Background:Uncertainties exist about the strength of the relation between socioeconomic position and depressive disorders. The aim of this study was to investigate the association between education, ...occupation, employment and income and depressive disorders measured as minor and major depression, as well as antidepressant prescriptions.Methods:Data were collected from a Danish cross-sectional study collected year 2000, comprising 9254 subjects, 55% women, and aged 36–56 years. Register-based information on education, income and prescription were used.Results:The prevalence of major depression DSM-IV algorithm was 3.3% among men and women, whereas minor depression and prescriptions revealed statistically significant higher prevalence among females. A social gradient was found for all depressive end-points with the strongest estimates related to major depressive disorder (MDD). The associations were as follows: MDD and low education odds ratio (OR) 2.38 (CI 95% 1.68 to 3.37), MDD and non-employment OR 11.67 (CI 95% 8.06 to 16.89), MDD and low income OR 9.78 (CI 95% 6.49 to 14.74). Education only explained a minor part of the association between non-employment and depressive disorders and no associations were found between education and prescription. This indicates a strong two-way association between depression and non-employment, low-income respectively.Conclusion:A social gradient in depressive disorders was found regardless of socioeconomic position being measured by education, occupation, employment or income. Severe socioeconomic consequences of depression are indicated by the fact that the associations with non-employment and low income were much stronger than the association with low education.
Abstract Aim To investigate whether cancer survivors are at an increased risk for unemployment after cancer. Materials and methods A cohort of 65,510 patients who were part of the workforce in the ...year before diagnosis and a random sample of 316,925 age and gender-matched controls were followed for up to 20 years in a longitudinal register-based cohort study. Demographic, socioeconomic and health-related information were obtained through Danish administrative registers. Results Cancer survivors had a small but significantly increased risk for unemployment following cancer. Stratified analyses showed that the risk for unemployment was highest amongst persons aged 50–60 years at time of diagnosis. Risk factors for unemployment were found to be manual work, medium income and vocational education. Conclusion Generally, cancer patients were at a small increased risk for unemployment and low socioeconomic position was a significant risk factor.
BACKGROUND:Alcohol-related mortality is more pronounced in lower than higher socioeconomic groups in Western countries. Part of the explanation is differences in drinking patterns. However, ...differences in vulnerability to health consequences of alcohol consumption across socioeconomic groups may also play a role. We investigated the joint effect of alcohol consumption and educational level on the rate of alcohol-related medical events.
METHODS:We pooled seven prospective cohorts from Denmark that enrolled 74 278 men and women aged 30-70 years (study period 1981 to 2009). We measured alcohol consumption at baseline using self-administrated questionnaires. Information on highest attained education one year before study entry and hospital and mortality data on alcohol-related medical events were obtained through linkage to nationwide registries. We performed analyses using the Aalen additive hazards model.
RESULTS:During follow-up (1 085 049 person-years), a total of 1718 alcohol-related events occurred. The joint effect of very high alcohol consumption (>21 (>28) drinks per week in women (men)) and low education on alcohol-related events exceeded the sum of their separate effects. Among men, we observed 289 (95% confidence interval, 123, 457) extra events per 100 000 person-years due to education–alcohol interaction (P <0.001). Similarly, among women we observed 239 (90, 388) extra events per 100 000 person-years due to this interaction (P <0.001).
CONCLUSIONS:High alcohol consumption is associated with a higher risk of alcohol-related medical events among those with low compared to high education. This interaction may be explained by differences in vulnerability and drinking patterns across educational groups.
To inform Danish health care reform efforts, we compared health care system inputs and performance and assessed the usefulness of these comparisons for informing policy.
Retrospective analysis of ...secondary data in the Danish Health Care System (DHS) with 5.3 million citizens and the Kaiser Permanente integrated delivery system (KP) with 6.1 million members in California. We used secondary data to compare population characteristics, professional staff, delivery structure, utilisation and quality measures, and direct costs. We adjusted the cost data to increase comparability.
A higher percentage of KP patients had chronic conditions than did patients in the DHS: 6.3% vs. 2.8% (diabetes) and 19% vs. 8.5% (hypertension), respectively. KP had fewer total physicians and staff compared to DHS, with 134 physicians/100,000 individuals versus 311 physicians/100,000 individuals. KP physicians are salaried employees; in contrast, DHS primary care physicians own and run their practices, remunerated by a mixture of capitation and fee-for-service payments, while most specialists are employed at largely public hospitals. Hospitalisation rates and lengths of stay (LOS) were lower in KP, with mean acute admission LOS of 3.9 days versus 6.0 days in the DHS, and, for stroke admissions, 4.2 days versus 23 days. Screening rates also differed: 93% of KP members with diabetes received retinal screening; only 46% of patients in the DHS with diabetes did. Per capita operating expenditures were PPP$1,951 (KP) and PPP $1,845 (DHS).
