Report on the Joint Workshop on the Relations between Health Inequalities, Ageing and Multimorbidity, Iceland, May 3-4, 2023.

This paper is a summary of key presentations from a workshop in Iceland on May 3-4, 2023 arranged by Aarhus University and with participation of the below-mentioned scientists. Below you will find the key messages from the presentations made by: Professor Jan Vandenbroucke, Department of Clinical Epidemiology, Aarhus University, Emeritus Professor, Leiden University; Honorary Professor, London School of Hygiene & Tropical Medicine, UKProfessor, Chair Henrik Toft Sørensen, Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, DenmarkProfessor David H. Rehkopf, Director, the Stanford Center for Population Health Sciences, Stanford University, CA., USProfessor Jaimie Gradus, Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts, USProfessor Johan Mackenbach, Emeritus Professor, Department of Public Health, Erasmus University Rotterdam, HollandProfessor, Chair M Maria Glymour, Department of Epidemiology, Boston University School of Public Health, Boston University, Boston, Massachusetts, USProfessor, Dean Sandro Galea, School of Public Health, Boston University, Boston, Massachusetts, USProfessor Victor W. Henderson, Departments of Epidemiology & Population Health and of Neurology & Neurological Sciences, Stanford University, Stanford, CA, US; Department of Clinical Epidemiology, Aarhus University, Aarhus, DK.

Associations between county-level public health expenditures and community health planning activities with COVID-19 incidence and mortality.

The COVID-19 pandemic has revealed consequences of past defunding of the U.S. public health system, but the extent to which public health infrastructure is associated with COVID-19 burden is unknown. We aimed to determine whether previous county-level public health expenditures and community health planning activities are associated with COVID-19 cases and deaths. We examined 3050 of 3143 U.S. counties and county equivalents from March 1, 2020 to February 28, 2022. Multivariable-adjusted linear regression and generalized additive models were used to estimate associations between county-level public health expenditures and completion of community health planning activities by a county health department with outcomes of county-level COVID-19 cases and deaths per 100,000 population. After adjusting for county-level covariates, counties in the highest tertile of public health expenditures per capita had on average 542 fewer COVID-19 cases per 100,000 population (95% CI, -1004 to -81) and 21 fewer deaths per 100,000 population (95% CI, -32 to -10) than counties in the lowest tertile. For analyses of community health planning activities, adjusted estimates of association remained negative for COVID-19 deaths, but confidence intervals included negative and positive values. In conclusion, higher levels of local public health expenditures and community health planning activities were associated with fewer county-level COVID-19 deaths, and to a lesser extent, cases. Future public health funding should be aligned with evidence for the value of county health departments programs and explore further which types of spending are most cost effective.

Socioeconomic inequalities in the risk of suicide attempts among sexual minority adolescents: Findings from the UK's Millennium Cohort Study.

Background: Both sexual minority and socioeconomically deprived young people are at an increased risk of making a suicide attempt. Intersectionality theory predicts these risk factors will interact synergistically to create unique vulnerabilities. We investigated the risk of suicide attempts in sexual minority socioeconomically deprived young people in a contemporary national cohort. Methods: The Millennium Cohort Study (MCS) is a birth cohort study in the UK following children born 2000-2002. Children in the MCS have been followed up over seven sweeps to date at ages 9 months, 3, 5, 7, 11, 14 and 17 years. The relative risk (RR) of self-reported suicide attempts at 17 years by sexual minority status and parental unemployment was estimated using multivariable log-binomial regression. Additive interaction, representing the synergistic effect, was estimated using the relative excess risk due to interaction (RERI). Findings: Between January, 2018 and March, 2019, 10,247 adolescents provided their sexuality and parents their employment status. 758 (7.4%) of 10,247 adolescents had made a suicide attempt. Relative to heterosexual young people living with no unemployed parents, the RR for sexual minorities living with no unemployed parents/carers was 2.93 (95% CI 2.26-3.79), one unemployed was 4.46 (95% CI 2.94-6.77), and two was 6.35 (95% CI 3.62-11.14). There was evidence of a positive additive interaction. The RERI for having one unemployed parent was 1.08 (95% CI -0.54 to 2.69) and two was 3.10 (95% CI -1.58 to 7.78). Sensitivity analyses using housing tenure and in a sample with no missing data generated comparable results. Interpretation: To our knowledge, this is the first evidence that socioeconomically deprived sexual minority adolescents are uniquely vulnerable to making a suicide attempt. Health and educational practitioners need to be aware of the increased risk of suicide attempts in socioeconomically deprived sexual minority adolescents. Funding: Economic and Social Research Council (ESRC).

