Experience of South and Southeast Asian minority women in Hong Kong during COVID-19 pandemic: a qualitative study.

BACKGROUND: Hong Kong has a relatively low incidence rate of COVID-19 across the globe. Nevertheless, ethnic minorities in Hong Kong, especially South Asians (SAs) and Southeast Asians (SEAs), face numerous physical, mental, social, economic, cultural and religious challenges during the pandemic. This study explores the experiences of SA and SEA women in a predominantly Chinese metropolitan city. METHODS: Ten SA and SEA women were recruited and face-to-face interviews were conducted. Questions about participants' daily life experience, physical and mental health conditions, economic situation and social interaction amid COVID-19 pandemic were asked to assess the impact of COVID-19. RESULTS: SAs and SEAs have a distinctive family culture, and women experienced significant physical and mental impact of COVID-19 due to their unique gender role in the family. In addition to taking care of their family in Hong Kong, SA and SEA women also had to mentally and financially support family members residing in their home countries. Access to COVID-related information was restricted due to language barrier. Public health measures including social distancing imposed extra burden on ethnic minorities with limited social and religious support. CONCLUSIONS: Even when COVID-19 incidence rate is relatively low in Hong Kong, the pandemic made life even more challenging for SAs and SEAs, which is a community already struggling with language barriers, financial woes, and discrimination. This in turn could have led to greater health inequalities. Government and civil organizations should take the social determinants of health inequalities into account when implementing COVID-19-related public health policies and strategies.

Action on the social determinants for advancing health equity in the time of COVID-19: perspectives of actors engaged in a WHO Special Initiative.

Since the 2008 publication of the reports of the Commission on Social Determinants of Health and its nine knowledge networks, substantial research has been undertaken to document and describe health inequities. The COVID-19 pandemic has underscored the need for a deeper understanding of, and broader action on, the social determinants of health. Building on this unique and critical opportunity, the World Health Organization is steering a multi-country Initiative to reduce health inequities through an action-learning process in 'Pathfinder' countries. The Initiative aims to develop replicable and reliable models and practices that can be adopted by WHO offices and UN staff to address the social determinants of health to advance health equity. This paper provides an overview of the Initiative by describing its broad theory of change and work undertaken in three regions and six Pathfinder countries in its first year-and-a-half. Participants engaged in the Initiative describe results of early country dialogues and promising entry points for implementation that involve model, network and capacity building. The insights communicated through this note from the field will be of interest for others aiming to advance health equity through taking action on the social determinants of health, in particular as regards structural determinants.

The mediating role of individual-level social capital among worries, mental health and subjective well-being among adults in Hong Kong during the COVID-19 pandemic.

The COVID-19 pandemic has substantially induced worries and affected individual mental health and subjective well-being. Nonetheless, a high level of social capital could potentially protect individuals who suffer from mental health problems and thus promote their subjective well-being, especially under the social distancing policies during the pandemic. To this end, based on a random sample of 1053 Hong Kong adults, structural equation modeling was applied to study the path relationships between the worries of COVID-19, social capital, mental health problems, and subjective well-being. The study found that worries during the pandemic were associated with mental health and subjective well-being, through social capital as a mediator. Moreover, social capital exhibited a stronger influence on mental health and subjective well-being in the economically inactive group than in the economically active group. This study highlights the important role of social capital during the COVID-19 pandemic. While Hong Kong's COVID-19 response has primarily focused on disease prevention, it must be noted that social services and mutual-help activities are also crucial for people to withstand the crisis.

Social determinants of mental health in Italy: the role of education in the comparison of migrant and Italian residents.

