Pathways to inequalities in child health Pearce, Anna; Dundas, Ruth; Whitehead, Margaret ...
Archives of disease in childhood,
10/2019, Letnik:
104, Številka:
10
Journal Article
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From birth, children living in disadvantaged socioeconomic circumstances (SECs) suffer from worse health than their more advantaged peers. The pathways through which SECs influence children’s health ...are complex and inter-related, but in general are driven by differences in the distribution of power and resources that determine the economic, material and psychosocial conditions in which children grow up. A better understanding of why children from more disadvantaged backgrounds have worse health and how interventions work, for whom and in what contexts, will help to reduce these unfair differences. Macro-level change is also required, including the reduction of child poverty through improved social security systems and employment opportunities, and continued investment in high-quality and accessible services (eg, childcare, key workers, children’s centres and healthy school environments). Child health professionals can play a crucial role by being mindful of the social determinants of health in their daily practice, and through advocating for more equitable and child-focussed resource allocation.
BackgroundThe mortality impact of COVID-19 has thus far been described in terms of crude death counts. We aimed to calibrate the scale of the modelled mortality impact of COVID-19 using ...age-standardised mortality rates and life expectancy contribution against other, socially determined, causes of death in order to inform governments and the public.MethodsWe compared mortality attributable to suicide, drug poisoning and socioeconomic inequality with estimates of mortality from an infectious disease model of COVID-19. We calculated age-standardised mortality rates and life expectancy contributions for the UK and its constituent nations.ResultsMortality from a fully unmitigated COVID-19 pandemic is estimated to be responsible for a negative life expectancy contribution of −5.96 years for the UK. This is reduced to −0.33 years in the fully mitigated scenario. The equivalent annual life expectancy contributions of suicide, drug poisoning and socioeconomic inequality-related deaths are −0.25, −0.20 and −3.51 years, respectively. The negative impact of fully unmitigated COVID-19 on life expectancy is therefore equivalent to 24 years of suicide deaths, 30 years of drug poisoning deaths and 1.7 years of inequality-related deaths for the UK.ConclusionFully mitigating COVID-19 is estimated to prevent a loss of 5.63 years of life expectancy for the UK. Over 10 years, there is a greater negative life expectancy contribution from inequality than around six unmitigated COVID-19 pandemics. To achieve long-term population health improvements it is therefore important to take this opportunity to introduce post-pandemic economic policies to ‘build back better’.
Minority ethnic groups have been disproportionately affected by the COVID-19 pandemic. While the exact reasons for this remain unclear, they are likely due to a complex interplay of factors rather ...than a single cause. Reducing these inequalities requires a greater understanding of the causes. Research to date, however, has been hampered by a lack of theoretical understanding of the meaning of ‘ethnicity’ (or race) and the potential pathways leading to inequalities. In particular, quantitative analyses have often adjusted away the pathways through which inequalities actually arise (ie, mediators for the effect of interest), leading to the effects of social processes, and particularly structural racism, becoming hidden. In this paper, we describe a framework for understanding the pathways that have generated ethnic (and racial) inequalities in COVID-19. We suggest that differences in health outcomes due to the pandemic could arise through six pathways: (1) differential exposure to the virus; (2) differential vulnerability to infection/disease; (3) differential health consequences of the disease; (4) differential social consequences of the disease; (5) differential effectiveness of pandemic control measures and (6) differential adverse consequences of control measures. Current research provides only a partial understanding of some of these pathways. Future research and action will require a clearer understanding of the multiple dimensions of ethnicity and an appreciation of the complex interplay of social and biological pathways through which ethnic inequalities arise. Our framework highlights the gaps in the current evidence and pathways that need further investigation in research that aims to address these inequalities.
There is a substantial gap in health and longevity between more affluent and more deprived areas, and more knowledge of the determinants of this health divide is required. Experience of the local ...residential environment is important for health although few studies have examined this in relation to biological markers of age such as telomere length. We sought to examine if residents' perceptions of neighbourhood stressors over time were associated with telomere length in a community study.
In a prospective cohort study of 2186 adults in the West of Scotland, we measured neighbourhood stressors at three time points over a 12-year period and telomere length at the end of the study. Using linear regression models, we found that a higher accumulation of neighbourhood stressors over time was associated with shorter telomere length, even after taking cohort, social class, health behaviours (smoking status, diet, physical activity), BMI and depression into account among females only (Beta = 0.007; 95%CI 0.001, 0.012; P<0.014).