Trends and inequities in the diagnosis and treatment of poststroke depression: a retrospective cohort study of privately insured patients in the USA, 2003-2020.

BACKGROUND: Depression is a common neuropsychiatric consequence of stroke, but there is little empiric evidence regarding clinical diagnosis and management of poststroke depression. METHODS: Retrospective cohort study among 831 471 privately insured patients with first stroke in the USA from 2003 to 2020. We identified diagnoses of poststroke depression using codes from the International Classification of Diseases. We identified treatment based on prescriptions for antidepressants. We used Cox proportional hazards regression analysis to examine rates of poststroke depression diagnosis by gender, age and race/ethnicity. Among individuals who received a diagnosis of poststroke depression, we estimated treatment rates by gender, race/ethnicity and age using negative binomial regression analysis. RESULTS: Annual diagnosis and treatment rates for poststroke depression increased from 2003 to 2020 (both p for trend<0.001). Diagnosis rates were higher in women than men (HR 1.53, 95% CI 1.51 to 1.55), lower among members of racial/ethnic minorities (vs white patients: Asian HR 0.63, 95% CI 0.60 to 0.66; Black HR 0.76, 95% CI 0.74 to 0.78; Hispanic HR 0.88, 95% CI 0.86 to 0.90) and varied by age. Among individuals diagnosed with poststroke depression, 69.8% were prescribed an antidepressant. Rates of treatment were higher in women vs men (rate ratio, RR=1.19, 95% CI: 1.17 to 1.21), lower among members of racial/ethnic minorities (vs white patients: Asian RR 0.85, 95% CI 0.80 to 0.90; Black RR 0.92, 95% CI 0.89 to 0.94; Hispanic RR 0.96, 95% CI 0.93 to 0.99) and higher among older patients. CONCLUSIONS: In this insured population, we identify potential inequities in clinical management of poststroke depression by gender, race/ethnicity and age that may reflect barriers other than access to healthcare.

Association Between Social Disadvantage and Otitis Media Treatment in US Children With Commercial Insurance.

Importance: It is well established that social disadvantage is associated with earlier, more frequent, and more severe otitis media in children. Appropriate medical and surgical treatment of otitis media can prevent hearing loss and other complications, which may affect future academic and employment opportunities in socially disadvantaged populations. Clinical treatment patterns for otitis media in the US are unclear. Objective: To describe and quantify social disparities in the treatment patterns of otitis media in children in the US. Design, Setting, and Participants: This cross-sectional study included claims data from the Optum Clinformatics Data Mart Database between January 1, 2003, and March 31, 2021, with linked inpatient, outpatient, and pharmaceutical claims for 4 831 408 children with otitis media. Exposures: Age at first otitis media diagnosis, sex, environmental allergies, gastroesophageal reflux, adenotonsillar hyperplasia, zip code, social deprivation index score, social vulnerability index score. Main Outcomes and Measures: Treatment of recurrent and suppurative otitis media in children, insertion of tympanostomy tubes, and treatment for severe complications of undertreated otitis media. The principal measure of social disadvantage was the social deprivation index. The social vulnerability index was used for sensitivity analyses to ensure external validity. Multiple logistic regression analyses were used to quantify the association of all projected variables with the study outcomes. Results: Among 4 831 408 US children with otitis media (median [IQR] age, 4 [1-8] years; 2 491 557 boys [51.57%]), 994 921 (20.59%) were treated for recurrent otitis media, 717 978 (14.86%) were treated for suppurative otitis media, 335 949 (6.95%) received tympanostomy tubes, and 10 975 (0.23%) had severe complications of otitis media. In multivariable regression models including patient factors and social indices, earlier age at diagnosis, male sex, environmental allergies, gastroesophageal reflux, and adenotonsillar hyperplasia were associated with increased treatment for otitis media, whereas social deprivation index was associated with lower odds of medical treatment for recurrent otitis media (odds ratio [OR], 0.86; 95% CI, 0.85-0.87), suppurative otitis media (OR, 0.61; 95% CI, 0.60-0.62), and insertion of tympanostomy tubes (OR, 0.76; 95% CI, 0.75-0.78) but higher odds of having severe complications (OR, 1.28; 95% CI, 1.19-1.37). Conclusions and Relevance: The findings of this cross-sectional study suggest that children with otitis media who were socially disadvantaged were less likely to receive treatment and more likely to experience complications for undertreated otitis media. As otitis media is a modifiable risk factor for hearing loss, efforts need to be made to ensure equitable access to treatment for all children.

Anomalously warm weather and acute care visits in patients with multiple sclerosis: A retrospective study of privately insured individuals in the US.

