Smoking among immigrants in Norway: a cross-sectional study.

BACKGROUND: Smoking among immigrants varies by country background and is high in some groups. More detailed information about smoking prevalence by country background and sociodemographic factors is needed to target interventions. METHODS: Data from the Survey on Living Conditions among immigrants 2016 were used, including immigrants from 12 countries and with ⩾2 years of residence (N = 3565). Data on smoking (daily and occasional) by country of birth, sex, age group, education, duration of residence, age at immigration, proficiency in the Norwegian language, and social support were reported. RESULTS: The highest proportions of daily smokers were seen among immigrants from Turkey (36%), Poland (34%), and Vietnam (29%) for men, and from Turkey (22%), Bosnia-Herzegovina (18%), and Poland (17%) for women. Differences in smoking by sociodemographic factors varied with country background, but for several groups of men, the lowest proportions of smokers were seen among those with the highest educational level, those who were employed, and those who immigrated during childhood or adolescence. CONCLUSIONS: Policies are warranted that target smoking among immigrant men in general, and particularly among men from Turkey, Poland, and Vietnam, as well as for women from Turkey, Bosnia-Herzegovina, and Poland.

Occupational risk of COVID-19 by country of birth. A register-based study.

BACKGROUND: Occupational exposure has been suggested to contribute to a disproportionate burden of COVID-19 among immigrants. We aim to assess this hypothesis in Norway. METHODS: In 2729 627 adults born in Norway, Somalia, Pakistan, Iraq, Afghanistan and Turkey, we examined whether persons employed as taxi drivers, bus and tram drivers, child care workers, nurses, personal care workers in health, food service counter attendants, waiters/bartenders, cleaners and shop sale persons had a higher risk of COVID-19, from 1 April 2020 to 2 December 2020, compared with (i) Norwegian-born in the same occupational group and (ii) all others with the same birth country and aged 20-70 years, using logistic regressions. RESULTS: Within each occupational group, immigrants had a greatly increased odds of COVID-19 when compared with Norwegian-born (odds ratio [OR] ~ 1.66-12.72). However, immigrants working in the selected occupations had the same odds of COVID-19 as person with same birth country not having the same occupation (OR ~ 1). Exceptions were Somalian, Afghani and Iraqi personal care workers in health services who had an increased odds of COVID-19 compared with others from the same country. CONCLUSION: Occupation is not an important driver of the high rates of COVID-19 among immigrants from Somalia, Pakistan, Iraq, Afghanistan and Turkey.

Health risks among long-term immigrants in Norway with poor Norwegian language proficiency.

BACKGROUND: Poor health among immigrants has been associated with longer duration of residence in the host country, poor host language proficiency and low education. However, the interplay among these factors is under-studied. OBJECTIVE: To assess health among immigrants in Norway by combinations of duration of residence, Norwegian language proficiency and education. METHODS: In 2015/2016 Statistics Norway carried out two cross-sectional Living Conditions Surveys in the general adult population (N=5703, response rate 59%) and among immigrants from 12 countries, with ⩾2 years of residence (N=3993, response rate 54%). Health outcomes (poor self-reported health, diabetes, cardiovascular disease, hypertension, obesity, mental health problems, back/neck pain) were assessed with logistic regressions according to combinations of duration of residence, Norwegian language proficiency and education. RESULTS: Negative health conditions were more common among immigrants than in the general population, and varied by duration of residence, proficiency in the Norwegian language and education. In age- and sex-adjusted regressions, immigrants had higher odds of all negative health conditions, except hypertension, regardless of their duration of residence, proficiency of the Norwegian language and educational level. Immigrants with a long duration of residence and poor proficiency in the Norwegian language had the highest odds of negative health conditions. CONCLUSIONS: Special attention is warranted towards health among immigrants who have lived in Norway the longest without acquiring good Norwegian language proficiency.

Proficiency in the Norwegian language and self-reported health among 12 immigrant groups in Norway: A cross-sectional study.

