Sexual orientation and gender identity inequities in cervical cancer screening by race and ethnicity.

BACKGROUND: In the United States, inequities in preventive health behaviors such as cervical cancer screening have been documented. Sexual orientation, gender identity, and race/ethnicity all individually contribute to such disparities. However, little work has investigated their joint impact on screening behavior. METHODS: Using sampling weighted data from the 2016 and 2018 Behavioral Risk Factor Surveillance System, we assessed differences in two metrics via chi-square statistics: 1) lifetime uptake, and 2) up-to-date cervical cancer screening by sexual orientation and gender identity, within and across racial/ethnic classifications. RESULTS: Within all races, individuals who identify as members of sexual and gender minority (SGM) communities reported higher rates of never being screened (except for Black transgender men) than straight or cisgender individuals (p < 0.0001). [*START* Across all races, the Asian/Pacific Islander transgender population (32.4%; weighted n (w.n.) = 1,313) had the lowest proportion of lifetime screening, followed by the Asian/Pacific Islander gay/lesbian (53.0%, w.n. = 21,771), Hispanic transgender (58.7%; w.n. = 24,780), Asian/Pacific Islander bisexual (61.8%, w.n. = 54,524), and Hispanic gay/lesbian (69.6%, w.n. = 125,781) populations. *END*] Straight or cisgender Non-Hispanic White (w.n. = 40,664,476) individuals had the highest proportion of lifetime screening (97.7% and 97.5%, respectively). However, among individuals who had been screened at least once in their lifetime, identifying as SGM was not associated with a decreased proportion of up-to-date screening within or between races. CONCLUSIONS: Due to small sample sizes, especially among Asian/Pacific Islander and Hispanic populations, confidence intervals were wide. Heterogeneity in screening participation by SGM status within and across racial/ethnic groups were observed. IMPACT: These screening disparities reveal the need to disaggregate data to account for intersecting identities and for studies with larger sample sizes to increase estimate reliability.

Neighbourhood social deprivation and risk of prostate cancer.

BACKGROUND: Striking geographic variations in prostate cancer incidence suggest an aetiological role for spatially-distributed factors. We assessed whether neighbourhood social deprivation, which can reflect limited social contacts, unfavourable lifestyle and environmental exposures, is associated with prostate cancer risk. METHODS: In 2005-2012, we recruited 1931 incident prostate cancer cases and 1994 controls in a case-control study in Montreal, Canada. Lifetime residential addresses were linked to an area-based social deprivation index around recruitment (2006) and about 10 years earlier (1996). Logistic regression estimated adjusted odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Men residing in areas characterised by greater social deprivation had elevated prostate cancer risks (ORs of 1.54 and 1.60 for recent and past exposures, respectively; highest vs lowest quintiles), independently from area- and individual-level confounders and screening patterns. The increase in risk with recent high social deprivation was particularly elevated for high-grade prostate cancer at diagnosis (OR 1.87, 95% CI 1.32-2.64). Associations were more pronounced for neighbourhoods with higher proportions of separated/divorced or widowed individuals in the past, and with higher percentages of residents living alone recently. CONCLUSIONS: These novel findings, suggesting that neighbourhood-level social deprivation increases the risk of prostate cancer, point out to potential targeted public health interventions.

Multidimensional school features associated with physical activity among youth at risk of obesity: an exploratory principal component and generalized estimating equation analysis.