Mental health is impacted by social, economic, and environmental factors, the Social Determinants of Health (SDH). Migrants experiencing precarious living and working conditions may be more at risk of poor mental health than the majority population.This paper aims to evaluate the relationship of educational attainment and other SDH with depressive symptoms among the resident population, including Italians and migrants.This study examined the respondents to the Italian "Progressi delle Aziende Sanitarie per la Salute in Italia" (PASSI) surveillance system, 2014-18. The sample of 144.055 respondents is composed of the resident working adults aged 25-69 with Italian citizenship (n = 136.514) and foreign citizenship (n = 7.491).Findings show that among Italians high level of education appears to be a protective factor for mental health, in accordance with the international evidence (adjPR: tertiary education 0,74 p-value = 0.000). However, among immigrants high level of education is associated with the presence of depressive symptoms (adjPR: tertiary education: 1.61 p-value = 0.006), particularly for men (adjPR: tertiary education: 2.40 p-value = 0.006). The longer the length of stay in Italy for immigrants the higher the risk of depressive symptoms: adjPR for 10+ years: 2.23 p-value = 0.005.The data show that high education could represent a risk factor for mental health of immigrants. Moreover, among migrants there are some significant mental health inequities between male and female related to the duration of stay in Italy, economic activity and educational level.Considering that health is related to the nature of society as well as to access to technical solutions, multicultural societies require culturally oriented interventions for tackling health inequities. This means developing evidence-based policies in order to tackle health inequalities in the population as a whole, including culturally oriented measures in the larger framework of developing diversity sensitive services.

Socioeconomic Patterns of COVID-19 Clusters in Low-Incidence City, Hong Kong.

Although coronavirus disease (COVID-19) outbreaks have been relatively well controlled in Hong Kong, containment remains challenging among socioeconomically disadvantaged persons. They are at higher risk for widespread COVID-19 transmission through sizable clustering, probably because of exposure to social settings in which existing mitigation policies had differential socioeconomic effects.

Family Health Strategy, Primary Health Care, and Social Inequalities in Mortality Among Older Adults in Bagé, Southern Brazil.

Objectives. To investigate the role of the Family Health Strategy (FHS) in reducing social inequalities in mortality over a 9-year follow-up period.Methods. We carried out a population-based cohort study of individuals aged 60 years and older from the city of Bagé, Brazil. Of 1593 participants at baseline (2008), 1314 (82.5%) were included in this 9-year follow-up (2017). We assessed type of primary health care (PHC) coverage and other variables at baseline. In 2017, we ascertained 579 deaths through mortality registers. Hazard ratios and their 95% confidence intervals modeled time to death estimated by Cox regression. We also tested the effect modification between PHC and wealth.Results. The FHS had a protective effect on mortality among individuals aged 60 to 64 years, a result not found among those not covered by the FHS. Interaction analysis showed that the FHS modified the effect of wealth on mortality. The FHS protected the poorest from all-cause mortality (hazard ratio [HR] = 0.59; 95% confidence interval [CI] = 0.36, 0.96) and avoidable mortality (HR = 0.46; 95% CI = 0.25, 0.85).Conclusions. FHS coverage reduced social inequalities in mortality among older adults. Our findings highlight the need to guarantee universal health coverage in Brazil by expanding and strengthening the FHS to promote health equity.

[Leadership, social determinants of health and health equity: the case of Costa Rica]. / Liderazgo, determinantes sociales de la salud y equidad en la salud: el caso de Costa Rica.

Costa Rica has long been a country of special interest in the Americas and in global health because of its good health. The United Nations Development Programme ranks countries according to their level of human development based on life expectancy, education and national income. Although Costa Rica is ranked at 63 and classified as 'High', in terms of health it belongs in the 'Very High' group. In 2018 mean life expectancy for the 'Very High' countries was 79.5, while in Costa Rica it was 80. In 2018, under five mortality was 8.8/1000 live births, lower than countries ranked in the 'Very High' human development group. Expected years of schooling in Costa Rica is 15.4, closer to the average, 16.4 years, of the 'Very High' human development group than the average of the 'High' group. The country is much healthier than would be predicted by its national income; rather, other features of society's development are likely to have played a key role in the development of good health. These include (i) the decision to cease investment in national defence, which freed up money to invest in health, education and the welfare of the population; (ii) the decision to create a universal health system financed by the State, employers and workers in the 1940s; and (iii) the educational system, that generated opportunities to lift important sectors of the population out of poverty, allowing them to have basic sanitary conditions that increase their possibilities to live longer and in better conditions. Despite these advances, inequalities in terms of income and social conditions persist, presenting challenges in the field of health, particularly for lower-income populations and those of African and indigenous descent. These inequalities must be addressed using decisions based on scientific evidence, a greater use of disaggregated data to reveal progress in addressing these inequalities, and with a broader articulation of the health sector with policies that act on the social determinants of health.

