Geographic remoteness and risk of advanced colorectal cancer at diagnosis in Queensland: a multilevel study.

BACKGROUND: We examine the relationships between geographic remoteness, area disadvantage and risk of advanced colorectal cancer. METHODS: Multilevel models were used to assess the area- and individual-level contributions to the risk of advanced disease among people aged 20-79 years diagnosed with colorectal cancer in Queensland, Australia between 1997 and 2007 (n=18,561). RESULTS: Multilevel analysis showed that colorectal cancer patients living in inner regional (OR=1.09, 1.01-1.19) and outer regional (OR=1.11, 1.01-1.22) areas were significantly more likely to be diagnosed with advanced cancer than those in major cities (P=0.045) after adjusting for individual-level variables. The best-fitting final model did not include area disadvantage. Stratified analysis suggested this remoteness effect was limited to people diagnosed with colon cancer (P=0.048) and not significant for rectal cancer patients (P=0.873). CONCLUSION: Given the relationship between stage and survival outcomes, it is imperative that the reasons for these rurality inequities in advanced disease be identified and addressed.

Built environment and cardio-metabolic health: systematic review and meta-analysis of longitudinal studies.

Built environment attributes may be related to cardio-metabolic diseases (e.g. type 2 diabetes, heart disease and stroke) and their risk factors, potentially by influencing residents' physical activity. However, existing literature reviews on the built environment and health for the most part focus on obesity as the outcome and rely on cross-sectional studies. This systematic review synthesized current evidence on longitudinal relationships between built environment attributes and cardio-metabolic health outcomes among adults and on the potential mediating role of physical inactivity. By searching eight databases for peer-reviewed journal articles published in the English language between January 2000 and July 2016, the review identified 36 articles. A meta-analysis method, weighted Z-test, was used to quantify the strength of evidence by incorporating the methodological quality of the studies. We found strong evidence for longitudinal relationships of walkability with obesity, type 2 diabetes and hypertension outcomes in the expected direction. There was strong evidence for the impact of urban sprawl on obesity outcomes. The evidence on potential mediation by physical activity was inconclusive. Further longitudinal studies are warranted to examine which specific built environment attributes influence residents' cardio-metabolic health outcomes and how physical inactivity may be involved in these relationships.

Does psychological stress mediate social deprivation in tooth loss?

It is unclear which theoretical dimension of psychological stress affects health status. We hypothesized that both distress and coping mediate the relationship between socio-economic position and tooth loss. Cross-sectional data from 2915 middle-aged adults evaluated retention of < 20 teeth, behaviors, psychological stress, and sociodemographic characteristics. Principal components analysis of the Perceived Stress Scale (PSS) extracted 'distress' (a = 0.85) and 'coping' (a =0.83) factors, consistent with theory. Hierarchical entry of explanatory variables into age- and sex-adjusted logistic regression models estimated odds ratios (OR) and 95% confidence intervals [95% CI] for retention of < 20 teeth. Analysis of the separate contributions of distress and coping revealed a significant main effect of coping (OR = 0.7 [95% CI = 0.7-0.8]), but no effect for distress (OR = 1.0 [95% CI = 0.9-1.1]) or for the interaction of coping and distress. Behavior and psychological stress only modestly attenuated socio-economic inequality in retention of < 20 teeth, providing evidence to support a mediating role of coping.

Gender and age differences in walking for transport and recreation: Are the relationships the same in all neighborhoods?

INTRODUCTION: Walking as regular physical activity (PA) is central to healthy aging, and environments influence walking. Multilevel neighborhood-based studies that only report average (fixed-effect) walking differences for gender and age implicitly assume that neighborhood environments influence the walking behavior of men and women, and younger and older persons, similarly. This study tests this assumption by examining whether gender and age differences in walking for transport (WfT) and walking for recreation (WfR) are similar or different across neighborhoods. METHODS: This paper used data from the HABITAT multilevel study, with 7,866 participants aged 42-68 years in 2009 living in 200 neighborhoods in Brisbane, Australia. Respondents reported minutes spent WfT and WfR in the previous week, categorized as: none (0 mins), low (1-59mins), moderate (60-149mins) and high (≥ 150 mins). Multilevel multinomial logistic models were used to estimate average differences in walking by gender and age, followed by random coefficients to examine neighborhood variation in these individual-level relationships. RESULTS: On average, women were more likely to engage in WfR at moderate and high levels (no gender differences found in WfT); and older persons were less likely to do WfT and more likely to do high levels of WfR. These average (Brisbane-wide) relationships varied significantly across neighborhoods. CONCLUSION: Relationships between gender and walking, and age and walking, are not the same in all neighborhoods, (i.e. the Brisbane average conceals important information) suggesting that neighborhood-level factors differentially influence the walking behaviors of men and women and younger and older persons. Identifying these factors should be a priority for future research.