BACKGROUND: Schools may be high-leverage points for the promotion of physical activity (PA), yet little is known about school built and social environments among youth at high risk of obesity. PURPOSE: To characterise school built and social environments that may be salient for PA and to examine associations between school PA environments and PA in youth at risk of obesity. METHODS: Data from youth attending 206 schools (314 youth in 2005-2008, and 129 youth in 2008-2010) within the QUALITY cohort study, a longitudinal investigation of youth at high risk of obesity were used. Features of schools, based on built, policy/programming and social environments were identified using principal components (PC) analysis. Gender-stratified generalized estimating equation (GEE) models were used to explore associations between school features and accelerometer measured mean counts per minute (MCPM), mean daily moderate-to-vigorous physical activity (MVPA) and the odds of meeting MVPA guidelines cross-sectionally and prospectively using 90% confidence intervals. RESULTS: Nine PCs were identified. Associations were observed between PA and 7 of the 9 PCs. The social environment seemed to be particularly important. Social Norms to Promote PA was associated with an increase in girls' baseline MCPM and MVPA. High Willingness to Promote PA was associated with boys' MCPM, MVPA, and odds of meeting MVPA guidelines, at both baseline and follow-up. CONCLUSION: School built and social contexts may be associated with PA cross-sectionally and over time. Further studies are necessary to confirm the direction and magnitude of effects and to establish their relevance to school-based health promotion efforts.

Associations of neighborhood walkability with moderate to vigorous physical activity: an application of compositional data analysis comparing compositional and non-compositional approaches.

BACKGROUND: We compared the relation between neighborhood features and moderate to vigorous physical activity (MVPA) using linear regression analysis and the more novel compositional data analysis (CoDA). Compositional data analysis allows us to take the time children allocate to different movement behaviours during a 24-hour time period into account. METHODOLOGY: Data from youth participants (n = 409) in the QUALITY (QUebec Adipose and Lifestyle InvesTigation in Youth) cohort were included. Time spent in MVPA, light physical activity, sedentary behavior, and sleep ("24-hour movement behaviours") was measured using accelerometers. Neighborhood data were collected using a geographic information system and through direct observation. In CoDA models, we used orthogonal logratio coordinates, which allows for the association of neighbourhood walkability with MVPA to be estimated with respect to the average composition of all other behaviours within a 24-hour time frame. In baseline linear regression models, MVPA was regressed cross-sectionally on neighborhood walkability. All models were stratified by sex, and controlled for BMI z-scores, pubertal development, seasonal variation, parental education, and neighbourhood safety. RESULTS: Based on CoDA, girls who lived in more walkable neighborhoods had 10% higher daily MVPA (95% CI: 2%, 19%), taking into account all other movement behaviours. Based on linear regression, girls who resided in more walkable neighborhoods engaged in 4.2 (95% confidence interval [CI]: 1.2, 6.6) more minutes of MVPA per day on average than girls residing in less walkable neighborhoods. CONCLUSIONS: Unlike with traditional linear models, all movement behaviours were included in a single model using CoDA, allowing for a more complete picture of the strength and direction of the association between neighbourhood Walkability and MVPA. Application of CoDA to investigate determinants of physical activity provides additional insight into potential mechanisms and the ways in which people allocate their time.

Racial/ethnic inequalities in cervical cancer screening in the United States: An outcome reclassification to better inform interventions and benchmarks.

In the United states (U.S.), prevailing understanding suggests significant racial/ethnic inequalities in cervical cancer screening exist. However, recent findings elsewhere in North America indicate the magnitude of these inequalities depend on the way screening is defined: lifetime screening versus up-to-date screening. As those who have never been screened are most at risk for invasive cancer, an improved understanding of inequalities in this outcome is necessary to better inform interventions. To describe racial/ethnic inequalities in 1) never screening and 2) not being up-to-date with screening among women who have been screened at least once in their lifetime, three years (2014-2016) of the U.S. Behavioral Risk Factor Surveillance Survey were utilized to estimate cervical cancer screening prevalence ratios via Poisson regression (N = 123,070). The sample was limited to women age 21 to 65 years. Women from racial/ethnic minority groups were more likely to never have been screened in comparison to White women, particularly women of Asian descent (Prevalence Ratio (PR) = 3.8, 95% CI = 3.3-4.3). However, among women who had been screened at least once in their lifetime, an inverse association was observed between being a member of a racial/ethnic minority group and not being up-to-date with screening (e.g. PRasian vs white = 0.7, 95% CI = 0.6-0.9). Physicians and public health institutions concerned with monitoring racial/ethnic inequalities should consider adding lifetime screening as a primary benchmark, as this outcome implies different intervention targets to address inequalities and the differential burden of cervical cancer.