BACKGROUND: Migration presents numerous significant changes in a person's life, physically, emotionally and socially. How health develops in the host country depends on a range of factors, including language proficiency. We aimed to investigate associations between language proficiency and health. METHODS: Statistics Norway carried out the Living Conditions Survey for Immigrants (2016), conducting telephone (82%) or face-to-face (18%) interviews with immigrants (two or more years of residence) from 12 countries. The survey collected data on self-reported proficiency in the Norwegian language, health and socio-economic variables, and included 4077 people aged 16-66 years. RESULTS: In logistic regression models adjusted for age, sex and duration of residence, poor or medium self-reported Norwegian proficiency, as compared to good, was associated with poorer health outcomes, including lower odds of self-rated health (odds ratio (OR)=0.46; 95% confidence interval (CI) 0.39-0.54) and higher odds of hypertension (OR=1.74; 95% CI 1.34-2.26), back or neck pain (OR=1.52; 95% CI 1.28-1.80), mental health problems (OR=1.34; 95% CI 1.09-1.65), sleep disturbances (OR=1.51; 95% CI 1.23-1.86) and being overweight (OR=1.20; 95% CI 1.03-1.40). Adjustment for socio-economic status attenuated the associations, but further adjustments for perceived discrimination and lifestyle (smoking and physical activity) did not further alter the estimates. CONCLUSIONS: Host language proficiency has implications for health among immigrants. Equitable access to health services and quality of care requires adjustment to the language level needs of patients. Facilitating language learning for immigrants may be vital in providing access to health services and supporting newcomers in being more active participants in managing their health.

Variation in disease in children according to immigrant background.

BACKGROUND: A growing proportion of children born in Europe are born to immigrant parents. Knowledge about their health is essential for preventive and curative medicine and health services planning. OBJECTIVE: To investigate differences in diagnoses given in secondary and tertiary healthcare between Norwegian-born children to immigrant and non-immigrant parents. METHODS: Data from the Medical Birth Registry of Norway, the Norwegian Patient Registry and Statistics Norway were linked by the national personal identification number. The study population included children born in Norway aged 0-10 years between 2008 and 2018 (N=1,015,267). Diagnostic categories from three main domains of physical health, given in secondary or tertiary care; infections, non-infectious medical conditions and non-infectious neurological conditions were included from 2008 onwards. Hazards of diagnoses by immigrant background were assessed by Cox regressions adjusted for sex and birth year. RESULTS: Children of immigrants generally had higher hazards than children with Norwegian background of some types of infections, obesity, nutrition-related disorders, skin diseases, blood disease and genital disease. Children of immigrants from Africa also had higher hazards of cerebral palsy, cerebrovascular diseases and epilepsy. Conversely, most groups of children of immigrants had lower hazards of acute lower respiratory tract infections, infections of the musculoskeletal system, infections of the central nervous system, diseases of the circulatory system, hearing impairment, immune system disorders, chronic lower respiratory disease and headache conditions. CONCLUSIONS: Children of immigrants did not present with overall worse health than children without immigrant background, but the distribution of health problems varied between groups.

Obesity diagnoses in children and adolescents in Norway by immigrant background.

AIM: Relatively few obese children and adolescents receive specialist treatment. Our aim was to assess associations between risk of receiving an obesity diagnosis in secondary/tertiary health services by socio-economic position and immigrant background in order ultimately to improve equity in health services. METHODS: The study population comprised Norwegian-born children aged 2-18 years between 2008 and 2018 (N=1,414,623), identified via the Medical Birth Registry. Cox regressions were used to calculate hazard ratios (HR) of an obesity diagnosis from secondary/tertiary health services (Norwegian Patient Registry) by parental education and household income and by immigrant background. RESULTS: Higher parental education and household income were associated with a lower hazard of obesity diagnosis regardless of Norwegian versus immigrant background. Compared to having a Norwegian background, having a Latin American (HR=4.12; 95% confidence interval (CI) 3.18-5.34), African (HR=1.54; 95% CI 1.34-1.76) and Asian (HR=1.60; 95% CI 1.48-1.74) background was associated with higher hazard of obesity diagnosis. Adjusted for parental education and household income, corresponding HRs were 3.28 (95% CI 2.95-3.65) for Latin America, 0.95 (95% CI 0.90-1.01) for Africa and 1.08 (95% CI 1.04-1.11) for Asia. Within Asia, those with a background from Pakistan, Turkey, Iraq and Iran had higher hazards than those with a Norwegian background, while those with a background from Vietnam had lower hazards, even after adjusting for parental education and household income. CONCLUSIONS: To ensure more equitable treatment, more knowledge is warranted about health-service access and referral patterns, and underlying population prevalence rates, for obese children and adolescents with different immigrant backgrounds.