Homicidal somnambulism: a case report.

A case of a homicide and an attempted homicide during presumed sleepwalking is reported in which somnambulism was the legal defense and led to an acquittal. Other possible explanations including complex partial seizures, dissociative state, rapid eye movement sleep behavior disorder and volitional waking behavior are discussed. The evidence supporting the probability that this act occurred during an episode of somnambulism and sleep-related confusional arousal is reviewed and weighed. This evidence includes personal and family history of somnambulism and related disorders; neurological, psychiatric and psychological assessments; presence of possible precipitating factors; and polysomnographic data.

Socioeconomic inequalities in all-cause and specific-cause mortality in Australia: 1985-1987 and 1995-1997.

BACKGROUND: Socioeconomic inequalities in mortality have been repeatedly observed in Britain, the US, and Europe, and in some countries there is evidence that the differentials are widening. This study describes trends in socioeconomic mortality inequality in Australia for males and females aged 0-14, 15-24 and 25-64 years over the period 1985-1987 to 1995-1997. METHODS: Socioeconomic status (SES) was operationalized using the Index of Relative Socioeconomic Disadvantage, an area-based measure developed by the Australian Bureau of Statistics. Mortality differentials were examined using age-standardized rates, and mortality inequality was assessed using rate ratios, gini coefficients, and a measure of excess mortality. RESULTS: For both periods, and for each sex/age subgroup, death rates were highest in the most disadvantaged areas. The extent and nature of socioeconomic mortality inequality differed for males and females and for each age group: both increases and decreases in mortality inequality were observed, and for some causes, the degree of inequality remained unchanged. If it were possible to reduce death rates among the SES areas to a level equivalent to that of the least disadvantaged area, premature all-cause mortality for males in each age group would be lower by 22%, 28% and 26% respectively, and for females, 35%, 70% and 56%. CONCLUSIONS: The mortality burden in the Australian population attributable to socioeconomic inequality is large, and has profound and far-reaching implications in terms of the unnecessary loss of life, the loss of potentially economically productive members of society, and increased costs for the health care system.

Childhood socioeconomic position and cognitive function in adulthood.

BACKGROUND: Risk of dementia and Alzheimer's disease is higher among adults with limited education, and the less educated perform poorer on cognitive function tests. This study determines whether the socioeconomic environment experienced during childhood has an impact on cognitive functioning in middle age. METHODS: A population-based study of eastern Finnish men (n = 496) aged 58 and 64 for whom there were data on parent's socioeconomic position (SEP), their own education level, and performance on neuropsychological tests. Cognitive function was measured using the Trail Making Test, the Selective Reminding Test, the Verbal Fluency Test, the Visual Reproduction Test, and the Mini Mental State Exam. RESULTS: We found a significant and graded association between parental SEP (combined as an index) and cognitive function both prior to and after adjustment for respondent's education. Those from more disadvantaged backgrounds exhibited the poorest performance. When the separate components of the parental SEP measure were used, father's occupation and mother's education were independently associated with the respondent's score for three and five of the tests, respectively (there was no association with father's education and mother's occupation). After adjustment for the respondent's education, father's occupation was no longer associated with respondent's test score, however, the results were essentially unchanged for mother's education. CONCLUSIONS: Higher SEP during childhood and greater educational attainment are both associated with cognitive function in adulthood, with mothers and fathers each contributing to their offspring's formative cognitive development and later life cognitive ability (albeit in different ways). Improvements in both parental socioeconomic circumstances and the educational attainment of their offspring could possibly enhance cognitive function and decrease risk of dementia later in life.

Income non-reporting: implications for health inequalities research.

