Lifetime healthcare expenditures across socioeconomic groups.

BACKGROUND: A socioeconomic gradient affects healthcare expenditures and longevity in opposite directions as less affluent individuals have higher current healthcare expenditures but simultaneously enjoy shorter lives. Yet, it is unclear whether this cross-sectional healthcare expenditure gradient persists from a lifetime perspective. This paper analyzes lifetime healthcare expenditures across socioeconomic groups using detailed individual-level healthcare expenditure data for the entire Danish population. METHOD: Using full population healthcare expenditures from Danish registries, we estimate lifetime healthcare expenditures as age-specific mean healthcare expenditures times the probability of being alive at each age. Our data enables the estimation of lifetime healthcare expenditures by sex, socioeconomic status, and by various types of healthcare expenditure. RESULTS: Once we account for mortality differences and all types of healthcare expenditures, all socioeconomic groups spend an almost equal amount on healthcare throughout a lifetime. Lower socioeconomic groups incur the lowest lifetime hospital expenditures, whereas higher socioeconomic groups experience the highest lifetime expenditures on long-term care services. Our findings remain robust across various socioeconomic measures and alternative estimation methodologies. CONCLUSION: Improving the health status of lower socioeconomic groups to align with that of higher socioeconomic groups is costly but may ultimately reduce current healthcare expenditures. Enhanced health outcomes likely increase lifespan, leading to extended periods of healthcare consumption. However, since all socioeconomic groups tend to have similar lifetime healthcare expenditures, this prolonged consumption has limited impact on overall lifetime healthcare costs. Additionally, a significant benefit is the deferment of healthcare expenditures into the future. Overall, our results diminish concerns about socially inequitable utilization of healthcare resources while socioeconomic differences in health and longevity persist, even in a universal healthcare system.

[Social inequalities in health]. / Les inégalités sociales de santé.

Social inequalities in health include all the impacts caused by the different social characteristics of individuals on their health. They strongly influence the health status of the French population. Socio-professional category, gender and ethnic origin are all determining factors in the health of people who, however, are not dependent on the healthcare system. Action in the healthcare field will therefore focus on the effects of these inequalities, to limit the number of people who forego healthcare, and to promote collective and individual health.

Adolescents' perceptions of family social status correlate with health and life chances: A twin difference longitudinal cohort study.

Children from lower-income households are at increased risk for poor health, educational failure, and behavioral problems. This social gradient is one of the most reproduced findings in health and social science. How people view their position in social hierarchies also signals poor health. However, when adolescents' views of their social position begin to independently relate to well-being is currently unknown. A cotwin design was leveraged to test whether adolescents with identical family backgrounds, but who viewed their family's social status as higher than their same-aged and sex sibling, experienced better well-being in early and late adolescence. Participants were members of the Environmental Risk Longitudinal Twin Study, a representative cohort of British twins (n = 2,232) followed across the first 2 decades of life. By late adolescence, perceptions of subjective family social status (SFSS) robustly correlated with multiple indicators of health and well-being, including depression; anxiety; conduct problems; marijuana use; optimism; not in education, employment, or training (NEET) status; and crime. Findings held controlling for objective socioeconomic status both statistically and by cotwin design after accounting for measures of childhood intelligence (IQ), negative affect, and prior mental health risk and when self-report, informant report, and administrative data were used. Little support was found for the biological embedding of adolescents' perceptions of familial social status as indexed by inflammatory biomarkers or cognitive tests in late adolescence or for SFSS in early adolescence as a robust correlate of well-being or predictor of future problems. Future experimental studies are required to test whether altering adolescents' subjective social status will lead to improved well-being and social mobility.

The social gradient in adolescent mental health: mediated or moderated by belief in a just world?