Compared to the DHS, KP had a population with more documented disease and higher operating costs, while employing fewer physicians and resources like hospital beds. Observed quality measures also appear higher in KP. However, simple comparisons between health care systems may have limited value without detailed information on mechanisms underlying differences or identifying translatable care improvement strategies. We suggest items for more in-depth analyses that could improve the interpretability of findings and help identify lessons that can be transferred.
The purpose of this study was to investigate whether there is an association between stage of incident breast cancer (BC) and personal income three years after diagnosis. The analysis further ...considered whether the association differed among educational groups.
The study was based on information from Danish nationwide registers. A total of 7,372 women aged 30-60 years diagnosed with BC, 48% with metastasis, were compared to 213,276 controls. Generalised linear models were used to estimate the effect of a cancer diagnosis on personal gross income three years after diagnosis, stratified by education and stage of cancer. The models were adjusted for income two years prior to cancer diagnosis and demographic, geographic and co-morbidity covariates.
Adjusting for income two years prior to cancer diagnosis and other baseline covariates (see above), cancer had a minor effect on personal income three years after diagnosis. The effect of metastatic BC was a statistically significant reduction in income three years after diagnosis of -3.4% (95% CI -4.8;-2.0), -2.8% (95% CI -4.3;-1.3) and -4.1 (95% CI -5.9;-2.3) among further, vocational and low educated women, respectively. The corresponding estimates for the effect of localised BC were -2.5% (95% CI -3.8; -1.2), -1.6% (95% CI -3.0; -0.2) and -1.7% (95% CI -3.7; 0.3); the latter estimate (for the low-educated) was not statistically different from zero. We found no statistically significant educational gradient in the effect of cancer stage on income.
In a Danish context, the very small negative effect of BC on personal income may be explained by different types of compensation in low- and high-income groups. The public income transfers are equal for all income groups and cover a relatively high compensation among low-income groups. However, high-income groups additionally receive pay-outs from private pension and insurance schemes, which typically provide higher coverage for high-income workers.
Health-related quality of life (HRQoL) measured on population level may be useful to guide policies for health. This study aims to describe the HRQoL; in EQ-5D dimensions, mean rating scale (RS) ...scores and mean EQ-5D index values, in the general population, by certain disease and socio-economic groups, in Stockholm County 1998. The EQ-5D self-classifier and a RS were included in the 1998 cross-sectional postal Stockholm County public health survey to a representative sample (n = 4950, 20-88 years), 63% response rate. Mean RS score ranged from 0.90 (20-29 years) to 0.69 (80-88 years), mean EQ-5D index value ranged from 0.89 (20-29 years) to 0.74 (80-88 years). For different diseases means RS scores ranged from 0.80 (asthma) to 0.69 (angina pectoris), mean EQ-5D index values ranged from 0.79 (asthma) to 0.66 (low back pain). The mean health state scores (RS and EQ-5D index) were 0.06 lower in the unskilled manual group than in the higher non-manual group after controlling for age and sex (p < 0.0001). This difference was 0.03 after controlling also for different diseases (p < 0.0001). In conclusion, our results show that the HRQoL varies greatly between socio-economic and disease groups. Furthermore, after controlling for age, sex and disease, HRQoL is lower in manual than in non-manual groups.
Background:
Previous studies show social inequality in tooth loss, but the underlying pathways are not well understood. The aim was to investigate the mediated proportion of sugary beverages (SBs) ...and diabetes and the association between educational level and tooth loss, and to investigate whether the indirect effect of SBs and diabetes varied between educational groups in relation to tooth loss.
Methods:
Data from 47,109 Danish men and women aged 50 years or older included in the Danish Diet, Cancer and Health Study was combined with data from Danish registers. Using natural effect models, SBs and diabetes were considered as mediators, and tooth loss was defined as having <15 teeth present.
Results:
In total, 10,648 participants had tooth loss. The analyses showed that 3% (95% confidence interval 2–4%) of the social inequality in tooth loss was mediated through SBs and diabetes. The mediated proportion was mainly due to differential exposure to SBs and diabetes among lower educational groups.