Immigrant and ethnic minority patients` reported experiences in psychiatric care in Europe - a scoping review.

BACKGROUND: There is little evidence on experiences in psychiatric care treatment among patients with immigrant or ethnic minority background. Knowledge about their experiences is crucial in the development of equal and high-quality services and is needed to validate instruments applied in national patient experience surveys in Norway. The aim of this scoping review is to assess and summarize current evidence on immigrant and ethnic minorities` experiences in psychiatric care treatment in Europe. METHODS: Guidelines from the Joanna Briggs Institute were followed and the research process adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. The literature search was carried out in Medline, Cinahl, Web of Science, Cochrane database of systematic reviews, Embase, and APA PsychInfo, up to Dec 2022, for articles on immigrant patients` experiences in psychiatric care. Reference lists of included articles were screened for additional relevant articles. Titles and abstracts were screened, and potentially relevant articles read in full-text, by two researchers. Evidence was extracted using an a priori extraction form and summarized in tables and text. Any disagreement between the reviewers regarding inclusion of articles or extracted information details were resolved through discussion between authors. RESULTS: We included eight studies in the scoping review. Immigrant and ethnic minority background patients did not differ from the general population in quantitative satisfaction questionnaires. However, qualitative studies showed that they experience a lack of understanding and respect of own culture and related needs, and difficulties in communication, which do not seem to be captured in questionnaire-based studies. CONCLUSION: Raising awareness about the importance of respect and understanding for patients` cultural background and communication needs for treatment satisfaction should be addressed in future quality improvement work.

The correlation between socioeconomic factors and COVID-19 among immigrants in Norway: a register-based study.

AIM: Immigrants in Norway have higher COVID-19 notification and hospitalisation rates than Norwegian-born individuals. The knowledge about the role of socioeconomic factors to explain these differences is limited. We investigate the relationship between socioeconomic indicators at group level and epidemiological data for all notified cases of COVID-19 and related hospitalisations among the 23 largest immigrant groups in Norway. METHODS: We used data on all notified COVID-19 cases in Norway up to 15 November 2020, and associated hospitalisations, from the Norwegian Surveillance System for Communicable Diseases and the emergency preparedness register at the Norwegian Institute of Public Health. We report notified COVID-19 cases and associated hospitalisation rates per 100,000 and their correlation to income, education, unemployment, crowded housing and years of residency at the group level. RESULTS: Crowded housing and low income at a group level were correlated with rates of both notified cases of COVID-19 (Pearson`s correlation coefficient 0.77 and 0.52) and related hospitalisations (0.72, 0.50). In addition, low educational level and unemployment were correlated with a high number of notified cases. CONCLUSIONS: Immigrant groups living in disadvantaged socioeconomic positions are important to target with preventive measures for COVID-19. This must include targeted interventions for low-income families living in overcrowded households.

COVID-19 vaccination coverage by immigrant background. / Vaksinasjonsdekning mot covid-19 etter innvandrerbakgrunn.

BACKGROUND: High vaccination coverage against COVID-19 limits COVID-19-related infections, hospitalisations and deaths. Studies have shown varying vaccine willingness and vaccine coverage in different minority groups. This study investigates the vaccination coverage among persons with various immigration and country backgrounds in Norway. MATERIAL AND METHOD: The study includes all persons over 18 years of age resident in Norway with a Norwegian national identity number. We used data from Beredt C19, the Norwegian emergency preparedness register for COVID-19, and investigated the association between vaccine status and immigrant and country background using logistic regression models, adjusted for income, education, sex, age, medical risk group and place of residence. RESULTS: Foreign- and Norwegian-born persons with foreign-born parents had a lower COVID-19 vaccine coverage than those who were Norwegian-born with Norwegian-born parents. Vaccination coverage for different country backgrounds varied from around 45 % for persons from Latvia, Bulgaria, Poland, Romania and Lithuania to 92 % for persons from Vietnam, Thailand and Sri Lanka. Those in the former group had from 15 to 18 times (unadjusted) and from 8 to 11 times (adjusted) higher odds of not having been vaccinated as persons with a country background from Norway. INTERPRETATION: There is considerable variation in COVID-19 vaccine coverage between different immigrant groups in Norway. The differences can be explained to some extent by income and education, but this does not explain the bulk of the observed differences. We cannot rule out the possibility that some differences are attributable to weaknesses in the registers.