PURPOSE: A social gradient in adolescent mental health exists: adolescents with higher socioeconomic status (SES) have fewer mental health problems than their peers with lower SES. Little is known about whether adolescents' societal beliefs play a role in this social gradient. Belief in a just world (BJW) may be a mediator or moderator of the social gradient in adolescent mental health. METHODS: Using data from 848 adolescents (Mage = 17) in the Netherlands, path analyses examined whether two indicators of BJW (general and personal) mediated or moderated the associations between two indicators of SES (family affluence and perceived family wealth), and four indicators of adolescent mental health problems (emotional symptoms, conduct problems, hyperactivity, and peer problems). RESULTS: Adolescents with lower family affluence and lower perceived family wealth reported more emotional symptoms, and the association between perceived family wealth and emotional symptoms was mediated by lower personal and general BJW. Furthermore, higher personal BJW amplified the negative association between SES and peer problems. CONCLUSION: This study suggests BJW may both mediate and amplify the social gradient in adolescent mental health. Adolescents' beliefs about society may be important to include in research aimed at understanding this social gradient.

Proportionate universalism intervention is effective for tackling nutritional social gradient in adolescents: the PRALIMAP-INÈS mixed randomised trial.

OBJECTIVE: This study aimed to investigate the effectiveness of proportionate universalism intervention to reduce the slope of the nutritional social gradient in adolescents. STUDY DESIGN: A mixed (experimental and quasi-experimental) multicentre trial. METHODS: Data from 985 adolescents of the PRALIMAP-INÈS trial (North-eastern France, 2012-2015) were analysed. For this, adolescents were split into five social classes according to the Family Affluence Scale: Highly Less Advantaged (H.L.Ad; n = 33), Less Advantaged (L.Ad; n = 155), Intermediate (Int; n = 404), Advantaged (Ad; n = 324) and Highly Advantaged (H.Ad; n = 69). The overweight care management was a standard care for all and a strengthened one adapted to the social class of adolescents. The main outcome was the 1-year change of the body mass index z-score (BMIz) slope. Other nutritional outcomes were BMI, ΔBMIp95 (BMI minus 95th percentile of the WHO reference), %BMIp95 (percent of 95th percentile of the WHO reference), leisure-time sport, consumption of fruits and vegetables and consumption of sugary foods and drinks. RESULTS: The inclusion data confirmed a weight social gradient expressed by a significant BMIz linear regression coefficient (ß = -0.09 [-0.14 to -0.04], P < 0.0001). The higher the social class, the lower the BMIz. The 1-year BMIz linear regression coefficient was -0.07 [-0.12 to -0.02], corresponding to a significant weight social gradient reduction of 23.3% (ß = 0.021 [0.001 to 0.041]; P = 0.04). Consistent results were found for other nutritional outcomes. CONCLUSIONS: PRALIMAP-INÈS shows that proportionate universalism intervention is effective to reduce the adolescents' nutritional social gradient and suggests that equitable health programmes and policies are a realistic goal.

Socio-economic inequality and healthcare costs over the life course - A dynamic microsimulation approach.

OBJECTIVES: Although there is well-established evidence for the existence of socio-economic inequalities in virtually all dimensions of health, little is known about the implications of these socio-economic disparities for healthcare costs from a cumulative life course perspective. Accounting for differentials in healthcare use patterns and mortality, we assess how lifetime costs differ between socio-economic groups. STUDY DESIGN: This study used dynamic microsimulation modelling. METHODS: Combining price weights for healthcare services with information on healthcare consumption from the 2014 Austrian Health Interview Survey (n = 15,771), we calculated average cost profiles by gender, age and education consistent with aggregate System of Health Accounts. A dynamic microsimulation model was used to project cumulative healthcare costs over the entire lifecycle for the 2019 birth cohort in four different scenarios to illustrate the influence of the different cost determinants on lifetime costs. RESULTS: Before considering social inequalities in mortality, men with compulsory education have close to 66% higher lifetime costs than men with tertiary education; for women, the difference is close to 20%. Accounting for longevity differentials reduces this gap to approximately 40% for men and 10% for women. Closing the gap in healthcare use and in longevity between socio-economic groups would reduce lifetime healthcare expenditure by 4.1% in the 2019 birth cohort and by 19% in the whole population. CONCLUSIONS: Accounting for mortality differentials between socio-economic groups has a large impact on estimated lifetime healthcare costs. Reducing social inequalities in health can contribute to containing healthcare expenditures against the backdrop of rising life expectancy.

Changes in the level of health literacy in Czechia between 2015 and 2020.