[Theoretical and practical challenges of proportionate universalism: a reviewAnálise dos desafios teóricos e práticos de universalismo proporcional]. / Desafíos teóricos y prácticos del universalismo proporcional: una revisión.

OBJECTIVE: In 2010, the principle of proportionate universalism (PU) has been proposed as a solution to reduce health inequalities. It had a great resonance but does not seem to have been widely applied and no guidelines exist on how to implement it. The two specific objectives of this scoping review were: (1) to describe the theoretical context in which PU was established, (2) to describe how researchers apply PU and related methodological issues. METHODS: We searched for all articles published until 6th of February 2020, mentioning "Proportionate Universalism" or its synonyms "Targeted universalism" OR "Progressive Universalism" as a topic in all Web of Science databases. RESULTS: This review of 55 articles allowed us a global vision around the question of PU regarding its theoretical foundations and practical implementation. PU principle is rooted in the social theories of universalism and targeting. It proposes to link these two aspects in order to achieve an effective reduction of health inequalities. Regarding practical implementation, PU interventions were rare and led to different interpretations. There are still many methodological and ethical challenges regarding conception and evaluation of PU interventions, including how to apply proportionality, and identification of needs. CONCLUSION: This review mapped available scientific literature on PU and its related concepts. PU principle originates from social theories. As highlighted by authors who implemented PU interventions, application raises many challenges from design to evaluation. Analysis of PU applications provided in this review answered to some of them but remaining methodological challenges could be addressed in further research.

OBJETIVO: Em 2010, o princípio do Universalismo Proporcional (UP) foi proposto como uma solução para reduzir as desigualdades na saúde. Houve uma grande receptividade, mas o princípio parece não ter sido amplamente aplicado e não há diretrizes sobre como implementá-lo. Os dois objetivos específicos desta análise de escopo foram: (1) descrever o contexto teórico no qual o UP foi estabelecido e (2) descrever como os pesquisadores aplicam o UP e questões metodológicas correlatas. MÉTODOS: Buscamos em todas as bases de dados científicas da Web todos os artigos publicados até 6 de fevereiro de 2020 que mencionavam, como tema, o "Universalismo Proporcional" ou seus sinônimos "Universalismo Visado" ou "Universalismo Progressivo". RESULTADOS: Essa análise de 55 artigos nos permitiu ter uma visão global relacionada com o UP, suas bases teóricas e sua implementação na prática. Os princípios do UP têm suas raízes nas teorias sociais do universalismo e na definição de metas. A proposta é vincular esses dois aspectos para atingir uma redução efetiva das desigualdades em saúde. Com relação ao aspecto prático da implementação, as intervenções de UP foram raras e levaram a diferentes interpretações. Ainda há muitos obstáculos metodológicos e éticos relativos ao conceito e à avaliação das intervenções de UP, inclusive sobre como aplicar o aspecto da proporcionalidade e a identificação das necessidades. CONCLUSÕES: Esta análise fez um mapeamento da literatura científica disponível sobre UP e seus conceitos correlatos. O princípio por trás do UP tem suas origens nas teorias sociais. Como destacam os autores que implementaram as intervenções de UP, sua aplicação produz muitas dificuldades, da elaboração à avaliação. A análise das aplicações de UP fornecidas nesta pesquisa permitiu a obtenção de algumas respostas. No entanto, pesquisas futuras poderiam abordar as dificuldades metodológicas remanescentes.

Patterning of educational attainment across inflammatory markers: Findings from a multi-cohort study.