Neighborhood environments are potentially modifiable, and future efforts directed towards improving deleterious local environments may be useful to lessen telomere attrition.
Increasing mortality among men from drugs, alcohol and suicides is a growing public health concern in many countries. Collectively known as "deaths of despair", they are seen to stem from ...unprecedented economic pressures and a breakdown in social support structures.
We use high-quality population wide Scottish data to calculate directly age-standardized mortality rates for men aged 15-44 between 1980 and 2018 for 15 leading causes of mortality. Absolute and relative inequalities in mortality by cause are calculated using small-area deprivation and the slope and relative indices of inequality (SII and RII
) for the years 2001-2018.
Since 1980 there have been only small reductions in mortality among men aged 15-44 in Scotland. In that period drug-related deaths have increased from 1.2 (95% CI 0.7-1.4) to 44.9 (95% CI 42.5-47.4) deaths per 100,000 and are now the leading cause of mortality. Between 2001 and 2018 there have been small reductions in absolute but not in relative inequalities in all-cause mortality. However, absolute inequalities in mortality from drugs have doubled from SII = 66.6 (95% CI 61.5-70.9) in 2001-2003 to SII = 120.0 (95% CI 113.3-126.8) in 2016-2018. Drugs are the main contributor to inequalities in mortality, and together with alcohol harm and suicides make up 65% of absolute inequalities in mortality.
Contrary to the substantial reductions in mortality across all ages in the past decades, deaths among young men are increasing from preventable causes. Attempts to reduce external causes of mortality have focused on a single cause of death and not been effective in reducing mortality or inequalities in mortality from external causes in the long-run. To reduce deaths of despair, action should be taken to address social determinants of health and reduce socioeconomic inequalities.
Abstract
Background
Average life expectancy has stopped increasing for many countries. This has been attributed to causes such as influenza, austerity policies and deaths of despair (drugs, alcohol ...and suicide). Less is known on the inequality of life expectancy over time using reliable, whole population, data. This work examines all-cause and cause-specific mortality rates in Scotland to assess the patterning of relative and absolute inequalities across three decades.
Methods
Using routinely collected Scottish mortality and population records we calculate directly age-standardized mortality rates by age group, sex and deprivation fifths for all-cause and cause-specific deaths around each census 1981–2011.
Results
All-cause mortality rates in the most deprived areas in 2011 (472 per 100 000 population) remained higher than in the least deprived in 1981 (422 per 100 000 population). For those aged 0–64, deaths from circulatory causes more than halved between 1981 and 2011 and cancer mortality decreased by a third (with greater relative declines in the least deprived areas). Over the same period, alcohol- and drug-related causes and male suicide increased (with greater absolute and relative increases in more deprived areas). There was also a significant increase in deaths from dementia and Alzheimer’s disease for those aged 75+.
Conclusions
Despite reductions in mortality, relative (but not absolute) inequalities widened between 1981 and 2011 for all-cause mortality and for several causes of death. Reducing relative inequalities in Scotland requires faster mortality declines in deprived areas while countering increases in mortality from causes such as drug- and alcohol-related harm and male suicide.
Previous UK and European research has highlighted important variations in mortality between populations after adjustment for key determinants such as poverty and deprivation. The aim here was to ...establish whether similar populations could be identified in the US, and to examine changes over time. We employed Poisson regression models to compare county-level mortality with national rates between 1968 and 2016, adjusting for poverty, education, race (a proxy for exposure to racism), population change and deindustrialisation. Results are presented by means of population-weighted cartograms, and highlight widening spatial inequalities in mortality over time, including an urban to rural, and south-westward, shift in areas with the highest levels of such unexplained ‘excess’ mortality. There is a need to understand the causes of the excess in affected communities, given that it persists after adjustment for such a broad range of important health determinants.
•For the first time, trends in ‘excess’ (adjusted) mortality in the US are analysed.•Population-weighted cartograms are used to present and explore county-level trends.•Maps highlight widening spatial inequalities over time in this form of mortality.•We identify urban and rural changes in excess mortality over c.50 years (1968–2016).•Policy-relevant analyses identify areas with highest levels of excess mortality.