During the five years from 2015 to 2020, the proportion of people with limited health literacy decreased by 12%. This finding results from international research on the level of health literacy, which took place since 2019 till 2021 in 17 countries of the European region of the World Health Organization. In total, more than 42,000 respondents were interviewed, in Czechia there were 1,650 respondents. In 2020, however, we recorded a limited level of health literacy in 47% of the population over the age of 18. Respondents have the greatest problems with understanding health information from the media and with assessing different treatment options. Czechs (like Slovaks) have the biggest problem with following the instructions of a doctor or pharmacist. Health literacy is influenced by gender, age and education: women, older people and less educated people show higher levels of health literacy. The respondent's social gradient, primarily subjective social status has positive influence to health literacy while financial deprivation has negative influence. On the other hand, health literacy positively affects the physical activity of the respondent; subjectively perceived health and consumption of medical services are influenced as well. The Czech Health Literacy Institute is currently preparing monitoring in 2024-2025.

How personalisation programs can exacerbate socio-economic inequities: findings from budget utilisation in the Australian National Disability Insurance Scheme.

BACKGROUND: Researchers and policymakers are increasingly concerned that personalisation schemes in social and health care might be worsening social and health inequities. This has been found internationally, where better outcomes from such schemes have been found amongst those who have higher education and more household income. METHOD: This study looks at one of the world's largest personalisation schemes, the Australian National Disability Insurance Scheme. Using publicly available data we examine the allocation and utilisation of NDIS funds according to social gradient. RESULTS: We find that the rate at which people with disability 'spend' or effectively use their disability care funds follows a social gradient. That is, those in areas of higher socioeconomic disadvantage are not spending as much of their allocated budgets on care services across the year compared to people in areas of higher socioeconomic advantage. This represents a clear issue of equity in the use of public money to people with disability in Australia. CONCLUSION: We argue that this points to the need to provide targeted supports for the use of disability care funds in areas of higher socioeconomic disadvantage. Without effective supports for fund use, the NDIS and other personalisation schemes may be positioned to worsen existing social inequalities.

Mediators of socioeconomic differences in overweight and obesity among youth in Ireland and the UK (2011-2021): a systematic review.

BACKGROUND: By 2025, adult obesity prevalence is projected to increase in 44 of 53 of European-region countries. Childhood obesity tracks directly onto adult obesity, and children of low socioeconomic position families are at disproportionately higher risk of being obese compared with their more affluent peers. A previous review of research from developed countries identified factors mediating this relationship. This systematic review updates and extends those findings specifically within the context of Ireland and the United Kingdom. OBJECTIVE: The aim of this systematic review is to summarise peer-reviewed research completed in Ireland and the United Kingdom between 2011-2021 examining mediators of socioeconomic differentials in adiposity outcomes for youth. DESIGN: An electronic search of four databases, Ovid MEDLINE, Embase, Web of Science and EBSCOhost was conducted. Quantitative studies, published in the English language, examining mediators of socioeconomic differentials in adiposity outcomes in youth, and conducted in Ireland and the United Kingdom between 2011-2021 were included. An appraisal of study quality was completed. The systematic review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: Following screening, a total of 23 papers were eligible for inclusion. Results indicate socioeconomic differentials for Ireland and the United Kingdom follow similar patterns to other developed countries and have similar mediating factors including early life and parent-level factors. However, this review identified additional factors that mediate the relationship, namely access to green space and favorable neighborhood conditions. Identifying these factors present further opportunities for potential interventions and confirm the requirement for tailored and appropriate research and interventions for Ireland and the United Kingdom. CONCLUSION: This review identified several modifiable factors that should be considered when planning interventions aimed at reducing socioeconomic differentials in adiposity among youth in Ireland and the United Kingdom. Support was found for interventions to be made as early as possible in an at-risk child's life, with the prenatal and preschool periods considered the most efficacious. Results were equivocal about the role of physical activity in the risk of childhood overweight and obesity. While multi-country analyses provide excellent overviews, country- or area-specific research may produce more nuanced, and potentially more powerful findings, which can help better inform policy responses and interventions.

Profiling the variability and inequity in the residential environment in Cyprus according to citizens' ratings: a cross-sectional internet-based "Place Standard" survey.