OBJECTIVES: To determine whether, in the context of a face to face interview, socioeconomic groups differ in their propensity to provide details about the amount of their personal income, and to discuss the likely consequences of any differences for studies that use income based measures of socioeconomic position. DESIGN AND SETTING: The study used data from the 1995 Australian Health Survey. The sample was selected using a stratified multi-stage area design that covered urban and rural areas across all States and Territories and included non-institutionalised residents of private and non-private dwellings. The response rate was 91.5% for selected dwellings and 97.0% for persons within dwellings. Data were collected using face to face interviews. Income response, the dependent measure, was binary coded (0 if income was reported and 1 for refusals, "don't knows" and insufficient information). Socioeconomic position was measured using employment status, occupation, education and main income source. The socioeconomic characteristics of income non-reporters were initially examined using sex specific age adjusted proportions with 95% confidence intervals. Multivariate analysis was performed using logistic regression. PARTICIPANTS: Persons aged 15-64 (n = 33,434) who were reportedly in receipt of an income from one or more sources during the data collection reference period. RESULTS: The overall rate of income non-response was 9.8%. Propensity to not report income increased with age (15-29 years 5.8%, 30-49 10.6%, 50-64 13.8%). No gender differences were found (men 10.2%, women 9.3%). Income non-response was not strongly nor consistently related to education or occupation for men, although there was a suggested association among these variables for women, with highly educated women and those in professional occupations being less likely to report their income. Strong associations were evident between income non-response, labour force status and main income source. Rates were highest among the employed and those in receipt of an income from their own business or partnership, and lowest among the unemployed and those in receipt of a government pension or benefit (which excluded the unemployed). CONCLUSION: Given that differences in income non-reporting were small to moderate across levels of the education and occupation variables, and that propensity to not report income was greater among higher socioeconomic groups, estimates of the relation between income and health are unlikely to be affected by socioeconomic variability in income non-response. Probability estimates from a logistic regression suggested that higher rates of income non-reporting among employed persons who received their income from a business or partnership were not attributable to socio-economic factors. Rather, it is proposed that these higher rates were attributable to recall effects, or concerns about having one's income information disclosed to taxation authorities. Future studies need to replicate this analysis to determine whether the results can be inferred to other survey and data collection contexts. The analysis should also be extended to include an examination of the relation between socio-economic position and accuracy of income reporting. Little is known about this issue, yet it represents a potential source of bias that may have important implications for studies that investigate the association between income and health.

A multilevel analysis of socioeconomic (small area) differences in household food purchasing behaviour.

STUDY OBJECTIVE: To examine the association between area and individual level socioeconomic status (SES) and food purchasing behaviour. DESIGN: The sample comprised 1000 households and 50 small areas. Data were collected by face to face interview (66.4% response rate). SES was measured using a composite area index of disadvantage (mean 1026.8, SD = 95.2) and household income. Purchasing behaviour was scored as continuous indices ranging from 0 to 100 for three food types: fruits (mean 50.5, SD = 17.8), vegetables (61.8, 15.2), and grocery items (51.4, 17.6), with higher scores indicating purchasing patterns more consistent with dietary guideline recommendations. SETTING: Brisbane, Australia, 2000. PARTICIPANTS: Persons responsible for their household's food purchasing. MAIN RESULTS: Controlling for age, gender, and household income, a two standard deviation increase on the area SES measure was associated with a 2.01 unit increase on the fruit purchasing index (95% CI -0.49 to 4.50). The corresponding associations for vegetables and grocery foods were 0.60 (-1.36 to 2.56) and 0.94 (-1.35 to 3.23). Before controlling for household income, significant area level differences were found for each food, suggesting that clustering of household income within areas (a composition effect) accounted for the purchasing variability between them. CONCLUSIONS: Living in a socioeconomically advantaged area was associated with a tendency to purchase healthier food, however, the association was small in magnitude and the 95% CI for area SES included the null. Although urban areas in Brisbane are differentiated on the basis of their socioeconomic characteristics, it seems unlikely that where you live shapes your procurement of food over and above your personal characteristics.

Socioeconomic status and infant mortality in Australia: a national study of small urban areas, 1985-89.

This study uses small-area data for the period 1985-89 to examine the relationship between socioeconomic status and infant mortality in each of the mainland State capital cities of Australia. An unweighted OLS regression analysis based on 195 Statistical Local Areas (SLAs) that recorded five or more deaths over the reference period shows that standardised infant mortality ratios were significantly higher in areas with greater concentrations of low income families. This relationship was independent of the effects of low birthweight, Aboriginality, ethnicity and variability between each of the capital cities. To test for the robustness of this result a sensitivity analysis was undertaken. This involved (a) performing a Principal Components Analysis on a wide range of sociodemographic variables to derive factor scales that were subsequently included in a regression analysis, (b) using weighted least-squares regression and a Poisson generalised linear model and (c) including in the analysis all SLAs irrespective of the number of infant deaths. The sensitivity analysis supported the results of this study, thus validating the observed association between the socioeconomic characteristics of urban areas and their rate of infant mortality. Despite marked reductions in overall rates of infant mortality over the last century in Australia. socioeconomic disparities were still evident during the mid-to-late 1980s. Whether and to what extent this situation persisted during the early-to-mid 1990s will be known in the near future when the next collection of area-based data are publicly released. The results of this study, therefore, represent an important baseline against which more contemporary national trends can be monitored.