BACKGROUND: Evidence suggests that the inflammatory reaction, an adaptive response triggered by a variety of harmful stimuli and conditions involved in the risk and development of many chronic diseases, is a potential pathway through which the socioeconomic environment is biologically embedded. Difficulty in interpreting the role of the inflammatory system in the embodiment dynamic arises because of heterogeneity across studies that use a limited but varied number of inflammatory markers. There is no consensus in the literature as to which inflammatory markers beyond the C-reactive protein and to a lesser extent interleukin 6 are related to the social environment. Accordingly, we aimed to investigate the association between educational attainment, and several markers of inflammation - C-reactive protein, fibrinogen, interleukin 6, interleukin 1ß and tumor necrosis factor α- in 6 European cohort studies. METHODS: Up to 17,470 participants from six European cohort studies with data on educational attainment, health behaviors and lifestyle factors, and at least two different inflammatory markers. Four sub-datasets were drawn with varying numbers of participants to allow pairwise comparison of the social patterning of C-reactive protein and any other inflammatory markers. To evaluate within each sub-dataset the importance of the context and cohort specificities, linear regression-based analyses were performed separately for each cohort and combined in a random effect meta-analysis to determine the relationship between educational attainment and inflammation. RESULTS: We found that the magnitude of the relationship between educational attainment and five inflammatory biomarkers (C-reactive protein, fibrinogen, interleukin 6 and 1ß and tumor necrosis factor α) was variable. By far the most socially patterned biomarker was C-reactive protein, followed by fibrinogen and to lesser extent interleukin 6, where a low educational attainment was associated with higher inflammation even after adjusting for health behaviours and body mass index. No association was found with interleukin 1ß and tumor necrosis factor α. CONCLUSIONS: Our study suggests different educational patterning of inflammatory biomarkers. Further large-scale research is needed to explore social differences in the inflammatory cascade in greater detail and the extent to which these differences contribute to social inequalities in health.

Theoretical and practical challenges of proportionate universalism: a review.

OBJECTIVE: In 2010, the principle of proportionate universalism (PU) has been proposed as a solution to reduce health inequalities. It had a great resonance but does not seem to have been widely applied and no guidelines exist on how to implement it.The two specific objectives of this scoping review were: (1) to describe the theoretical context in which PU was established, (2) to describe how researchers apply PU and related methodological issues. METHODS: We searched for all articles published until 6th of February 2020, mentioning "Proportionate Universalism" or its synonyms "Targeted universalism" OR "Progressive Universalism" as a topic in all Web of Science databases. RESULTS: This review of 55 articles allowed us a global vision around the question of PU regarding its theoretical foundations and practical implementation. PU principle is rooted in the social theories of universalism and targeting. It proposes to link these two aspects in order to achieve an effective reduction of health inequalities. Regarding practical implementation, PU interventions were rare and led to different interpretations. There are still many methodological and ethical challenges regarding conception and evaluation of PU interventions, including how to apply proportionality, and identification of needs. CONCLUSION: This review mapped available scientific literature on PU and its related concepts. PU principle originates from social theories. As highlighted by authors who implemented PU interventions, application raises many challenges from design to evaluation. Analysis of PU applications provided in this review answered to some of them but remaining methodological challenges could be addressed in further research.

OBJETIVO: En 2010 se propuso el principio del universalismo proporcional como solución para reducir las desigualdades en materia de salud. Aunque tuvo una gran resonancia, no parece haber sido aplicado ampliamente y no existen directrices sobre cómo aplicarlo. Los dos objetivos específicos de esta revisión sistemática exploratoria fueron: 1) describir el contexto teórico en el que se estableció el universalismo proporcional, y 2) describir cómo los investigadores aplican el universalismo proporcional y las cuestiones metodológicas relacionadas. MÉTODOS: Se buscó en todas las bases de datos de la Web of Science los artículos publicados hasta el 6 de febrero de 2020 que tuvieran como tema "universalismo proporcional" o sus sinónimos "universalismo dirigido" o "universalismo progresivo". RESULTADOS: Esta revisión de 55 artículos permitió tener una visión global del universalismo proporcional en cuanto a sus fundamentos teóricos y su aplicación práctica. El principio del universalismo proporcional se basa en las teorías sociales del universalismo y el direccionamiento, y propone vincular estos dos aspectos para lograr una reducción efectiva de las desigualdades en materia de salud. Respecto de su aplicación práctica, las intervenciones basadas en este principio son poco frecuentes y dan lugar a diferentes interpretaciones. Todavía existen muchos desafíos metodológicos y éticos en relación con la concepción y la evaluación de las intervenciones relacionadas con el universalismo proporcional, incluida la forma de aplicar la proporcionalidad y la identificación de las necesidades. CONCLUSIÓN: En esta revisión se llevó a cabo un mapeo de la literatura científica disponible sobre el universalismo proporcional y sus conceptos relacionados. Este principio se basa en teorías sociales. Tal como lo destacaron autores que implementaron intervenciones de universalismo proporcional, su aplicación plantea muchos desafíos, desde el diseño hasta la evaluación. El análisis de las aplicaciones del universalismo proporcional presentado en esta revisión respondió a algunos de ellos, pero los desafíos metodológicos restantes requieren ser abordados en futuras investigaciones.