BACKGROUND: The "Place Standard Tool" (PST) offers a practical framework for structuring conversations about physical and social dimensions of Place which impact on health and well-being. The aim of this study was to survey citizens' perceptions of Place across diverse settings in Cyprus. While the PST has been extensively used in the context of community engagement, its properties as a measurement tool haven't been explored. METHODS: An open call was addressed to citizens to rate their neighbourhood environment across the 14 PST items (1: large to 7: little room for improvement). Exploratory factor, cluster and regression analyses were used to explore the dimensionality of the scale, depict neighbourhood profiles and explore differences in ratings according to socio-demographic characteristics, area-level census indicators and residents' assessment of neighbourhood social position (10-step ladder). RESULTS: With the exception of safety (M = 4.4, SD = 1.7), 492 participants (mean age 42, 50% residents for > 10 years) from 254 postcodes (21.7% islandwide) did not rate other features favourably, with lowest scores for "influence and sense of control" and "public transport". A stepwise pattern of dissatisfaction was observed along the social position continuum both for features rated less as well as more favourably (e.g. social contact). For instance, among participants who placed their neighbourhood at the three top steps of the ladder, 48.8% gave a low rating for "influence and sense of control", while the equivalent figure was 81.0% at the bottom three steps (OR = 4.5, 95% CI 2.3, 8.6). A clear dimensionality of Built (6 items, Cronbach's α = 0.798), Physical (3 items, α = 0.765), Social (2 items, α = 0.749) and Service (3 items, α = 0.58) environment was identified. A social gradient was evident according to census measures of socio-economic disadvantage (e.g. pre-1980 housing, single-parent households) with larger differences in terms of the built than the social environment. CONCLUSIONS: The study profiled the variability and documented the inequity in the health-related neighbourhood environment across Cypriot communities. The readily interpretable dimensionality of the scale supports its construct validity, allowing calculation of composite scores. The PST can be used as measurement tool in research as well as public health practice to advocate for neighbourhood initiatives which support and enhance citizens' participation.

Who Engaged in Home-Based Arts Activities During the COVID-19 Pandemic? A Cross-Sectional Analysis of Data From 4,731 Adults in the United States.

Arts engagement is a health-related behavior that may be influenced by social inequalities. While the COVID-19 pandemic provided new opportunities for some people to engage in the arts, it might have created barriers for others. We aimed to examine whether there was social patterning in home-based arts engagement during the pandemic in the United States, and whether predictors of engagement differed according to the type of arts activity. We included 4,731 adults who participated in the United States COVID-19 Social Study between April and July 2020. Three types of home-based arts engagement were considered: reading for pleasure, arts or crafts activities, and digital arts activities. Using logistic regression models, we tested cross-sectional associations between a broad range of demographic, socioeconomic, psychosocial, and health-related factors as well as adverse events and worries during lockdown and each type of arts engagement. The factors most strongly associated with all three types of arts engagement were social support, social network size, age, race/ethnicity, keyworker status, and experiencing physical or psychological abuse during the pandemic. However, most socioeconomic and health-related factors were not associated with arts engagement, including household income and mental and physical health problems. Overall, our findings indicate that the social gradient in arts engagement was reduced in the first 4 months of the COVID-19 pandemic in the United States. Given the health benefits of arts engagement, the potential diversification of arts audiences during the pandemic is promising for both population-level health and wellbeing and the future of the arts and cultural sector.

A unified framework to account for selective mortality in lifecycle analyses of the social gradient in health.

This paper establishes a unified framework to fully account for the changing social gradient over the lifecycle in terms of a sufficient set of mobility indices characterizing the coevolution of socioeconomic status and health within each of a series of overlapping cohorts. We proceed to demonstrate the impact of selective mortality on health inequality changes, making use of a counterfactual health distribution for the start of the study period that leaves out those who are known to die before the end. Specifically, initial differences between the average health and educational attainment rank of survivors and nonsurvivors are found in our empirical study to be an increasingly important factor explaining changes in the education-health gradient in older cohorts in Great Britain. Our identification strategy has the advantage that it does not require the imputation of the "would be" health of nonsurvivors, which if carried out using inverse probability weighting procedures-as in several previous studies-is shown to bias estimates of this direct effect of selective mortality toward zero. Parallel results for the income-health gradient exhibit stronger confounding influences due to a number of other factors given that income is a less stable indicator of socioeconomic status in adulthood.