Structural, material and economic influences on the food-purchasing choices of socioeconomic groups.

Australian and overseas studies have found that respondents in low socioeconomic groups are least likely to purchase food that accords with recommendations in dietary guidelines. British and United States researchers have proposed that this consistently observed association is partly due to structural, material and economic factors that differentially affect socioeconomic groups. This study tested that proposition. Specifically, this study examined the notion that socioeconomic variability in food-purchasing choices are in part a function of the availability, accessibility and affordability of food recommended by dietary guidelines. Data collected from socioeconomic groups in the general community, and information provided by welfare recipients living in low-income areas of Brisbane and Logan city provided little support for this notion. Although significant differences were found between socioeconomic groups in terms of their food-purchasing choices, most respondents from all socioeconomic groups shopped at large supermarkets where recommended food was readily available, few reported difficulties obtaining access to these facilities, and the price difference between recommended and regular foods was, in most cases, small or nonexistent. This evidence leaves largely unanswered the question of why socioeconomic groups differ in their food-purchasing behaviours.

Psychological distress among female sex workers.

The prevalence and correlates of psychological distress were examined in a sample of 171 female sex workers in Queensland. It was found that 28 per cent were above the GHQ-28 threshold for mild psychiatric morbidity, a rate that is not appreciably different from that of women in the general community. The sample included only eight street sex workers, all of whom reported significant distress. Logistic regression analyses showed that a history of injecting drug use, an early age at leaving home and wanting to leave the sex industry were independent predictors of poor mental health. Distressed sex workers reported fewer sexual health examinations and less consistent condom use with their clients than those who were not distressed.

Compliance with the Australian Dietary Guidelines in the early 1990's: have population-based health promotion programs been effective?

In an attempt to change the dietary behaviours of the population (and reduce the incidence of diet-related disease), governments and health authorities in Australia have developed Dietary Guidelines. These guidelines have been communicated to the wider society through a range of channels, such as health promotion programs and education campaigns. Studies conducted during the 1980's suggested that up to 30 percent of the population were engaging in food-related behaviours consistent with dietary guideline recommendations, although the extent of compliance varied by population sub-group (eg women and high socioeconomic groups were more likely to comply). More recent research has suggested that compliance with some of the guideline recommendations has increased, although disparities between population sub-groups remain. The aim of this present study is to determine the extent of compliance with the Australian Dietary Guidelines in the early 1990's, and thereby (indirectly) assess the degree to which health promotion efforts have affected the dietary behaviours of the population. The study is based on a representative sample (n = 403, 80.6% response rate) of Brisbane city. Overall, it was estimated that between 40 and 60 percent of the population were regularly engaging in food behaviours consistent with guideline recommendations. This rate of compliance, however, differed markedly depending on the type of behaviour being examined, and it varied significantly (albeit modestly) across different population sub-groups. It is concluded that health promotion has influenced the population's dietary behaviours, although traditional beliefs and attitudes also inform our food behaviours to a considerable extent.

Making a difference to the socioeconomic determinants of health: policy responses and intervention options.

APACPH has previously highlighted the profound effect of global economic change on increasing health disparities in most countries in the Asian Pacific Region of the world, with those citizens who are most disadvantaged and vulnerable, suffering most. This presentation identifies two key issues that should underpin efforts to reduce socioeconomic health disparities: (1) the current evidence base on policies and interventions successful in reducing inequalities; and, (2) how to implement such strategies. Actions to reduce such disparities should ideally include: (1) changes in macro-level social and economic policies, (2) improving living and working conditions, (3) strengthening communities for health, (4) influencing behavioural risk factors, (5) strengthening individuals and their social networks, and (5) an improved response from the health care system and associated services. Other than a few notable exceptions, few countries have developed a coordinated and integrated approach to addressing health inequalities. However, previously successful public health interventions represent a good starting point. Health professionals have an important role to play in not only recognising that the determinants of health are rooted in the economic, social and cultural fabric of our society, but in supporting and advocating strategies and approaches that lie upstream from the health care system.