The Society for Epidemiologic Research and the Future of Diversity and Inclusion in Epidemiology.

"The mission of the Diversity and Inclusion Committee (D&I) in the Society for Epidemiologic Research is to foster the diversity of our membership and work towards the engagement of all members, from diverse backgrounds at all stages of their careers, in the Society's activities, with the intent of enhancing discovery in public health." As a foundational step in implementing our mission, the D&I Committee conducted a survey of SER membership. Here we report on the efforts we have undertaken to expand the diversity and inclusiveness of our Society and our aspirations for future efforts in support of D&I. Early on, we established the SERvisits program to conduct outreach to institutions and students that have historically been underrepresented at SER; we hope this program continues to grow in its reach and impact. We have also taken steps to increase the inclusiveness of SER activities, for example, by engaging members on issues of D&I through symposia and workshops at SER annual meetings and through social media. DeVilbiss et al. (Am J Epidemiol. 2020;189(10):998-1010) have demonstrated that there is substantial room for improvement with regards to diversity and inclusion within SER. We invite SER members to become involved and collaborate on this long-term goal.

Assessing Representation and Perceived Inclusion among Members in the Society for Epidemiologic Research.

Using web-based survey data collected June - August 2018 from the Society for Epidemiologic Research (SER) members, we characterized numerous dimensions of social identity and lived experience, and assessed relationships between these characteristics and perceptions of inclusion and society participation. We quantified associations between characteristics, feeling very welcomed, high (top 25th percentile) self-initiated participation, and any (top 10th percentile) society-initiated participation. Racial/ethnic and religious minority categories were blinded to preserve anonymity and we accounted for missing data. Most 2018 SER members (n = 1631) were white (62%) or female (66%). Females with racial/ethnic non-response were least likely, while white males were most likely to report feeling very welcomed. Members who did not report race, identified with a specific racial/ethnic minority, or were politically conservative/right-leaning were less likely than white or liberal/left-leaning members to have high self-initiated participation. Women and individuals of a specific racial/ethnic minority or minority religious affiliations were less likely to participate in events initiated by the society. These data represent a baseline for assessing trends and the impact of future initiatives aimed at improving diversity, inclusion, representation and participation within SER.

Is Smoking Cessation in Young Adults Associated With Tobacco Retailer Availability in Their Activity Space?

INTRODUCTION: The presence of tobacco retailers in residential neighborhoods has been inversely associated with residents' likelihood of quitting smoking. Few studies have yet explored whether this association holds when accounting for tobacco retailers found in the multiple environments where people conduct their daily activities, that is, their activity space. METHODS: We analyzed cross-sectional data from 921 young adults (18- to 25-years old) participating in the Interdisciplinary Study of Inequalities in Smoking (Montreal, Canada). Respondents self-reported sociodemographic, smoking, and activity location data. Log-binomial regression was used to estimate prevalence ratios (PRs) for the association between smoking cessation and (1) the number of tobacco retailers (counts), and (2) the distance to the closest retailer (proximity) in participants' residential neighborhood and activity space. RESULTS: Smoking cessation was positively associated with low and intermediate tertile levels of tobacco retailer counts in both the residential neighborhood and activity space, and with the furthest distance level in the activity space [PR (95% CI) = 1.21 (1.02 to 1.43)]. CONCLUSIONS: Individuals encounter resources in the course of their regular daily activities that may hamper smoking cessation. This study highlights the relevance of considering the tobacco retail environment of both individuals' residential neighborhood and activity space to understand its association with smoking cessation. IMPLICATIONS: This article contributes to the literature on the association between the tobacco retail environment and smoking cessation in young adults by moving beyond the residential neighborhood to also assess individuals' access to tobacco retailers in the multiple areas where they regularly spend time, that is, their activity space. Findings suggest that lower numbers of tobacco retailers in both the residential neighborhood and activity space, and further distance to tobacco retailers in the activity space are associated with increased smoking cessation.