COVID-19 vaccination among immigrants from Europe and in their countries of birth. / Covid-19-vaksinasjon blant innvandrarar frå Europa og i fødelanda deira.

BACKGROUND: Vaccination coverage for COVID-19 varies among immigrant groups in Norway and between different countries. Most likely, childhood/adolescence and consistent contact with the country of birth help form the attitudes to and the desire for vaccination. We therefore compared the vaccination rate among European-born immigrants in Norway and the vaccination coverage in their countries of birth. MATERIAL AND METHOD: Vaccination coverage, the percentage of the adult population that had received at least one vaccination dose, for 22 European countries with universal access to vaccines by 31 August 2021 was retrieved from the European Centre for Disease Prevention and from the Norwegian emergency preparedness register for COVID-19 for the equivalent immigrant groups in Norway on 30 September 2021. Scatter plots with least-squares regression lines showed the association between the vaccination coverage in the country of birth and the rate in the equivalent immigration group in Norway, in total and by time of residence in Norway (< 6 years and ≥ 6 years). RESULT: The model estimated an increase in the vaccination rate in immigrant groups in Norway of 0.64 percentage points for each percentage point increase in the vaccination coverage in their European countries of birth, and explained 63 % of the variation in the vaccination rate in the immigrant groups. There was no statistically significant difference in the co-variation with the country of birth when comparing immigrants with short versus long time of residence. INTERPRETATION: There is a correlation between the vaccination rate for COVID-19 among European-born immigrants in Norway and the coverage in their countries of birth. Attitudes to and desire for vaccination varies between countries and can explain part of the observed differences between immigrant groups in Norway.

COVID-19 among immigrants in Norway, notified infections, related hospitalizations and associated mortality: A register-based study.

Aim: Research concerning COVID-19 among immigrants is limited. We present epidemiological data for all notified cases of COVID-19 among the 17 largest immigrant groups in Norway, and related hospitalizations and mortality. Methods: We used data on all notified COVID-19 cases in Norway up to 18 October 2020, and associated hospitalizations and mortality, from the emergency preparedness register (including Norwegian Surveillance System for Communicable Diseases) set up by The Norwegian Institute of Public Health to handle the pandemic. We report numbers and rates per 100,000 people for notified COVID-19 cases, and related hospitalizations and mortality in the 17 largest immigrant groups in Norway, crude and with age adjustment. Results: The notification, hospitalization and mortality rates per 100,000 were 251, 21 and five, respectively, for non-immigrants; 567, 62 and four among immigrants; 408, 27 and two, respectively, for immigrants from Europe, North-America and Oceania; and 773, 106 and six, respectively for immigrants from Africa, Asia and South America. The notification rate was highest among immigrants from Somalia (2057), Pakistan (1868) and Iraq (1616). Differences between immigrants and non-immigrants increased when adjusting for age, especially for mortality. Immigrants had a high number of hospitalizations relative to notified cases compared to non-immigrants. Although the overall COVID-19 notification rate was higher in Oslo than outside of Oslo, the notification rate among immigrants compared to non-immigrants was not higher in Oslo than outside. Conclusions: We observed a higher COVID-19 notification rate in immigrants compared to non-immigrants and much higher hospitalization rate, with major differences between different immigrant groups. Somali-, Pakistani- and Iraqi-born immigrants had especially high rates.

Early adulthood weight, subsequent midlife weight change and risk of cardiovascular disease mortality: an analysis of Norwegian cardiovascular surveys.

