measures of general health. This study analyses the influence of tooth loss on self‐rated health (SRH), hypothesizing that, relatively to certain morbidity conditions, tooth loss is a health condition associated with SRH. This study analyses the influence of tooth loss on self‐rated health (SRH), hypothesizing that, relative to certain morbidity conditions, tooth loss is a health condition associated with SRH.
Methods
Data were obtained from the Costa Rican Longevity and Healthy Aging Study 1945‐1955 Retirement Cohort, a national representative longitudinal survey including residents born between 1945 and 1955. The association between severe tooth loss and SRH was analysed cross‐sectionally using the first wave of the study conducted in 2010. A multivariable logistic regression, adjusted for potential confounders, was performed on 2797 participants. A counterfactual analysis was additionally performed to illustrate the theoretical change on SRH prevalence—if all the participants were not to have had severe tooth loss.
Results
Severe tooth loss was associated with poor SRH, after adjustment for smoking, morbidity, biomarkers and performance‐based physical measures. The counterfactual analysis showed that severe tooth loss was the fifth most important morbidity condition in determining poor SRH. Declaring a poor SRH would have been decreased by 2.0 percentage points if those participants having severe tooth loss had shared the same risk pattern of those who had not lost the majority of their teeth.
Conclusion
Individuals consider their oral health status to a similar extent as other morbidity conditions when evaluating their general health. A stronger focus on oral health, and its impact on general health, could lead to better planning of national resources, thereby improving accessibility to health care and modifying prevailing conceptions of health care in low‐ and middle‐income countries.
•A positive social gradient in all-cancer combined incidence in Costa Rica.•The relationship between socioeconomic position and cancer incidence varied according to the cancer site.•For skin cancer, ...incidence was higher in rural as compared to urban areas after adjustment for wealth.•For lung, cervical and uterine cancer, incidence was lower in rural as compared to urban area after adjustment for wealth.
The main evidence regarding social inequalities in cancer risk comes from industrialized countries. The aim of this manuscript was to analyze the association between cancer incidence and socioeconomic position (SEP) in a middle-income country (Costa Rica) between 2011 and 2015.
An ecological study at the level of the electoral district was conducted. The 477 districts were divided by area and wealth using the 2011 Census. The sample was defined using the National Electoral Rolls used for presidential elections of 2006 and 2010 (N = 2 798 517). 44 799 cancer cases were included coming from the Costa Rican Cancer Registry. Cox models were used.
All cancer sites combined, we observed a positive gradient, with incidence being lower in the poorest districts than in the wealthiest (HRQ2 = 0.98 0.93−1.03, HRQ3 = 0.92 0.85−0.99, HRQ4 = 0.83 0.77−0.88). For colon, skin, breast, prostate, thyroid and other cancer sites, a positive social gradient was observed. For stomach, lung, and cervical (invasive or in-situ) cancers, a negative social gradient was found. For uterine cancer and lymphoma (no-Hodgkin), there was no significant relationship between wealth and incidence. For skin cancer, incidence was higher in rural as compared to urban areas after adjustment for wealth. For lung, cervical and uterine cancer, incidence was lower in rural as compared to urban area after adjustment for wealth.
The all-cancer combined results were in contradiction with the international literature but confirmed recent study results in Costa Rica. It confirmed the importance of studying socioeconomic inequalities in middle-income countries.
Introducción. En la mayoría de los países de los continentes americanos y oceánicos, las personas indígenas tienen peores indicadores de salud que el resto de la población. El objetivo de este ...estudio es analizar las diferencias de mortalidad y de causas de muerte entre las zonas indígenas y el resto de Costa Rica, en el periodo de 2010 a 2018. Metodología. La población de estudio se conformó a partir del padrón de las elecciones presidenciales de 2010 y las causas de muerte (ICD-10) se extrajeron del registro del Instituto Nacional de Estadísticas y Censos (INEC); fueron incluidas 2 747 616 personas para 23 985 602 personas-año de seguimiento. Resultados. No se observaron diferencias de mortalidad entre los hombres de ambas poblaciones, en cambio, fue ligeramente superior en las mujeres indígenas. En las zonas indígenas, por un lado, dicho índice fue más alto en quienes tenían menos de 50 años al inicio del seguimiento, en particular, por enfermedades del sistema digestivo y causas externas de morbilidad y mortalidad; por otro, fue inferior en mayores de 70 años y se debió a tumores y enfermedades del sistema circulatorio. Conclusiones. Los resultados obtenidos niegan la hipótesis de una mortalidad sistemáticamente mayor en las poblaciones que viven en las zonas indígenas.
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