Associations between area-level disadvantage and DMFT among a birth cohort of Indigenous Australians.

BACKGROUND: Individual-level factors influence DMFT, but little is known about the influence of community environment. This study examined associations between community-level influences and DMFT among a birth cohort of Indigenous Australians aged 16-20 years. METHODS: Data were collected as part of Wave 3 of the Aboriginal Birth Cohort study. Fifteen community areas were established and the sample comprised 442 individuals. The outcome variable was mean DMFT with explanatory variables including diet and community disadvantage (access to services, infrastructure and communications). Data were analysed using multilevel regression modelling. RESULTS: In a null model, 13.8% of the total variance in mean DMFT was between community areas, which increased to 14.3% after adjusting for gender, age and diet. Addition of the community disadvantage variable decreased the variance between areas by 4.8%, indicating that community disadvantage explained one-third of the area-level variance. Residents of under-resourced communities had significantly higher mean DMFT (ß = 3.86, 95% CI 0.02, 7.70) after adjusting for gender, age and diet. CONCLUSIONS: Living in under-resourced communities was associated with greater DMFT among this disadvantaged population, indicating that policies aiming to reduce oral health-related inequalities among vulnerable groups may benefit from taking into account factors external to individual-level influences.

Neighborhood disadvantage, individual-level socioeconomic position, and self-reported chronic arthritis: a cross-sectional multilevel study.

OBJECTIVE: To examine the association between individual- and neighborhood-level disadvantage and self-reported arthritis. METHODS: We used data from a population-based cross-sectional study conducted in 2007 among 10,757 men and women ages 40-65 years, selected from 200 neighborhoods in Brisbane, Queensland, Australia using a stratified 2-stage cluster design. Data were collected using a mail survey (68.5% response). Neighborhood disadvantage was measured using a census-based composite index, and individual disadvantage was measured using self-reported education, household income, and occupation. Arthritis was indicated by self-report. Data were analyzed using multilevel modeling. RESULTS: The overall rate of self-reported arthritis was 23% (95% confidence interval [95% CI] 22-24). After adjustment for sociodemographic factors, arthritis prevalence was greatest for women (odds ratio [OR] 1.5, 95% CI 1.4-1.7) and in those ages 60-65 years (OR 4.4, 95% CI 3.7-5.2), those with a diploma/associate diploma (OR 1.3, 95% CI 1.1-1.6), those who were permanently unable to work (OR 4.0, 95% CI 3.1-5.3), and those with a household income <$25,999 (OR 2.1, 95% CI 1.7-2.6). Independent of individual-level factors, residents of the most disadvantaged neighborhoods were 42% (OR 1.4, 95% CI 1.2-1.7) more likely than those in the least disadvantaged neighborhoods to self-report arthritis. Cross-level interactions between neighborhood disadvantage and education, occupation, and household income were not significant. CONCLUSION: Arthritis prevalence is greater in more socially disadvantaged neighborhoods. These are the first multilevel data to examine the relationship between individual- and neighborhood-level disadvantage upon arthritis and have important implications for policy, health promotion, and other intervention strategies designed to reduce the rates of arthritis, indicating that intervention efforts may need to focus on both people and places.

Socioeconomic differences in takeaway food consumption and their contribution to inequalities in dietary intakes.

BACKGROUND: Takeaway consumption has been increasing and may contribute to socioeconomic inequalities in overweight/obesity and chronic disease. This study examined socioeconomic differences in takeaway consumption patterns and their contributions to dietary intake inequalities. METHOD: Cross-sectional dietary intake data from adults aged between 25 and 64 years from the Australian National Nutrition Survey (n = 7319, 61% response rate). Twenty-four-hour dietary recalls ascertained intakes of takeaway food, nutrients and fruit and vegetables. Education was used as a socioeconomic indicator. Data were analysed using logistic regression and general linear models. RESULTS: Thirty-two per cent (n = 2327) consumed takeaway foods in the 24-hour period. Lower educated participants were less likely than their higher educated counterparts to have consumed total takeaway foods (OR 0.64; 95% CI 0.52 to 0.80). Of those consuming takeaway foods, the lowest educated group was more likely to have consumed "less healthy" takeaway choices (OR 2.55; 95% CI 1.73 to 3.77), and less likely to have consumed "healthy" choices (OR 0.52; 95% CI 0.36 to 0.75). Takeaway foods made a greater contribution to energy, total fat, saturated fat and fibre intakes among lower than among higher educated groups. Lower likelihood of fruit and vegetable intakes were observed among "less healthy" takeaway consumers, whereas a greater likelihood of their consumption was found among "healthy" takeaway consumers. CONCLUSIONS: Total and the types of takeaway foods consumed may contribute to socioeconomic inequalities in intakes of energy, total and saturated fats. However, takeaway consumption is unlikely to be a factor contributing to the lower fruit and vegetable intakes among socioeconomically disadvantaged groups.