Cervical cancer screening in Montreal: Building evidence to support primary care and policy interventions.

In Canada, over 40% of invasive cervical cancers occur among women who have never been screened. Although 12% of Canadian women have never been screened, this number can be as high as 43% among certain social groups. Little is published on factors associated with screening uptake and inequalities among women residing in Quebec. Four waves of the Canadian Community Health Survey (2003, 2005, 2008, 2012, N = 6393) were utilized to assess lifetime screening and screening in the previous 3 years among women residing in Montreal. Chi-squared statistics were calculated, Poisson regression was utilized to model prevalence ratios, and prevalence differences were calculated. In total, 13.6% of women had never been screened and 12.1% had not been screened in the previous 3 years. Immigrant status was the strongest predictor of never being screened [recent vs non-immigrant: Prevalence Ratio (PR), 3.9 (95% Confidence Interval (CI): 2.9-5.4)] and not having a primary care physician (PCP) was the strongest predictors of not being screened recently [PR = 3.0 (95% CI: 2.3-3.9)]. The two most common reasons for not being screened were not "know[ing] it was necessary" and not "get[ting] around to it." These results provide a description of sub-populations which might benefit from cervical screening interventions: immigrants and women without a PCP. Interventions targeting access to PCPs, expanding training of non-physicians to conduct screening, organized screening, or autoadministered screening test may mitigate inequalities. Future work should assess their acceptability and feasibility, and evaluate the impact of these types of primary care and policy interventions.

Measuring colorectal cancer incidence: the performance of an algorithm using administrative health data.

BACKGROUND: Certain cancer case ascertainment methods used in Quebec and elsewhere are known to underestimate the burden of cancer, particularly for some subgroups. Algorithms using claims data are a low-cost option to improve the quality of cancer surveillance, but have not frequently been implemented at the population-level. Our objectives were to 1) develop a colorectal cancer (CRC) case ascertainment algorithm using population-level hospitalization and physician billing data, 2) validate the algorithm, and 3) describe the characteristics of cases. METHODS: We linked physician billing, hospitalization, and tumor registry data for 2,013,430 Montreal residents age 20+ (2000-2010). We compared the performance of three algorithms based on diagnosis and treatment codes from different data sources. We described identified cases according to age, sex, socioeconomic status, treatment patterns, site distribution, and time trends. All statistical tests were two-sided. RESULTS: Our algorithm based on diagnosis and treatment codes identified 11,476 of the 12,933 incident CRC cases contained in the tumor registry as well as 2317 newly-captured cases. Our cases share similar overall time trends and site distributions to existing data, which increases our confidence in the algorithm. Our algorithm captured proportionally 35% more individuals age 50 and younger among CRC cases: 8.2% vs. 5.3%. The newly captured cases were also more likely to be living in socioeconomically advantaged areas. CONCLUSIONS: Our algorithm provides a more complete picture of population-wide CRC incidence than existing case ascertainment methods. It could be used to estimate long-term incidence trends, aid in timely surveillance, and to inform interventions, in both Quebec and other jurisdictions.

Social disparities in children's exposure to secondhand smoke in privately owned vehicles.