BACKGROUND: The time between early adulthood and midlife is important for obesity development. There is paucity of studies using objectively measured body mass index (BMI) at both time points with full range of midlife cardiovascular risk factors. We aimed to investigate the risk of cardiovascular disease (CVD) mortality associated with different levels of objectively measured change in body weight from early adulthood to midlife, and to assess whether risk is primarily explained by midlife cardiovascular risk factors. METHODS: Pooled data from Norwegian health surveys (1985-2003), Tuberculosis screenings, Conscript data and the Norwegian Educational database were linked to the Cause of Death Registry. Health survey participants with data on objectively measured weight and height in both early adulthood (18-20 years) and midlife (40-50 years) were included, n = 148,021. Cox regression models were used to assess associations between weight change and CVD mortality. RESULTS: Total analysis time included 2,841,174 person years. Mean follow-up was 19 (standard deviation 4) years. Participants being normal weight in early adulthood and obese in midlife had a hazard ratio (HR) of CVD mortality of 2.09 (95% CI 1.74-2.50) relative to those who were normal weight at both times. The corresponding HR of those being obese at both times was 5.15 (3.61-7.36). Adjustment for CVD risk factors attenuated these associations. Gaining ≥15 kg between early adulthood and midlife was associated with higher CVD mortality after adjustment for early adulthood weight (HR 1.51 (1.20-1.89)), and for smoking and education (HR 1.63 (1.30-2.04)), however not after adjustment for mediating CVD risk factors. CONCLUSIONS: Obesity both in early adulthood and in midlife was associated with CVD mortality. Weight gain of ≥15 kg from early adulthood to midlife was also associated with CVD mortality, but not after adjustment for mediating CVD risk factors.

Patient experiences with general practice in Norway: a comparison of immigrant groups and the majority population following a national survey.

BACKGROUND: Patient experience is an important indicator of quality of health care. In Norway, little is known about the quality of health care for immigrants. The aim of this study was to compare patient-reported experiences with general practice between the Norwegian-born population and immigrant groups. METHODS: We performed secondary analyses of data from a national survey on patient experiences with general practice, including assessments of general practitioners (GPs) and their GP offices. The survey was carried out in Norway in 2018-19. The total number of respondents was 2029, with a response rate of 42.6%. Region of birth was available for 1981 participants, and these were included in the analyses ("Norway" (N = 1756), "Asia, Africa or South America" (N = 95), "Eastern Europe" (N = 70) and "Western Europe, North America or Oceania" (N = 60)). Five indicators of patient experiences were used as dependent variables in bivariate and multivariate analyses, with region of birth as the main exposure variable and other background variables about the patient as adjustment variables: "the GP" (measures related to communication and competency), "auxiliary staff" (politeness, competency, organization), "accessibility" (waiting times), "coordination" (with other services) and `enablement` (GP facilitates coping with/understanding illness). RESULTS: Immigrants as a whole reported poorer experiences with general practice than the majority population, with significantly poorer scores on four of five patient experience indicators. Patients from Asia/Africa/South America reported poorer experiences than those from Norway on the indicators "GP", "auxiliary staff", "accessibility" and "coordination": on a scale from 0 to 100 where 100 is the best, the difference ranged from 7.8 (GP) to 20.3 (accessibility). Patients from Eastern Europe reported lower scores on "GP" and patients from Western Europe/North America/Oceania reported lower scores on "auxiliary staff". These associations were still significant after adjustment for sex, age, self-rated physical and mental health, number of contacts with the GP and education. CONCLUSIONS: For countries with a substantial proportion of foreign-born patients in the health system, immigrant background is an important parameter in quality improvement work. Immigrant background is also an important parameter in health service research.

Effects of dietary and physical activity interventions on the risk of type 2 diabetes in South Asians: meta-analysis of individual participant data from randomised controlled trials.