Who engages in the arts in the United States? A comparison of several types of engagement using data from The General Social Survey.

BACKGROUND: Engaging in the arts is a health-related behavior that may be influenced by social inequalities. While it is generally accepted that there is a social gradient in traditional arts and cultural activities, such as attending classical music performances and museums, previous studies of arts engagement in the US have not adequately investigated whether similar demographic and socioeconomic factors are related to other forms of arts engagement. METHODS: Using cross-sectional data from the General Social Survey (GSS) in the US, we examined which demographic, socioeconomic, residential, and health factors were associated with attendance at arts events, participation in arts activities, membership of creative groups, and being interested in (but not attending) arts events. We combined data from 1993 to 2016 in four analytical samples with a sample size of 8684 for arts events, 4372 for arts activities, 4268 for creative groups, and 2061 for interested non-attendees. Data were analysed using logistic regression. RESULTS: More education was associated with increased levels of all types of arts engagement. Parental education demonstrated a similar association. Being female, compared to male, was also consistently associated with higher levels of engagement. Attendance at arts events was lower in participants with lower income and social class, poorer health, and those living in less urban areas. However, these factors were not associated with participation in arts activities or creative groups or being an interested non-attendee. CONCLUSIONS: Overall, we found evidence for a social gradient in attendance at arts events, which was not as pronounced in participation in arts activities or creative groups or interest in arts events. Given the many benefits of engagement in the arts for education, health, and wider welfare, our findings demonstrate the importance of identifying factors to reduce barriers to participation in the arts across all groups in society.

Understanding the excess psychosis risk in ethnic minorities: the impact of structure and identity.

PURPOSE: Psychotic disorders, which are associated with substantially increased morbidity and mortality, are up to five times more common in some ethnic minority groups compared with the white majority in Western countries. This long-standing and well-replicated public mental health disparity has hitherto largely eluded adequate explanation. We argue that this might have arisen in part due to the lack of attention given to theoretical work characterising the complex and multidimensional social nature of ethnicity by those epidemiological investigations that have dominated the literature. METHODS: To bridge this gap, we draw on theoretical and empirical literature from across the social sciences considering the ontological significance of ethnicity (as biology, migration, racialised structures and identity) and its relationships with psychotic disorders to illuminate probable drivers of excess psychosis risk. RESULTS: The largest gains in our theoretical understanding of excess psychosis risk among ethnic minority groups are to be made by considering ethnicity in relation to disempowerment resulting from structural and identity-based exclusion. The former is readily studied through the social gradient in health: socioeconomic disadvantage clusters in some ethnic minorities and increases the risk of poor health outcomes, including psychosis. Furthermore, limitations on identity acquisition and expression imposed by the ethnic majority can further contribute to alienate ethnic minorities and increase psychosocial disempowerment (a lack of control over one's life). CONCLUSION: We theorise that structural and identity-based exclusion act as the primary drivers shaping variation in rates of psychotic disorder by ethnic minority status.

Socioeconomic inequalities in cancer mortality: Is Costa Rica an exception to the rule?

Socioeconomic inequalities in cancer mortality have been described for a range of cancers sites worldwide, using diverse measures of socioeconomic position (SEP). These studies have shown a negative social gradient where lower SEP was associated with greater odds of having cancer, particularly in men. However, there is a lack of information regarding low and middle-income countries. The objective of our study was to analyze the relationship between the socioeconomic characteristics of patients' residential districts and mortality due to cancer in Costa Rica between 2011 and 2017. An ecological study at the level of the district of residence was conducted using the multilevel mixed-effects Poisson regression. All cancer-caused deaths between January 1, 2011 and December 31, 2017 were included (n = 32,117). Eleven cancer sites were analyzed independently. The 477 Costa Rican districts were divided by area (urban/mixed/rural) and wealth using census data. All-cancer combined a significant association between cancer mortality and wealth was found. Cancer mortality was lower in the poorest as compared to the richest districts (IRRQ4 = 0.79 [0.73-0.86]). The majority of cancer sites followed a similar pattern, showing a positive social gradient. These results contradict the international literature mostly conducted in high-income countries. These findings confirmed the importance of conducting studies in middle-income countries, since the socioeconomic and cultural contexts are different from those in high-income countries, which influence the social distribution of lifestyles and risk behaviors.