INTRODUCTION: Secondhand smoke (SHS) can quickly attain high concentrations in cars, posing health risks to passengers and especially to children. This paper assesses whether there are social disparities in children's exposure to SHS in privately owned vehicles. METHODS: On weekday mornings and afternoons from September to November 2011, trained observers were stationed at 100 selected street intersections in Montreal, Canada. For each car transporting at least one passenger aged 0-15 years travelling through the intersection, observers recorded the estimated age of the youngest child in the car, whether any occupant was smoking and the licence plate number of the car. Licence plate numbers were linked to an area material deprivation index based on the postal code of the neighbourhood in which the car was registered. RESULTS: Smoking was observed in 0.7% of 20 922 cars transporting children. There was an apparent dose-response in the association between area material deprivation level and children's exposure to SHS in cars. Children travelling in cars registered in the most disadvantaged areas of Montreal were more likely to be exposed to SHS than children travelling in cars registered in the most advantaged areas (unadjusted OR=3.46, 95% CI 1.99 to 6.01). CONCLUSIONS: This study revealed social disparities in children's exposure to SHS in privately owned vehicles.

A reliability assessment of a direct-observation park evaluation tool: the parks, activity and recreation among kids (PARK) tool.

BACKGROUND: Parks are increasingly being viewed as a resource that may influence youth obesity and physical activity (PA). Assessing park quality can be challenging as few tools assess park characteristics geared towards youth PA. Additionally, no studies have compared reliability estimates of items assessed in different countries, hindering aims towards generalizable park audit items. Finally, new satellite imaging technology is allowing for desktop identification of parks, however it remains unclear how this compares to direct observation park identification. The purpose of this study is 1) to describe the development and reliability of a youth-oriented direct-observation park audit tool tested in Montreal, Canada, and; 2) to compare reliability estimates of items with those drawn from a tool previously tested in Perth, Australia, with those same items tested in Montreal, Canada. METHODS: Items were drawn and adapted from two existing tools and 13 new items were newly developed for a total of 92 items. Parks were pre-identified using a GIS software and then verified and audited on-site by observers. A total of 576 parks were evaluated. Cohen's kappa and percent agreement were used to assess the inter- and intra-rater reliability of each item. Inter-rater reliabilities of 17 items drawn from a tool previously tested in Australia were compared. RESULTS: Eighty-six percent of items had ≥ 75 % agreement and 83 % had kappa coefficients between 0.41 and 1. Among 40 test-retest episodes kappa agreement was relatively high (≥ 0.40) for all but four items. Percent agreement was excellent (≥ 75 % agreement) for all but eight items. Inter-rater reliability estimates of the 17 items tested in Montreal and Perth were of similar magnitude. CONCLUSIONS: The tool is generally reliable and can be used to assess park characteristics that may be associated with youth PA. The items tested in Montreal and Perth are likely generalizable to other urban environments.

Chronic Health Conditions, Disability, and Physical and Cognitive Limitations Among LGBTQ+ Cancer Survivors.

BACKGROUND: Cancer survivors are at high risk for chronic health conditions and physical and cognitive limitations. However, few studies have explored these outcomes among LGBTQ+ survivors. METHODS: We used pooled, weighted Behavioral Risk Factor Surveillance System data from 23 states that completed two specific modules from 2020-2022. We calculated age-adjusted prevalence for heart disease, asthma, COPD, depressive disorders, myocardial infarction, kidney disease, stroke, diabetes, hearing disability, vision disability, cognitive limitations, and difficulty walking, dressing, and running errands in LGBTQ+, lesbian, gay, or bisexual (LGB), transgender or gender non-conforming (TGNC), and non-LGBTQ+ cancer survivors. Four multivariable logistic regression models controlling for different factors were run for each outcome. RESULTS: Of 40,990 cancer survivors, 1,715 were LGBTQ+. LGBTQ+ survivors had significantly higher age-adjusted prevalence of all outcomes. The prevalence of all outcomes was highest among TGNC survivors except for depressive disorders and cognitive limitations. LGBTQ+ survivors had higher odds of reporting asthma (aOR: 1.5, 95%CI:1.2-1.9), depressive disorders (aOR: 1.9, 95%CI:1.6-2.4), kidney disease (aOR: 1.5, 95%CI:1.1-2.1), stroke (aOR: 1.7, 95%CI:1.3-2.3), diabetes (aOR: 1.3, 95%CI:1.0-1.6), vision disability (aOR: 1.6, 95%CI:1.2-2.2), cognitive limitations (aOR: 2.3, 95%CI:1.8-2.9), difficulty walking (aOR: 1.7, 95%CI:1.3-2.0), dressing (aOR: 2.0, 95%CI:1.5-2.7), and running errands (aOR: 1.6, 95%CI:1.3-2.1). In TGNC models, TGNC cancer survivors had increased odds of most outcomes. CONCLUSIONS: LGBTQ+ cancer survivors have an elevated burden of all chronic health conditions, disabilities, and limitations assessed. TGNC cancer survivors experience even higher burden of the same outcomes. IMPACT: Findings highlight substantial disparities regarding the health of LGBTQ+ cancer survivors.