Risk thresholds for alcohol consumption: combined analysis of individual-participant data for 599 912 current drinkers in 83 prospective studies.

BACKGROUND: Low-risk limits recommended for alcohol consumption vary substantially across different national guidelines. To define thresholds associated with lowest risk for all-cause mortality and cardiovascular disease, we studied individual-participant data from 599 912 current drinkers without previous cardiovascular disease. METHODS: We did a combined analysis of individual-participant data from three large-scale data sources in 19 high-income countries (the Emerging Risk Factors Collaboration, EPIC-CVD, and the UK Biobank). We characterised dose-response associations and calculated hazard ratios (HRs) per 100 g per week of alcohol (12·5 units per week) across 83 prospective studies, adjusting at least for study or centre, age, sex, smoking, and diabetes. To be eligible for the analysis, participants had to have information recorded about their alcohol consumption amount and status (ie, non-drinker vs current drinker), plus age, sex, history of diabetes and smoking status, at least 1 year of follow-up after baseline, and no baseline history of cardiovascular disease. The main analyses focused on current drinkers, whose baseline alcohol consumption was categorised into eight predefined groups according to the amount in grams consumed per week. We assessed alcohol consumption in relation to all-cause mortality, total cardiovascular disease, and several cardiovascular disease subtypes. We corrected HRs for estimated long-term variability in alcohol consumption using 152 640 serial alcohol assessments obtained some years apart (median interval 5·6 years [5th-95th percentile 1·04-13·5]) from 71 011 participants from 37 studies. FINDINGS: In the 599 912 current drinkers included in the analysis, we recorded 40 310 deaths and 39 018 incident cardiovascular disease events during 5·4 million person-years of follow-up. For all-cause mortality, we recorded a positive and curvilinear association with the level of alcohol consumption, with the minimum mortality risk around or below 100 g per week. Alcohol consumption was roughly linearly associated with a higher risk of stroke (HR per 100 g per week higher consumption 1·14, 95% CI, 1·10-1·17), coronary disease excluding myocardial infarction (1·06, 1·00-1·11), heart failure (1·09, 1·03-1·15), fatal hypertensive disease (1·24, 1·15-1·33); and fatal aortic aneurysm (1·15, 1·03-1·28). By contrast, increased alcohol consumption was log-linearly associated with a lower risk of myocardial infarction (HR 0·94, 0·91-0·97). In comparison to those who reported drinking >0-≤100 g per week, those who reported drinking >100-≤200 g per week, >200-≤350 g per week, or >350 g per week had lower life expectancy at age 40 years of approximately 6 months, 1-2 years, or 4-5 years, respectively. INTERPRETATION: In current drinkers of alcohol in high-income countries, the threshold for lowest risk of all-cause mortality was about 100 g/week. For cardiovascular disease subtypes other than myocardial infarction, there were no clear risk thresholds below which lower alcohol consumption stopped being associated with lower disease risk. These data support limits for alcohol consumption that are lower than those recommended in most current guidelines. FUNDING: UK Medical Research Council, British Heart Foundation, National Institute for Health Research, European Union Framework 7, and European Research Council.

To what extent can the activities of the South Australian Health in All Policies initiative be linked to population health outcomes using a program theory-based evaluation?