BACKGROUND: As the global climate changes in response to anthropogenic greenhouse gas emissions, weather and temperature are expected to become increasingly variable. Although heat sensitivity is a recognized clinical feature of multiple sclerosis (MS), a chronic demyelinating disorder of the central nervous system, few studies have examined the implications of climate change for patients with this disease. METHODS AND FINDINGS: We conducted a retrospective cohort study of individuals with MS ages 18-64 years in a nationwide United States patient-level commercial and Medicare Advantage claims database from 2003 to 2017. We defined anomalously warm weather as any month in which local average temperatures exceeded the long-term average by ≥1.5°C. We estimated the association between anomalously warm weather and MS-related inpatient, outpatient, and emergency department visits using generalized log-linear models. From 75,395,334 individuals, we identified 106,225 with MS. The majority were women (76.6%) aged 36-55 years (59.0%). Anomalously warm weather was associated with increased risk for emergency department visits (risk ratio [RR] = 1.043, 95% CI: 1.025-1.063) and inpatient visits (RR = 1.032, 95% CI: 1.010-1.054). There was limited evidence of an association between anomalously warm weather and MS-related outpatient visits (RR = 1.010, 95% CI: 1.005-1.015). Estimates were similar for men and women, strongest among older individuals, and exhibited substantial variation by season, region, and climate zone. Limitations of the present study include the absence of key individual-level measures of socioeconomic position (i.e., race/ethnicity, occupational status, and housing quality) that may determine where individuals live-and therefore the extent of their exposure to anomalously warm weather-as well as their propensity to seek treatment for neurologic symptoms. CONCLUSIONS: Our findings suggest that as global temperatures rise, individuals with MS may represent a particularly susceptible subpopulation, a finding with implications for both healthcare providers and systems.

High School Composition and Health Outcomes in Adulthood: A Cohort Study.

BACKGROUND: A multitude of empirical evidence documents links between education and health, but this focuses primarily on educational attainment and not on characteristics of the school setting. Little is known about the extent to which aggregate characteristics of the school setting, such as student body demographics, are associated with adult health outcomes. METHODS: We use the U.S. nationally representative National Longitudinal Survey of Youth 1979 cohort to statistically assess the association between two different measures of high school student composition (socioeconomic composition, racial/ethnic composition) and two different health outcomes at age 40 (self-rated health and obesity). RESULTS: After adjusting for confounders, high school socioeconomic composition, but not racial/ethnic composition, was weakly associated with both obesity and worse self-rated health at age 40. However, after adding adult educational attainment to the model, only the association between high school socioeconomic composition and obesity remained statistically significant. CONCLUSIONS: Future research should explore possible mechanisms and also if findings are similar across other populations and in other school contexts. These results suggest that education policies that seek to break the link between socioeconomic composition and negative outcomes remain important but may have few spillover effects onto health.

Short-term effects of the earned income tax credit on mental health and health behaviors.

Poverty has consistently been linked to poor mental health and risky health behaviors, yet few studies evaluate the effectiveness of programs and policies to address these outcomes by targeting poverty itself. We test the hypothesis that the earned income tax credit (EITC)-the largest U.S. poverty alleviation program-improves short-term mental health and health behaviors in the months immediately after income receipt. We conducted parallel analyses in two large longitudinal national data sets: the National Health Interview Survey (NHIS, 1997-2016, N = 379,603) and the Panel Study of Income Dynamics (PSID, 1985-2015, N = 29,808). Outcomes included self-rated health, psychological distress, tobacco use, and alcohol consumption. We employed difference-in-differences analysis, a quasi-experimental technique. We exploited seasonal variation in disbursement of the EITC, which is distributed as a tax refund every spring: we compared outcomes among EITC-eligible individuals interviewed immediately after refund receipt (Feb-Apr) with those interviewed in other months more distant from refund receipt (May-Jan), "differencing out" seasonal trends among non-eligible individuals. For most outcomes, we were unable to rule out the null hypothesis that there was no short-term effect of the EITC. Findings were cross-validated in both data sets. The exception was an increase in smoking in PSID, although this finding was not robust to sensitivity analyses. While we found no short-term "check effect" of the EITC on mental health and health behaviors, others have found long-term effects on these outcomes. This may be because recipients anticipate EITC receipt and smooth their income accordingly.

Predicting mortality from 57 economic, behavioral, social, and psychological factors.