Physical activity rather than sedentary behaviour is socially determined in French adolescents with overweight and obesity.

Social differences in prevalence of overweight and obesity among adolescents, known as the weight social gradient, could be explained by differences in behaviours between social classes. This study examined the respective association of physical activity (PA), sedentary behaviour (SB) and weight status with adolescents' socioeconomic status. We used cross-sectional data for 1935 adolescents (13-18 years old) with overweight or obesity who participated in the PRALIMAP-INÉS (PRomotion de l'ALImentation et de l'Activité Physique - INÉgalités de Santé) trial conducted in northeastern France between 2012 and 2015. Adolescents completed the International Physical Activity Questionnaire for PA and SB and the Family Affluence Scale for socioeconomic status. Weight status was assessed by the body mass index (BMI) and BMI z-score. Social gradient of weight status, PA and SB were described according to the Family Affluence Scale (slopes) and evidenced by the linear trend test (p). Adolescents' socioeconomic status was positively associated with PA practice (frequency, vigorous PA and leisure-time PA), but there was no association with their SB. The results confirmed a significant weight social gradient: BMI (ß = 0.37, p < .0001) and BMI z-score (ß = 0.07, p = .0001). The weight social gradient in adolescents was mostly associated with PA (5.7% to 8.1%) rather than SB (2.7% to 5.7%). Nearly 14% of BMI z-scores could be related to a combined PA and SB effect. PA was found an important factor of weight social gradient in adolescence. Actions aimed at preventing weight social inequalities among adolescents could include PA promotion as lever. CLINICAL TRIALS REGISTRY AND NUMBER: ClinicalTrials.gov (NCT01688453).

The effects of different lookback periods on the sociodemographic structure of the study population and on the estimation of incidence rates: analyses with German claims data.

BACKGROUND: Defining incident cases has always been a challenging issue for researchers working with routine data. Lookback periods should enable researchers to identify and exclude recurrent cases and increase the accuracy of the incidence estimation. There are different recommendations for lookback periods depending on a disease entity of up to 10 years. Well-known drawbacks of the application of lookback periods are shorter remaining observation period in the dataset or smaller number of cases. The problem of selectivity of the remaining population after introducing lookback periods has not been considered in the literature until now. METHODS: The analyses were performed with pseudonymized claims data of a German statutory health insurance fund with annual case numbers of about 2,1 million insured persons. Proportions of study population excluded due to the application of lookback periods are shown according to age, occupational qualification and income. Myocardial infarction and stroke were used to demonstrate changes in incidence rates after applying lookback periods of up to 5 years. RESULTS: Younger individuals show substantial dropouts after the application of lookback periods. Furthermore, there are selectivities regarding occupational qualification and income, which cannot be handled by age standardization. Due to selective dropouts of younger individuals, crude incidence rates of myocardial infarction and stroke increase after applying lookback periods. Depending on the income group, age-standardized incidence rates changed differentially, leading to a decrease and possible underestimation of the social gradient after applying lookback periods. CONCLUSIONS: Selectivity analyses regarding age and sociodemographic structure should be performed for the study population after applying lookback periods since the selectivity can affect the outcome especially in health care research. The selectivity effects might occur not only in claims data of one health insurance fund, but also in other longitudinal data with left- or right-censoring not covering the whole population. The effects may also apply to health care systems with a mix of public and private health insurance. A trade-off has to be considered between selectivity effects and eliminating recurrent events for more accuracy in the definition of incidence.

Prevalence of disability among the major cities in Australia 2012 with geographical representation of distribution in Western Australia.