AIMS/HYPOTHESIS: Individuals of South Asian origin have a high risk of type 2 diabetes and of dying from a diabetes-attributable cause. Lifestyle modification intervention trials to prevent type 2 diabetes in high-risk South Asian adults have suggested more modest effects than in European-origin populations. The strength of the evidence of individual studies is limited, however. We performed an individual participant data meta-analysis of available RCTs to assess the effectiveness of lifestyle modification in South Asian populations worldwide. METHODS: We searched PubMed, EMBASE, Cochrane Library and Web of Science (to 24 September 2018) for RCTs on lifestyle modification interventions incorporating diet and/or physical activity in South Asian adults. Reviewers identified eligible studies and assessed the quality of the evidence. We obtained individual participant data on 1816 participants from all six eligible trials (four from Europe and two from India). We generated HR estimates for incident diabetes (primary outcome) and mean differences for fasting glucose, 2 h glucose, weight and waist circumference (secondary outcomes) using mixed-effect meta-analysis overall and by pre-specified subgroups. We used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system to rate the quality of evidence of the estimates. The study is registered with the International Prospective Register of Systematic Reviews ([PROSPERO] CRD42017078003). RESULTS: Incident diabetes was observed in 12.6% of participants in the intervention groups and in 20.0% of participants in the control groups. The pooled HR for diabetes incidence was 0.65 (95% CI 0.51, 0.81; I2 = 0%) in intervention compared with control groups. The absolute risk reduction was 7.4% (95% CI 4.0, 10.2), with no interactions for the pre-specified subgroups (sex, BMI, age, study duration and region where studies were performed). The quality of evidence was rated as moderate. Mean difference for lifestyle modification vs control groups for 2 h glucose was -0.34 mmol/l (95% CI -0.62, -0.07; I2 = 50%); for weight -0.75 kg (95% CI -1.34, -0.17; I2 = 71%) and for waist -1.16 cm (95% CI -2.16, -0.16; I2 = 75%). No effect was found for fasting glucose. Findings were similar across subgroups, except for weight for European vs Indian studies (-1.10 kg vs -0.08 kg, p = 0.02 for interaction). CONCLUSIONS/INTERPRETATION: Despite modest changes for adiposity, lifestyle modification interventions in high-risk South Asian populations resulted in a clinically important 35% relative reduction in diabetes incidence, consistent across subgroups. If implemented on a large scale, lifestyle modification interventions in high-risk South Asian populations in Europe would reduce the incidence of diabetes in these populations.

The prevalence of selected risk factors for non-communicable diseases in Hargeisa, Somaliland: a cross-sectional study.

BACKGROUND: Non-communicable diseases (NCDs), particularly cardiovascular diseases, diabetes, respiratory conditions and cancers, are the most common causes of morbidity and mortality globally. Information on the prevalence estimates of NCD risk factors such as smoking, low fruit & vegetable intake, physical inactivity, raised blood pressure, overweight, obesity and abnormal blood lipid are scarce in Somaliland. The aim of this study was to determine the prevalence of these selected risk factors for NCDs among 20-69 year old women and men in Hargeisa, Somaliland. METHODS: A cross-sectional study was conducted in five districts of Hargeisa (Somaliland), using the STEPwise approach to noncommunicable disease risk factor surveillance (STEPS) to collect data on demographic and behavioral characteristics and physical measurements (n = 1100). The STEPS approach is a standardized method for collecting, analysing and disseminating data on NCD risk factor burden. Fasting blood sugar, serum lipids (total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), and triglycerides) were collected in half of the participants. RESULTS: The vast majority of participants had ≤1 serving of fruits daily (97.7%) and ≤ 1 serving of vegetables daily (98.2%). The proportion of participants with low physical activity levels was 78.4%. The overall prevalence of high salt intake was 18.5%. The prevalence of smoking and khat chewing among men was 27 and 37% respectively, and negligible among women. In women, the prevalence of hypertension increased from 15% in the age group 20-34 years to 67% in the age group 50-69 years, the prevalence of overweight and obesity (BMI ≥ 25 kg/m2) from 51 to 73%, and the prevalence of diabetes from 3 to 22%. Similar age-trends were seen in men. CONCLUSION: Most of the selected risk factors for noncommunicable diseases were high and increased by age in both women and men. Overweight and obesity and low physical activity needs intervention in women, while hypertension and low fruit and vegetable consumption needs intervention in both men and women. Somaliland health authorities should develop and/or strengthen health services that can help in treating persons with hypertension and hyperlipidaemia, and prevent a future burden of NCDs resulting from a high prevalence of NCD risk factors.

The association between obesity and cardiovascular disease mortality in different strata of socioeconomic position: evidence from pooled Norwegian health surveys.

BACKGROUND: Socioeconomic position (SEP) is related to both obesity and cardiovascular disease (CVD). There is little evidence on whether SEP modifies the relation between obesity and CVD. The aim of the study was to investigate whether the association between obesity and CVD mortality is stronger among people with disadvantaged than among people with advantaged life course SEP. METHODS: Data from Norwegian population-based cardiovascular health surveys (1985-2003), including body mass index and CVD risk factors (cholesterol, blood pressure, smoking, current treatment for hypertension) were linked to socioeconomic indicators from register and census data (1960-90), and to the Cause of Death Registry (up until 2014). The total number of participants was 398 297. RESULTS: In comparison with normal weight, the age-adjusted hazard ratios and 95% confidence intervals of CVD mortality among obese participants were 2.39 (2.07-2.75) and 2.08 (1.70-2.53) among men and women with high SEP, respectively and 1.88 (1.60-2.21) and 1.75 (1.43-2.14) among men and women with low SEP. Adjustment for CVD risk factors attenuated the results in a similar manner in all SEP groups, and among both women and men. CONCLUSION: Obesity was consistently associated with a higher risk of CVD mortality, with only minor variation according to SEP. This means that preventing or treating obesity is, for the purpose of reducing CVD risk, equally important for an individual with high or low SEP.