Inequities in colorectal and breast cancer screening: At the intersection of race/ethnicity, sexuality, and gender.

Objective: To investigate the joint impact of sexual orientation, gender identity, and race/ethnicity on colorectal and breast cancer screening disparities in the United States. Methods: Utilizing sampling weighted data from the 2016 and 2018 Behavioral Risk Factor Surveillance System, we assessed differences in two metrics via chi-square statistics: 1) lifetime uptake, and 2) up-to-date colorectal and breast cancer screening by sexual orientation and gender identity, within and across racial/ethnic classifications. Results: Within specific races/ethnicities, lifetime CRC screening was higher among gay/lesbian (within NH-White, Hispanic, and Asian/Pacific Islander) and bisexual individuals (Hispanic) compared to straight individuals, and lowest overall among transgender women and transgender nonconforming populations (p < 0.05). Asian transgender women had the lowest lifetime CRC screening (13.0%; w.n. = 1,428). Lifetime breast cancer screening was lowest among the Hispanic bisexual population (86.6%; w.n. = 26,940) and Hispanic transgender nonconforming population (71.8%; w.n. = 739); within all races, SGM individuals (except NH-White, Hispanic, and Black bisexual populations, and NH-White transgender men) had greater breast cancer screening adherence compared to straight individuals. Conclusions: Due to small, unweighted sample sizes, results should be interpreted with caution. Heterogeneity in screening participation by SGM status within and across racial/ethnic groups were observed, revealing the need to disaggregate data to account for intersecting identities and for studies with larger sample sizes to increase estimate reliability.

Prostate cancer mortality and birth or adult residence in the southern United States.

PURPOSE: Although there are few confirmed risk factors for prostate cancer (PCa), mortality rates are known to vary geographically across the United States. PCa mortality is higher among black and younger white men in a band of states spanning from Washington DC to Louisiana (the "PCa belt"). This study assessed the associations of birth and adult residence in the PCa belt with PCa mortality among black and white men and trends in these associations over time. METHODS: PCa-specific mortality rates in 1980, 1990, and 2000 for black and white men born in the continental US, aged 40-89, were calculated by linking national mortality records with population data based on birth state, state of residence at the census, race, and age. PCa belt (Washington DC, Virginia, North Carolina, South Carolina, Georgia, Mississippi, Alabama, and Louisiana) birth was cross-classified against PCa belt adult residence. RESULTS: Black men born in the PCa belt had elevated PCa mortality in 1980, 1990, and 2000. Associations were independent of adult residence in the PCa belt. For example, in 2000, black men aged 65-89 who were born in the PCa belt but no longer lived there in adulthood had an odds ratio of 1.19 (1.14-1.24) for PCa mortality compared to black men born and residing outside the PCa belt. The PCa belt was not associated with PCa mortality among whites. CONCLUSIONS: Geographically patterned childhood exposures, for example, differences in social or environmental conditions, or behavioral norms, may influence PCa mortality.

Area-level social fragmentation and walking for exercise: cross-sectional findings from the Quebec Adipose and Lifestyle Investigation in Youth Study.