ISSUE ADDRESSED: The aim of this study was to use a novel approach to geographically model the relationship between socio-economic disadvantage and prevalence of profound and severe disability. METHOD: This study used national census data and the survey of disability, ageing and carers data to geographically model the relationship between socio-economic disadvantage and prevalence of profound and severe disability. RESULT: The results in this study show that there were more people living in the least disadvantaged areas (wealthiest) when compared to the most disadvantaged (poorest) areas. Whereas for people with a disability as the relative socio-economic disadvantage of the area increased, the number of people reporting any disability also increased, with the highest number coming from the most disadvantaged areas. The maps show a significant distribution with fewer cases of disability in metropolitan areas and relatively higher number in the rural area along with the higher proportion of people with disability living in the relatively more disadvantaged areas. CONCLUSION: Socio-economic profile is one of the key factors influencing the various aspects of health and hence should hold an important place during policy making. Policy should be formulated and implemented to help reduce the inequality by either directly aiming at the most disadvantaged group or by trying to bridge the gap between them. SO WHAT?: This paper provides a geographic visualisation of the distribution of people with profound and severe disability to help identify priority areas with high prevalence of disability.

Marital Transitions and Depressive Symptoms among Older Adults: Examining Educational Differences.

BACKGROUND: Later decades of the life course have undergone rapid transformations due to demographic changes in ageing societies, such as more frequent occurrences of later-life marital transitions. Adaption to these transitions, even when welcomed, brings novel chances and challenges in negotiating new social roles in old age, which could reinforce preexisting disparities in the acquisition and mastery of resources, social ties, and coping strategies. OBJECTIVES: Because the ability to weather later-life marital transitions may depend on the long arm of education acquired earlier in the life course, the present study aims to identify and track trends in the prevalence of marriage, divorce/separation, and widowhood among sociodemographic subgroups; link the occurrence of those transitions with mental health; and test the influence of educational attainment on these associations. METHODS: We employ an intraindividual, within-person approach to quantify the occurrence of marital transitions and their impact using data from the Health and Retirement Study (n = 22,013; 1992-2010). Measures of transition occurrence, depressive symptoms, and educational attainment were available across up to 10 biennial assessments. RESULTS: Individuals with less than a high school diploma displayed the highest likelihood of losing their significant other through divorce/separation or death. Marital loss was associated with increasing, and marital gain with decreasing, depressive symptoms. Compared to those with less than a high school diploma, individuals with a high school or general equivalency diploma exhibited larger increases in depressive symptoms associated with widowhood, even though their average levels of depressive symptoms were lower in the absence of this transition. CONCLUSIONS: Our findings revealed a predictable educational gradient for the occurrence of marital transitions and later-life mental health. Yet higher, formalized education did not protect the participants from increased depression in the presence of a loss-related transition, which could suggest that the strains of spousal loss may to some degree function as a leveler of the preexisting social inequalities of stratified life courses. We conclude that the benefits conferred by education are not necessarily ubiquitous, and its impact on the adaptation to spousal loss may be more complex and nuanced depending on the range of prior experiences and available coping strategies.

Comparison of national cross-sectional breast-feeding surveys by maternal education in Europe (2006-2016).

OBJECTIVE: Breast-feeding is an important determinant of health of mothers and their offspring. The present study aimed to compare breast-feeding rates across Europe disaggregated by maternal education and establish what proportion achieves at least 50 % exclusive breast-feeding (EBF) at 6 months.Design/SettingSecondary analysis of national or sub-national studies' breast-feeding data for EU Member States plus Norway and Iceland, published in 2006-2016. Nineteen EU Member States plus Norway reported rates of EBF and any breast-feeding disaggregated by maternal education, of which only thirteen could be matched to the International Standard Classification of Education.ParticipantsMothers and their infants aged 0-12 months. RESULTS: Data on EBF rates at 6 and 4 months were found in only four and six countries, respectively. At 6 months, EBF rates of 49 % in Slovakia and 44 % in Hungary were closest to WHO's target of at least 50 % EBF. At 4 months, mothers with high education level in Denmark, the Netherlands and Germany had the highest EBF rates (71, 52 and 50 %, respectively). Mothers with low education level were less likely to initiate breast-feeding and cessation occurred early. The inequality gap ranged from 63 % in Irish mothers to no gap or very low levels of inequality in Poland, Sweden and Norway. CONCLUSIONS: More mothers with high, compared with low, education initiate breast-feeding and practise EBF for longer. More European policies should be targeted to protect, support and promote breast-feeding, especially among mothers with only mandatory education.