The educational gradient in cardiovascular risk factors: impact of shared family factors in 228,346 Norwegian siblings.

BACKGROUND: Various indicators of childhood socioeconomic position have been related to cardiovascular disease (CVD) risk in adulthood. We investigated the impact of shared family factors on the educational gradient in midlife CVD risk factors by assessing within sibling similarities in the gradient using a discordant sibling design. METHODS: Norwegian health survey data (1980-2003) was linked to educational and generational data. Participants with a full sibling in the health surveys (228,346 individuals in 98,046 sibships) were included. Associations between attained educational level (7-9 years, 10-11 years, 12 years, 13-16 years, or >16 years) and CVD risk factor levels in the study population was compared with the corresponding associations within siblings. RESULTS: Educational gradients in risk factors were attenuated when factors shared by siblings was taken into account: A one category lower educational level was associated with 0.7 (95% confidence interval 0.6 to 0.8) mm Hg higher systolic blood pressure (27% attenuation), 0.4 (0.4 to 0.5) mmHg higher diastolic blood pressure (30%), 1.0 (1.0 to 1.1) more beats per minute higher heart rate (21%), 0.07 (0.06 to 0.07) mmol/l higher serum total cholesterol (32%), 0.2 (0.2 to 0.2) higher smoking level (5 categories) (30%), 0.15 (0.13 to 0.17) kg/m2 higher BMI (43%), and 0.2 (0.2 to 0.2) cm lower height (52%). Attenuation increased with shorter age-difference between siblings. CONCLUSION: About one third of the educational gradients in modifiable CVD risk factors may be explained by factors that siblings share. This implies that childhood environment is important for the prevention of CVD.

Changes in prevalence, awareness, treatment and control of hypertension from 2004 to 2014 among 25-74-year-old citizens in the Yangon Region, Myanmar.

BACKGROUND: Hypertension is the leading risk factor for cardiovascular diseases, and little is known about trends in prevalence, awareness, treatment and the control of hypertension in Myanmar. This study aims at evaluating changes from 2004 to 2014 in the prevalence, awareness, treatment and control of hypertension in the Yangon Region, Myanmar, and to compare associations between hypertension and selected socio-demographic, behavioural- and metabolic risk factors in 2004 and 2014. METHODS: In 2004 and 2014, household-based cross-sectional studies were conducted in urban and rural areas of Yangon Region using the WHO STEPS protocol. Through a multi-stage cluster sampling method, a total of 4448 and 1486 participated in 2004 and 2014, respectively, with the response rates above 89%. RESULTS: From 2004 to 2014, there was a significant increase in the age-standardized prevalence of hypertension from 26.7% (95% CI:24.4-29.1) - 34.6% (32.2-37.1), as well as an awareness from 19.4% (17.2-21.9) to 27.8% (24.9-31.0), while treatment and control rates did not change. The age-standardized mean systolic blood pressure increased from 122.8 (SE) ± 0.82 mmHg in 2004 to 128.1 ± 0.53 mmHg in 2014, whereas diastolic blood pressure increased from 76.2 ± 0.35 mmHg to 80.9 ± 0.53 mmHg. In multivariate analyses, hypertension was significantly associated with age, alcohol consumption, overweight and diabetes in both 2004 and 2014, and additionally associated with low physical activity and hypercholesterolemia in 2004. Combining all data, a significant association between study-year and hypertension persisted in different models with an adjustment for socio-demographic variables and behavioural variables, but not when adjusting for a combination of socio-demographic variables, the metabolic variables, BMI and hypercholesterolemia. CONCLUSION: The prevalence of hypertension has risen from 2004 to 2014 in both urban and rural areas of the Yangon Region, while, the awareness, treatment and control rate of hypertension remains low in urban and rural areas among both males and females. It is likely that changes in the metabolic variables, BMI and hypercholesterolemia have contributed to an increase in the prevalence of hypertension from 2004 to 2014. Factors associated with hypertension in both study years were age, alcohol consumption, overweight and diabetes. A national hypertension control programme should be implemented in order to reduce premature deaths in Myanmar.