BACKGROUND: This paper reports on a five-year study using a theory-based program logic evaluation, and supporting survey and interview data to examine the extent to which the activites of the South Australian Health in All Policies initiative can be linked to population health outcomes. METHODS: Mixed-methods data were collected between 2012 and 2016 in South Australia (144 semi-structured key informant interviews; two electronic surveys of public servants in 2013 (n = 435) and 2015 (n = 483); analysis of state government policy documents; and construction of a program logic model to shape assessment of the feasibility of attribution to population health outcomes). RESULTS: Multiple actions on social determinants of health in a range of state government sectors were reported and most could be linked through a program logic model to making some contribution to future population health outcomes. Context strongly influences implementation; not all initiatives will be successful and experimentation is vital. Successful initiatives included HiAP influencing the urban planning department to be more concerned with the health impacts of planning decisions, and encouraging the environment department to be concerned with the health impacts of its work. CONCLUSIONS: The theory-based program logic suggests that SA HiAP facilitated improved population health through working with multiple government departments. Public servants came to appreciate how their sectors impact on health. Program logic is a mechanism to evaluate complex public health interventions in a way that takes account of political and economic contexts. SA HiAP was mainly successful in avoiding lifestyle drift in strategy. The initiative encouraged a range of state government departments to tackle conditions of daily living. The broader underpinning factors dictating the distribution of power, money and resources were not addressed by HiAP. This reflects HiAP's use of a consensus model which was driven by (rather than drove) state priorities and sought 'win-win' strategies.

Education and mortality in three Eastern European populations: findings from the PrivMort retrospective cohort study.

BACKGROUND: The aim of the study is 2-fold. Firstly, it attempts to investigate the potential impact of major political and economic changes on inequalities in all-cause mortality among men and women with different levels of education in three Eastern European countries. Secondly, to identify changes in contribution of smoking and drinking to educational differences in all-cause mortality. Study covers the period from 1982 to 2013. METHODS: Data were collected in 2013-14 as a part of the PrivMort retrospective cohort study. Participants in Russia, Belarus and Hungary provided information on their educational attainment, health-related behaviors and vital statistics of their close relatives (N = 179 691). Odds ratios for mortality and relative indices of inequality (RII) were estimated for individuals aged 20-65 years, stratifying by three levels of educational attainment: higher, secondary and less than secondary education. RESULTS: Those in lower educational groups were significantly more likely to die, through most time periods and sub-groups. The RII increased over time in all countries and both genders, except for Hungarian men. Alcohol consumption and smoking have increasingly contributed to educational inequalities in mortality during this period. CONCLUSION: Educational inequalities in mortality in these Eastern European countries have increased during recent decades. Smoking and alcohol consumption, two major health-related behaviors, made a significant contribution to these increases in inequality.

Italian Atlas of mortality inequalities by education level. / Atlante italiano delle disuguaglianze di mortalità per livello di istruzione.