Conclusions:
The findings show that SBs and diabetes to a minor degree contribute to tooth-loss inequalities. The explanation indicates that individuals in lower educational groups have higher consumption of SBs and more often suffer from diabetes than higher educational groups.
It has been hypothesized that areas with an unequal income distribution are less likely to invest in health and more likely to have a social environment that influences the development of ischaemic ...heart disease (IHD) METHODS: We used pooled data from two cohort studies conducted in Copenhagen to analyse the association between area income inequality and first admission to hospital or death from IHD in women and men while controlling for individual income and other IHD risk factors. A total of 11 685 women and 10 036 men, with initial health examinations between 1964 and 1992, were followed for a median of 13.8 years. Information on median income share at parish and municipality levels was obtained from population registers.
During follow-up 1700 men and 1204 women experienced an IHD event. At parish level income share was inversely associated with an increased risk of IHD in men (hazard ratio HR(most versus least equal quartile) = 0.85 (95% CI: 0.73-0.98). Among women there was no relation between parish income inequality and IHD. Subject's household income was inversely related to IHD, and when this variable was controlled for, the association between income inequality at parish level and IHD in men attenuated slightly. When behavioural and biological risk factors were entered into the Cox model this relation attenuated further. However, some of these risk factors might mediate rather than confound the effect of income inequality. The association between income inequality at municipality level and IHD was insignificant for men, while in women the relation had a curved shape with those living in the least equal areas having the lowest risk.
This study provides no clear evidence for an association between income inequality measured at parish or municipality level and IHD in Danish adults. The associations were weak and varied between different strata and geographical levels.
Background: Differential exposures to behavioral risk factors have been shown to play an important mediating role on the education–mortality relation. However, little is known about the extent to ...which educational attainment interacts with health behavior, possibly through differential vulnerability. Methods: In a cohort study of 76,294 participants 30 to 70 years of age, we estimated educational differences in cause-specific mortality from 1980 through 2009 and the mediating role of behavioral risk factors (smoking, alcohol intake, physical activity, and body mass index). With the use of marginal structural models and three-way effect decomposition, we simultaneously regarded the behavioral risk factors as intermediates and clarified the role of their interaction with educational exposure. Results: Rate differences in mortality comparing participants with low to high education were 1,277 (95% confidence interval = 1,062 to 1,492) per 100,000 person-years for men and 746 (598 to 894) per 100,000 person-years for women. Smoking was the strongest mediator for cardiovascular disease, cancer, and respiratory disease mortality when conditioning on sex, age, and cohort. The proportion mediated through smoking was most pronounced in cancer mortality as a combination of the pure indirect effect, owing to differential exposure (men, 42% 25% to 75%; women, 36% 17% to 74%) and the mediated interactive effect, owing to differential vulnerability (men, 18% 2% to 35%, women, 26% 8% to 50%). The mediating effects through body mass index, alcohol intake, or physical activity were partial and varied for the causes of deaths. Conclusion: Differential exposure and vulnerability should be addressed simultaneously, as these mechanisms are not mutually exclusive and may operate at the same time.
BackgroundDenmark and Sweden have implemented reforms that narrowed disability benefit eligibility criteria. Such reforms in combination with increasing work demands create a pincer movement where in ...particular those with moderate health problems might be unable to comply with work demands, but still not qualify for permanent disability benefits, ending up with temporary means-tested or no benefits. This paper examines whether this actually happened before and after the reforms.MethodsThe Survey of Health, Ageing and Retirement in Europe (SHARE) study waves 1–2 and 4–6 in Denmark and Sweden for the age group 50–59 years (N=5384) was used to analyse changes in employment rates and benefits among people with different levels of health before, during and after disability benefit reforms. Interaction between time and health in relation to employment versus permanent or temporary benefits was used as a criterion for whether our hypotheses was confirmed.ResultsOverall, employment rates have increased in the age group, but only among the healthy. The OR for receiving temporary or no benefits increased from 1.25 (95% CI: 0.81 to 1.90) before to 1.73 (95% CI: 1.14 to 2.61) after policy reforms for the 29% with moderate health problems and from 2.89 (95% CI: 1.66 to 5.03) to 6.71 (95% CI: 3.94 to 11.42) among the 11% with severe health problems. The interaction between time and health was statistically significant (p<0.001).ConclusionPeople with impaired health and workability are forced into a life with temporary means-tested or no benefits when pressed by rising work demands and stricter disability benefit eligibility criteria.
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