Urban-rural differences in the prevalence of non-communicable diseases risk factors among 25-74 years old citizens in Yangon Region, Myanmar: a cross sectional study.

BACKGROUND: Recent societal and political reforms in Myanmar may upturn the socio-economy and, thus, contribute to the country's health transition. Baseline data on urban-rural disparities in non-communicable disease (NCD) risk factors are not thoroughly described in this country which has been relatively closed for more than five decades. We aim to investigate urban-rural differences in mean values and the prevalence of selected behavioral and metabolic risk factors for non-communicable diseases and 10-years risk in development of coronary heart diseases (CHD). METHODS: Two cross-sectional studies were conducted in urban and rural areas of Yangon Region in 2013 and 2014 respectively, using the WHO STEPwise approach to surveillance of risk factors of NCDs. Through a multi-stage cluster sampling method, 1486 participants were recruited. RESULTS: Age-standardized prevalence of the behavioral risk factors tended to be higher in the rural than urban areas for all included factors and significantly higher for alcohol drinking (19.9% vs. 13.9%; p = 0.040) and low fruit & vegetable consumption (96.7% vs. 85.1%; p = 0.001). For the metabolic risk factors, the tendency was opposite, with higher age-standardized prevalence estimates in urban than rural areas, significantly for overweight and obesity combined (40.9% vs. 31.2%; p = 0.023), obesity (12.3% vs.7.7%; p = 0.019) and diabetes (17.2% vs. 9.2%; p = 0.024). In sub-group analysis by gender, the prevalence of hypercholesterolemia and hypertriglyceridemia were significantly higher in urban than rural areas among males, 61.8% vs. 40.4%; p = 0.002 and 31.4% vs. 20.7%; p = 0.009, respectively. Mean values of age-standardized metabolic parameters showed higher values in urban than rural areas for both male and female. Based on WHO age-standardized Framingham risk scores, 33.0% (95% CI = 31.7-34.4) of urban dwellers and 27.0% (95% CI = 23.5-30.8) of rural dwellers had a moderate to high risk of developing CHD in the next 10 years. CONCLUSION: The metabolic risk factors, as well as a moderate or high ten-year risk of CHD were more common among urban residents whereas behavioral risk factors levels were higher in among the rural people of Yangon Region. The high prevalences of NCD risk factors in both urban and rural areas call for preventive measures to reduce the future risk of NCDs in Myanmar.

Do smoking and fruit and vegetable intake mediate the association between socio-economic status and plasma carotenoids?

BACKGROUND: The aim was to study whether the association between educational attainment and antioxidant status is mediated by smoking and fruit and vegetable intake. METHODS: Cross-sectional analyses of the Oslo Youth Study 2006 wave were carried out. Information about education, smoking habits and diet was collected by questionnaire for 261 subjects (142 women and 119 men aged 38-42 years). Blood samples, height and weight measurements were taken by the participants' General Practitioner. Blood were analysed for plasma carotenoids. Linear regression analyses were used to examine whether smoking and fruit and vegetable intake mediate the association between education and plasma carotenoids. RESULTS: Educational level was positively associated with ß-cryptoxanthin, α-carotene and lutein/zeaxanthin, but not with total carotenoids, ß-carotene or lycopene. Education was negatively associated with smoking and positively associated with fruit and vegetable intake. Smoking was negatively associated with ß-cryptoxanthin, and fruit and vegetable intake was positively associated with ß-cryptoxanthin (adjusted for educational level). Moreover, cigarette consumption mediated the association between education and ß-cryptoxanthin by 37%, while fruit and vegetable intake mediated this association by 18%. The total mediation effect was 55%. CONCLUSION: Smoking seemed to be more important as a mediator between education and plasma levels of ß-cryptoxanthin than the intake of fruit and vegetables, but more studies are needed to establish the relative importance of smoking and diet as mediators of the association between education and antioxidant status.