OBJECTIVES: To evaluate the geographical and socioeconomic differences in mortality and in life expectancy in Italy; to evaluate the proportion of mortality in the population attributable to a medium-low education level through the use of maps and indicators. DESIGN: Longitudinal design of the population enrolled in the 2011 Italian Census, following the population over time and registering any exit due to death or emigration. SETTING AND PARTICIPANTS: The study used the database of the Italian National Institute of Statistics (Istat) developed by linking the 2011 Census with the Italian National Register of Causes of Death (2012-2014) for 35 groups of causes of death. Age, sex, residence, and education level information were collected from the Census. MAIN OUTCOME MEASURES: Life expectancy at birth was calculated by sex, Italian region, and education level. For the population aged 30-89 years, the following items were developed by sex: 1. provincial maps showing, for each cause of death, the distribution in quintiles of smoothed standardized mortality ratio (SMR), adjusted for age and education level and estimated with Bayesian models for small areas (spatial conditional autoregressive model); 2. regional maps of population attributable fraction (PAF) for low and medium education levels, calculated starting from age-standardized mortality ratios; 3. tables illustrating for each region standardized mortality rates and standardized years of life lost rate by age (standardized YLL rate), and mortality rate ratios standardized by age (MMRs). RESULTS: Males with a lower education level throughout Italy show a life expectancy at birth that is 3 years less than those with higher education; residents in Southern Italy lose an additional year in life expectancy, regardless of education level. Social inequalities in mortality are present in all regions, but are more marked in the poorer regions of Southern Italy. Geographical differences, taking into account the different population distributions in terms of age and education level, produce mortality differences for all causes: from -15% to +30% in women and from -13% to +26% in men, compared to the national average. Among the main groups of causes, the geographical differences are greater for cardiovascular diseases, respiratory diseases, and accidents, and lower for many tumour sites. A clear mortality gradient with an excess in Southern Italy can be seen for cardiovascular diseases: there are some areas where mortality for people with higher education level is higher than that for residents in Northern Italy with low education level. The gradient for "All tumours", instead, is from South to North, as it is for most single tumour sites. Population attributable fraction for low education level in Italy, taking into account the population distribution by age, is 13.4% in women and 18.3% in men. CONCLUSIONS: The study highlighted important geographical differences in mortality, regardless of age and socioeconomic level, with a more significant impact in the poorer Southern regions, revealing a never-before-seen health advantage in the regions along the Adriatic coast. A lower education level explains a considerable proportion of mortality risk, although with differing effects by geographical area and cause of death. There are still mortality inequalities in Italy, therefore, representing a possible missed gain in health in our Country; these inequalities suggest a reassessment of priorities and definition of health targets. Forty years after the Italian National Health Service was instituted, the goal of health equity has not yet been fully achieved.

Socioeconomic status and the 25 × 25 risk factors as determinants of premature mortality: a multicohort study and meta-analysis of 1·7 million men and women.

BACKGROUND: In 2011, WHO member states signed up to the 25 × 25 initiative, a plan to cut mortality due to non-communicable diseases by 25% by 2025. However, socioeconomic factors influencing non-communicable diseases have not been included in the plan. In this study, we aimed to compare the contribution of socioeconomic status to mortality and years-of-life-lost with that of the 25 × 25 conventional risk factors. METHODS: We did a multicohort study and meta-analysis with individual-level data from 48 independent prospective cohort studies with information about socioeconomic status, indexed by occupational position, 25 × 25 risk factors (high alcohol intake, physical inactivity, current smoking, hypertension, diabetes, and obesity), and mortality, for a total population of 1 751 479 (54% women) from seven high-income WHO member countries. We estimated the association of socioeconomic status and the 25 × 25 risk factors with all-cause mortality and cause-specific mortality by calculating minimally adjusted and mutually adjusted hazard ratios [HR] and 95% CIs. We also estimated the population attributable fraction and the years of life lost due to suboptimal risk factors. FINDINGS: During 26·6 million person-years at risk (mean follow-up 13·3 years [SD 6·4 years]), 310 277 participants died. HR for the 25 × 25 risk factors and mortality varied between 1·04 (95% CI 0·98-1·11) for obesity in men and 2 ·17 (2·06-2·29) for current smoking in men. Participants with low socioeconomic status had greater mortality compared with those with high socioeconomic status (HR 1·42, 95% CI 1·38-1·45 for men; 1·34, 1·28-1·39 for women); this association remained significant in mutually adjusted models that included the 25 × 25 factors (HR 1·26, 1·21-1·32, men and women combined). The population attributable fraction was highest for smoking, followed by physical inactivity then socioeconomic status. Low socioeconomic status was associated with a 2·1-year reduction in life expectancy between ages 40 and 85 years, the corresponding years-of-life-lost were 0·5 years for high alcohol intake, 0·7 years for obesity, 3·9 years for diabetes, 1·6 years for hypertension, 2·4 years for physical inactivity, and 4·8 years for current smoking. INTERPRETATION: Socioeconomic circumstances, in addition to the 25 × 25 factors, should be targeted by local and global health strategies and health risk surveillance to reduce mortality. FUNDING: European Commission, Swiss State Secretariat for Education, Swiss National Science Foundation, the Medical Research Council, NordForsk, Portuguese Foundation for Science and Technology.