Socioeconomic inequality and mortality--a regional Danish cohort study.

BACKGROUND: Socioeconomic inequalities in mortality pose a serious impediment to enhance public health even in highly developed welfare states. This study aimed to improve the understanding of socioeconomic disparities in all-cause mortality by using a comprehensive approach including a range of behavioural, psychological, material and social determinants in the analysis. METHODS: Data from The North Denmark Region Health Survey 2007 among residents in Northern Jutland, Denmark, were linked with data from nationwide administrative registries to obtain information on death in a 5.8-year follow-up period (1(st) February 2007- 31(st) December 2012). Socioeconomic position was assessed using educational status as a proxy. The study population was assigned to one of five groups according to highest achieved educational level. The sample size was 8,837 after participants with missing values or aged below 30 years were excluded. Cox regression models were used to assess the risk of death from all causes according to educational level, with a step-wise inclusion of explanatory covariates. RESULTS: Participants' mean age at baseline was 54.1 years (SD 12.6); 3,999 were men (45.3%). In the follow-up period, 395 died (4.5%). With adjustment for age and gender, the risk of all-cause mortality was significantly higher in the two least-educated levels (HR = 1.5, 95%, CI = 1.2-1.8 and HR = 3.7, 95% CI = 2.4-5.9, respectively) compared to the middle educational level. After adjustment for the effect of subjective and objective health, similar results were obtained (HR = 1.4, 95% CI = 1.1-1.7 and HR = 3.5, 95% CI = 2.0-6.3, respectively). Further adjustment for the effect of behavioural, psychological, material and social determinants also failed to eliminate inequalities found among groups, the risk remaining significantly higher for the least educated levels (HR = 1.4, 95% CI = 1.1-1.9 and HR = 4.0, 95% CI = 2.3-6.8, respectively). In comparison with the middle level, the two highest educated levels remained statistically insignificant throughout the entire analysis. CONCLUSION: Socioeconomic inequality influenced mortality substantially even when adjusted for a range of determinants that might explain the association. Further studies are needed to understand this important relationship.

How do experts define relevance criteria when initiating Health Impact Assessments of national policies?

AIM: The aim of this article is to present how the Danish Disease Prevention Committee (DDPC) members and HIA-experts understand when HIA is "relevant", which in this context means when there is "presumed to be a direct and documented effect on the health and morbidity of citizens". METHOD: DDPC members were interviewed face-to-face; HIA experts participated in an e-survey. RESULTS: Six DDPC members were interviewed and 100 HIA-experts participated in a survey. The DDPC members consider direct as the link between determinants and the related risk factors. The HIA experts consider direct as the link between policy and the related risk factors. Both groups favour the use of scientific evidence according to the traditional biomedical evidence hierarchy but HIA-experts also judge that there is value in using evidence that can be considered weak such as local community knowledge. CONCLUSIONS: It is clear that the DDPC recommendation gives rise to a discussion on differing perceptions of relevance. The same definition can be used for both direct and indirect effects depending on interpretation. Documented evidence for an effect is desirable in the form provided by the traditional biomedical evidence hierarchy but HIA-experts emphasises use of local knowledge. The primary criteria for initiating a HIA, is whether the outcome of the HIA is expected to be taken into account in the decision-making process. The second criteria, is how do decision-makers perceive or interpret a decision to be relevant for HIA. This has implications for how and whether HIA will be implemented in Denmark in the future.

Individual social capital and survival: a population study with 5-year follow-up.

BACKGROUND: The concept of social capital has received increasing attention as a determinant of population survival, but its significance is uncertain. We examined the importance of social capital on survival in a population study while focusing on gender differences. METHODS: We used data from a Danish regional health survey with a five-year follow-up period, 2007-2012 (n = 9288, 53.5% men, 46.5% women). We investigated the association between social capital and all-cause mortality, performing separate analyses on a composite measure as well as four specific dimensions of social capital while controlling for covariates. Analyses were performed with Cox proportional hazard models by which hazard ratios and 95% confidence intervals were calculated. RESULTS: For women, higher levels of social capital were associated with lower all-cause mortality regardless of age, socioeconomic status, health, and health behaviour (HR = 0.586, 95% CI = 0.421-0.816) while no such association was found for men (HR = 0.949, 95% CI = 0.816-1.104). Analysing the specific dimensions of social capital, higher levels of trust and social network were significantly associated with lower all-cause mortality in women (HR = 0.827, 95% CI = 0.750-0.913 and HR = 0.832, 95% CI = 0.729-0.949, respectively). For men, strong social networks were associated with a higher risk of all-cause mortality (HR = 1.132, 95% CI = 1.017-1.260). Civic engagement had a similar effect for both men (HR = 0.848, 95% CI = 0.722-0.997) and women (HR = 0.848, 95% CI = 0.630-1.140). CONCLUSIONS: We found differential effects of social capital in men compared to women. The predictive effects on all-cause mortality of four specific dimensions of social capital varied. Gender stratified analysis and the use of multiple indicators to measure social capital are thus warranted in future research.

Screening tool development for health impact assessment of large administrative structural changes.

AIMS: Screening is the first, extremely important step of health impact assessment (HIA) methodology. It contributes to the decision to conduct or not conduct a full assessment, and predefines the main fields of interest of the assessment. METHODS: Although there are examples of screening tools available on the Internet and in the scientific literature, in many cases lack of access to those tools creates a barrier to the use of HIA. RESULTS: Denmark is undergoing a major structural change in state administration, moving many responsibilities from the state to the local level. Newly constructed councils are faced with challenges regarding their responsibilities in health promotion and other fields, and this has opened a window for the introduction of HIA at a local level. Owing to the lack of experience with HIA in Denmark, screening tools are lacking and are frequently requested by councils. CONCLUSIONS: This article describes a newly constructed screening tool for use at the local level, and describes how we approached the construction of the tool.