Affluent neighborhoods reduce excess risk of tooth loss among the poor.

The effect of neighborhood on health may vary according to the characteristics of the residents. We tested the hypothesis that, in affluent neighborhoods, low-income adults retain more teeth than their income-equivalent peers in poor neighborhoods. In 2003, the Adelaide Small Area Dental Study collected sociodemographic and tooth retention information from 2860 adults in 60 neighborhoods. Neighborhood socio-economic position was a census-based composite measure. Using multilevel modelling, we fitted a series of two-level random intercept variance component models. Findings revealed significant main effects for individual and neighborhood predictors and a significant interaction between neighborhood disadvantage and low income. In affluent areas, disparities in tooth retention were negligible, but in poor neighborhoods, substantial variation in tooth retention between individuals was found based on their level of income. Low-income adults appeared to benefit from living in affluent areas, while wealthier adults living in poor neighborhoods did not lose their oral health advantage.

Area variation in recreational cycling in Melbourne: a compositional or contextual effect?

OBJECTIVE: To examine whether compositional and/or contextual area characteristics are associated with area socioeconomic inequalities and between-area differences in recreational cycling. SETTING: The city of Melbourne, Australia. PARTICIPANTS: 2349 men and women residing in 50 areas (58.7% response rate). MAIN OUTCOME MEASURE: Cycling for recreational purposes (at least once a month vs never). DESIGN: In a cross-sectional survey participants reported their frequency of recreational cycling. Objective area characteristics were collected for their residential area by environmental audits or calculated with Geographic Information Systems software. Multilevel logistic regression models were performed to examine associations between recreational cycling, area socioeconomic level, compositional characteristics (age, sex, education, occupation) and area characteristics (design, safety, destinations or aesthetics). RESULTS: After adjustment for compositional characteristics, residents of deprived areas were less likely to cycle for recreation (OR 0.66; 95% CI 0.43 to 1.00), and significant between-area differences in recreational cycling were found (median odds ratio 1.48 (95% credibility interval 1.24 to 1.78). Aesthetic characteristics tended to be worse in deprived areas and were the only group of area characteristics that explained some of the area deprivation differences. Safety characteristics explained the largest proportion of between-area variation in recreational cycling. CONCLUSION: Creating supportive environments with respect to safety and aesthetic area characteristics may decrease between-area differences and area deprivation inequalities in recreational cycling, respectively.

Socioeconomic inequalities in food purchasing: the contribution of respondent-perceived and actual (objectively measured) price and availability of foods.

BACKGROUND: Research has shown that lower socioeconomic groups purchase foods that are less consistent with dietary recommendations. The price and availability of foods are thought to be important mediating factors between socioeconomic position and food purchasing. OBJECTIVES: We examined the relative contribution of the perceived and objectively measured price and availability of recommended foods to household income differences in food purchasing. METHODS: Using a face-to-face interview, a random sample of Brisbane residents (n=812) were asked about their food purchasing choices in 2000. They were also asked about their perceptions of the price and availability of 'recommended' foods (i.e. choices lower in fat, saturated fat, sugar, salt or higher in fibre) in the supermarkets where they usually shopped. Audits measuring the actual availability and price of identical foods were conducted in the same supermarkets. RESULTS: Lower socioeconomic groups were less likely to make food purchasing choices consistent with dietary guideline recommendations. Objective availability and price differences were not associated with purchasing choices, nor did they contribute to socioeconomic inequalities in food purchasing choices. Perceived availability and price differences were associated with the purchase of recommended foods. Perceived availability made a small contribution to inequalities in food purchasing, however perceived price differences did not. CONCLUSION: Socioeconomic inequalities in food purchasing are not mediated by differential availability of recommended foods and differences in price between recommended and regular foods in supermarkets, or by perceptions of their relative price. However, differential perceptions of the availability of recommended foods may play a small role in food purchasing inequalities.