Behavioral and social scientists have identified many nonbiological predictors of mortality. An important limitation of much of this research, however, is that risk factors are not studied in comparison with one another or from across different fields of research. It therefore remains unclear which factors should be prioritized for interventions and policy to reduce mortality risk. In the current investigation, we compare 57 factors within a multidisciplinary framework. These include (i) adverse socioeconomic and psychosocial experiences during childhood and (ii) socioeconomic conditions, (iii) health behaviors, (iv) social connections, (v) psychological characteristics, and (vi) adverse experiences during adulthood. The current prospective cohort investigation with 13,611 adults from 52 to 104 y of age (mean age 69.3 y) from the nationally representative Health and Retirement Study used weighted traditional (i.e., multivariate Cox regressions) and machine-learning (i.e., lasso, random forest analysis) statistical approaches to identify the leading predictors of mortality over 6 y of follow-up time. We demonstrate that, in addition to the well-established behavioral risk factors of smoking, alcohol abuse, and lack of physical activity, economic (e.g., recent financial difficulties, unemployment history), social (e.g., childhood adversity, divorce history), and psychological (e.g., negative affectivity) factors were also among the strongest predictors of mortality among older American adults. The strength of these predictors should be used to guide future transdisciplinary investigations and intervention studies across the fields of epidemiology, psychology, sociology, economics, and medicine to understand how changes in these factors alter individual mortality risk.

Psychological Distress Mediates the Prospective Association of Household Income with Body Mass Index in Adolescent Girls.

The primary objective of this study was to examine whether psychological distress mediates the relationship between income and increases in body mass index in adolescent girls. To answer this question, we analyzed data from 2379 participants in the longitudinal NHLBI Growth and Health Study using regularized regression and path analysis. The exposure was household income at age 9-10 and the outcome was body mass index at age 18-19. Income negatively predicted psychological distress, which in turn predicted psychological and behavioral factors that were associated with increases in body mass index. Overall, psychological distress and related variables accounted for around 20% of the relationship between income and increases in body mass index in adolescent girls. The impacts of income on a complex constellation of psychological risks for obesity support the evaluation of income support policies for reducing economic inequalities in obesity. Obesity reduction programs focused on changing psychological distress should be developed with consideration of the household economic environment.

Socioeconomic Differences in the Epidemiologic Transition From Heart Disease to Cancer as the Leading Cause of Death in the United States, 2003 to 2015: An Observational Study.

Background: Recent data suggest that the United States is in the midst of an epidemiologic transition in the leading cause of death. Objective: To examine county-level sociodemographic differences in the transition from heart disease to cancer as the leading cause of death in the United States. Design: Observational study. Setting: U.S. death records, 2003 to 2015. Participants: Decedents aged 25 years or older, classified by racial/ethnic group. Measurements: All-cause, heart disease, and cancer mortality stratified by quintiles of county median household income. Age- and sex-adjusted mortality rates and average annual percentage of change were calculated. Results: Heart disease was the leading cause of death in 79% of counties in 2003 and 59% in 2015. Cancer was the leading cause of death in 21% of counties in 2003 and 41% in 2015. The shift to cancer as the leading cause of death was greatest in the highest-income counties. Overall, heart disease mortality rates decreased by 28% (30% in high-income counties vs. 22% in low-income counties) from 2003 to 2015, and cancer mortality rates decreased by 16% (18% in high-income counties vs. 11% in low-income counties). In the lowest-income counties, heart disease remained the leading cause of death among all racial/ethnic groups, and improvements were smaller for both heart disease and cancer. Limitation: Use of county median household income as a proxy for socioeconomic status. Conclusion: Data show that heart disease is more likely to be the leading cause of death in low-income counties. Low-income counties have not experienced the same decrease in mortality rates as high-income counties, which suggests a later transition to cancer as the leading cause of death in low-income counties. Primary Funding Source: National Institute on Minority Health and Health Disparities.

Estimating the Short-Term Effects of the Earned Income Tax Credit on Child Health.

The Earned Income Tax Credit (EITC) is the largest US poverty-alleviation program, yet few studies examine its effects on the health of recipients' children. We employed quasiexperimental techniques to test the hypothesis that EITC refund receipt is associated with short-term improvements in child health. The data set included children in families surveyed in the Third National Health and Nutrition Examination Survey (n = 7,444). We employed a difference-in-differences approach, exploiting the seasonal nature of EITC refund receipt. We compared children of EITC-eligible families interviewed immediately after refund receipt (February to April) with those interviewed during other months (May to January), differencing out seasonal variation among non-EITC-eligible families. We examined outcomes that were likely to be affected immediately after refund receipt, including general health, nutrition, metabolic and inflammatory biomarkers, and test scores. There were improvements in physician-reported overall health after refund receipt but no changes in infection, serum metabolic or inflammatory markers, or test scores, and there were contradictory findings for food insufficiency. In summary, EITC refunds are not strongly associated with most short-term health outcomes among recipients' children, although numerous previous studies have demonstrated impacts on longer-term outcomes. This highlights the importance of examining the effects of public policies on beneficiaries and their children using varying study designs.