Abstract Background Many policies have been implemented to improve health in early years, but an assessment of such interventions is needed. The Healthy Start Voucher scheme, introduced across the UK ...in 2006, is intended to provide low-income pregnant women and children under 4 years old with appropriate nutrition. Eligible mothers receive weekly vouchers (£3.10) for milk, formula milk, fruit, and vegetables. The aim of this qualitative study was to explore processes involved in take-up or non-take-up of the scheme, and how vouchers are used. It is part of a wider evaluation of the effectiveness and cost-effectiveness of the scheme. Methods Semi-structured interviews were conducted with 40 low-income mothers in Scotland: women claiming Healthy Start Vouchers, eligible women not claiming, and women who just missed eligibility criteria. Experiences accessing and using Healthy Start Vouchers were explored, along with barriers and facilitators to providing children with a nutritional diet. The interviewer and a coinvestigator reviewed transcripts to identify and reduce instances of interviewer bias. The data were coded thematically, after discussion on emerging themes with the wider study team. Deviant cases were sought to ensure validity and refine analysis. Findings The main reason eligible mothers had not taken up Healthy Start Vouchers was lack of awareness. Awareness was especially poor among women in employment, women with higher or further education, or those living in less deprived areas. Women reported learning of the scheme after their baby had been born, so they had missed out while pregnant. Providing a healthy diet was deemed important, and mothers demonstrated innovative and resourceful ways of ensuring that their children ate what they believed was a healthy diet. However, discussions about diet revealed inadequate knowledge. Interpretation This study highlights poor awareness of the existence of the Healthy Start Voucher scheme, the importance that low-income mothers place on providing children with nutritional diets, and the value of the scheme in this endeavour. It demonstrates scope to improve uptake of Healthy Start Vouchers and for health professionals to engage mothers in discussions around nutrition. Funding National Institute for Health Research (project number 13/164/10).
•Cancer mortality rates have declined but inequalities in rates have widened.•Relative inequalities are dominated by inequalities in lung cancer mortality.•There is also a contribution from liver and ...head and neck cancers (men).•And from breast cancer (women), stomach and cervical cancer (younger women).•Understanding these patterns is important in reducing preventable cancer deaths.
In many high-income countries cancer mortality rates have declined, however, socioeconomic inequalities in cancer mortality have widened over time with those in the most deprived areas bearing the greatest burden. Less is known about the contribution of specific cancers to inequalities in total cancer mortality.
Using high-quality routinely collected population and mortality records we examine long-term trends in cancer mortality rates in Scotland by age group, sex, and area deprivation. We use the decomposed slope and relative indices of inequality to identify the specific cancers that contribute most to absolute and relative inequalities, respectively, in total cancer mortality.
Cancer mortality rates fell by 24 % for males and 10 % for females over the last 35 years; declining across all age groups except females aged 75+ where rates rose by 14 %. Lung cancer remains the most common cause of cancer death. Mortality rates of lung cancer have more than halved for males since 1981, while rates among females have almost doubled over the same period.
Current relative inequalities in total cancer mortality are dominated by inequalities in lung cancer mortality, but with contributions from other cancer sites including liver, and head and neck (males); and breast (females), stomach and cervical (younger females). An understanding of which cancer sites contribute most to inequalities in total cancer mortality is crucial for improving cancer health and care, and for reducing preventable cancer deaths.
Prenatal nutrition is associated with offspring autism spectrum disorder (herein referred to as autism), yet, it remains unknown if the association is causal. Triangulation may improve causal ...inference by integrating the results of conventional multivariate regression with several alternative approaches that have unrelated sources of bias. We systematically reviewed the literature on the relationship between prenatal multivitamin supplements and offspring autism, and evidence for the causal approaches applied. Six databases were searched up to 8 June 2020, by which time we had screened 1309 titles/abstracts, and retained 12 articles. Quality assessment was guided using Newcastle-Ottawa in individual studies, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) for the body of evidence. The effect estimates from multivariate regression were meta-analysed in a random effects model and causal approaches were narratively synthesised. The meta-analysis of prenatal multivitamin supplements involved 904,947 children (8159 cases), and in the overall analysis showed no robust association with offspring autism; however, a reduced risk was observed in the subgroup of high-quality observational studies (RR 0.77, 95% CI (0.62, 0.96), I
= 62.4%), early pregnancy (RR 0.76, 95% CI (0.58; 0.99), I
= 79.8%) and prospective studies (RR 0.69, 95% CI (0.48, 1.00), I
= 95.9%). The quality of evidence was very low, and triangulation was of limited utility because alternative methods were used infrequently and often not robustly applied.
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