OBJECTIVES: We determined whether social fragmentation, which is linked to the concept of anomie (or normlessness), was associated with a decreased likelihood of willingness to walk for exercise. METHODS: Data were collected from mothers and fathers of 630 families participating in the Quebec Adipose and Lifestyle Investigation in Youth Cohort, an ongoing longitudinal study investigating the natural history of obesity and insulin resistance in children. Social fragmentation was defined as the breakdown of social bonds between individuals and their communities. We used log-binomial multiple regression models to estimate the association between social fragmentation and walking for exercise. RESULTS: Higher social fragmentation was associated with a decreased likelihood of walking for exercise among women but not men. Compared with women living in neighborhoods with the lowest social fragmentation scores (first quartile), those living in neighborhoods in the second (relative risk [RR] = 0.91; 95% confidence interval [CI] = 0.78, 1.05), third (RR = 0.83; 95% CI = 0.70, 1.00), and fourth (RR = 0.80; 95% CI = 0.65, 0.99) quartiles were less likely to walk for exercise (P = .02). CONCLUSIONS: Social fragmentation is associated with reduced walking among women. Increasing neighborhood stability may increase walking behavior, especially among women.

SRH and HrQOL: does social position impact differently on their link with health status?

BACKGROUND: Self-rated Health (SRH) and health-related quality of life (HRQoL) are used to evaluate health disparities. Like all subjective measures of health, they are dependent on health expectations that are associated with socioeconomic characteristics. It is thus needed to analyse the influence played by socioeconomic position (SEP) on the relationship between these two indicators and health conditions if we aim to use them to study health disparities. Our objective is to assess the influence of SEP on the relationship between physical health status and subjective health status, measured by SRH and HRQoL using the SF-36 scale. METHODS: We used data from the French National Health Survey. SEP was assessed by years of education and household annual income. Physical health status was measured by functional limitations and chronic low back pain. RESULTS: Regardless of their health status, people with lower SEP were more likely than their more socially advantaged counterparts to report poor SRH and poorer HRQoL, using any of the indicators of SEP. The negative impact of chronic low back pain on SRH was relatively greater in people with a high SEP than in those with a low SEP. In contrast, chronic low back pain and functional limitations had less impact on physical and mental component scores of quality of life for socially advantaged men and women. CONCLUSIONS: Both SRH and HRQoL were lower among those reporting functional limitations or chronic low back pain. However, the change varied according SEP and the measure. In relative term, the negative impact of a given health condition seems to be greater on SRH and lower on HRQoL for people with higher SEP in comparison with people with low SEP. Using SRH could thus decrease socioeconomic differences. In contrast using HRQoL could increase these differences, suggesting being cautious when using these indicators for analyzing health disparities.

What role does socio-economic position play in the link between functional limitations and self-rated health: France vs. USA?

BACKGROUND: Our objective was to analyse the influence of education on the link between functional limitation (FL) and self-rated health (SRH) in two countries, France and the USA. METHODS: The data of the North American NHANES study (n = 9254) and the French National Health Survey (n = 25 559) were used. FL was measured by the ADL and IADL scales. We constructed a logistic regression model with SRH as the outcome and included variables for education, FL and the interaction between education and FL. All results were adjusted for age. RESULTS: Poor SRH was more frequently reported in France than in the USA (24.1% vs. 18.4% for men, 29.0% vs. 19.7% for women). The most highly educated persons in the USA had similar FL (25.4% for men, 32.9% for women) to the least educated French persons (22.8% for men, 31.8% for women). In the USA, FL was associated more strongly with poor SRH in the most educated men than in the least educated. In France, the same interaction was observed although the link was weaker than in the USA. FL was more strongly associated with poor SRH in the most educated women than in the least educated in both countries. CONCLUSION: Functional limitation had a greater impact on the most highly educated persons in both France and the USA. Using SRH as a measure of health for evaluating social inequalities could lead to underestimation of the true magnitude of functional health inequalities existing within and between countries.