The association of early life socioeconomic position on breast cancer incidence and mortality: a systematic review.

OBJECTIVES: We conducted a systematic review of the literature relating early life socioeconomic position (SEP) to breast cancer incidence and mortality from a critical period and life-course trajectory perspective. METHODS: PubMed, EMBASE and Web of Science were searched to identify cohort studies that evaluated the impact of early life SEP indicators on the incidence and/or mortality from breast cancer in adulthood. RESULTS: Nine distinct studies evaluated the relationship between early life SEP and breast cancer between 1990 and 2016. Five reports assessed breast cancer incidence and five assessed breast cancer mortality as outcomes; one study assessed both incidence and mortality. While lower early life SEP was associated with reduced breast cancer incidence and increased breast cancer mortality in the US, studies conducted in Europe were unable to establish a consistent association. CONCLUSIONS: We found moderate support for the association between early life SEP and incidence and mortality from breast cancer. The impact of early life SEP on breast cancer incidence and mortality appeared to vary between countries. We urge further investigation of the role of lifelong SEP trajectories in breast cancer outcomes.

Association Between Cardiorespiratory Fitness and Health Care Costs: The Veterans Exercise Testing Study.

OBJECTIVE: To determine the association between cardiorespiratory fitness (CRF) and annual health care costs in Veterans. PATIENTS AND METHODS: The sample included 9942 subjects (mean age, 59±11 years) undergoing a maximal exercise test for clinical reasons between January 2005 and December 2012. Cardiorespiratory fitness, expressed as a percentage of age-predicted peak metabolic equivalents (METs) achieved, was categorized in quartiles. Total and annualized health care costs, derived from the Veterans Administration Allocated Resource Center, were compared using multiple regression, controlling for demographic and clinical characteristics. RESULTS: A gradient for reduced health care costs was observed as CRF increased, with subjects in the least-fit quartile having approximately $14,662 (P<.001) higher overall costs per patient per year compared with those in the fittest quartile, after controlling for potential confounding variables. Each 1-MET higher increment in fitness was associated with a $1592 annual reduction in health care costs (5.6% lower cost per MET), and each higher quartile of fitness was associated with a $4163 annual cost reduction per patient. The effect of CRF was more pronounced among subjects without cardiovascular disease (CVD), suggesting that the results were not driven by the possibility that less-fit individuals had greater CVD. Cost savings attributable to higher fitness were greatest in overweight and obese subjects, with lower savings observed among those individuals with a body mass index less than 25 kg/m2. In a model including historical, clinical, and exercise test responses, heart failure was the strongest predictor of health care costs, followed by CRF (P<.01). CONCLUSION: Low CRF is associated with higher health care costs. Efforts to improve CRF may not only improve health but also result in lower health care costs.

Motherhood, Fatherhood and Midlife Weight Gain in a US Cohort: Associations differ by race/ethnicity and socioeconomic position.

While there is an association of greater short-term weight gain with childbearing among women, less is known about longer-term weight gain, whether men have similar gains, and how this varies by race/ethnicity and socioeconomic position. Our cohort consisted of a nationally representative sample of 7,356 Americans with oversampling of Black and Hispanic populations. We estimated the associations between number of biological children and parental weight, measured as both change in self-reported body mass index (BMI) from age 18 and overweight/obese status (BMI ≥ 25) at age 40. We performed multivariate linear and logistic regression analysis and tested for effect modification by gender. For change in BMI, men gained on average 0.28 BMI (95% CI: (0.01, 0.55)) units per child, while women gained 0.13 units per child (95% CI: (-0.22, 0.48)). The adjusted odds ratios for overweight/obesity associated with each child were 1.32 (95% CI: (1.11, 1.58)) for men and 1.15 (95% CI: (1.01, 1.31)) for women. Stratified analyses by race/ethnicity and socioeconomic position suggested that the observed full-cohort differences were driven primarily by gendered differences in low-income Hispanics and Whites - with the greatest associations among Hispanic men. For example, among low-income Hispanic men we observed a positive relationship between the number of children and weight change by age 40, with average weight change of 0.47 units per child (95%CI: (-0.65, 1.59 For low-income Hispanic women, however, the average weight change was -0.59 units per child (95%CI: (-1.70, 0.47), and the P-value for the test of interaction between gender and number of children was P < 0.001. Our findings suggest that the shared social and economic aspects of raising children play an important role in determining parental weight at mid-life.