Distinguishing independent and shared effects of material/structural conditions and psychosocial resources on educational inequalities in self-rated health: results from structural equation modelling.

OBJECTIVES: The aim of this study was to distinguish independent and shared effects of material/structural factors and psychosocial resources in explaining educational inequalities in self-rated health (SRH) by using structural equation modelling. STUDY DESIGN: Cross-sectional survey. METHODS: Data were derived from a questionnaire sent to a random sample of the population in five counties in Sweden in 2008. The study population (aged 25-75 years) included 15,099 men and 17,883 women. Exploratory structural equation modelling was used to analyse the pathways from educational level to SRH. RESULTS: The pathway including both material/structural factors (e.g. financial buffer and unemployment) and psychosocial resources (e.g. sense of coherence and social participation) explained about 40% of educational differences in SRH for both men and women. The pathways including only the independent effects of psychosocial resources (14% in men and 20% in women) or material/structural factors (9% and 18%, respectively) explained substantial but smaller proportions of the differences. CONCLUSIONS: The major pathway explaining educational inequalities in SRH included both material/structural factors and psychosocial resources. Therefore, to reduce educational inequalities in SRH, interventions need to address both material/structural conditions and psychosocial resources across educational groups.

Socioeconomic inequalities in relative survival of rectal cancer most obvious in stage III.

INTRODUCTION: The association between socioeconomic status (SES) and relative survival of rectal cancer is little investigated. We hypothesized that the impact on risk of death by SES would be much smaller when differences in background mortality (comorbidity, lifestyle factors) were taken into account, i.e. in modelling relative survival of rectal cancer. METHODS: Individual data on civil status, education, and income were linked to the Swedish Rectal Cancer Registry 1995-2005 (n = 16,713). Specific life tables by socioeconomic group were used to calculate relative survival, and modelling included age, sex, stage, time period, and SES. The same covariates were applied in a Cox regression based on absolute survival. RESULTS: Stage distribution was associated with civil status, education, and income (p < 0.001). In spite of modelling based on relative survival, an increased risk of death was found for all other patients compared with those who were married, as well as for all other patients compared with those with the highest income. The pattern was fundamentally the same as in a Cox regression model, only the point estimates were slightly reduced using the relative approach. In stage-specific modelling of relative survival, income was of particular importance in stage III; the hazard ratio (HR) for lowest versus the highest income was 1.37 [95 % confidence interval (CI) 1.15-1.64]. There were also significant differences by income among patients who had a major surgical resection (stage IV excluded). CONCLUSION: Large and clinically relevant socioeconomic inequalities remained in stage-adjusted analyses of relative survival, also in a setting of universal healthcare and no screening program operating.

A population-based audit of the clinical use of faecal occult blood testing in primary care for colorectal cancer.

AIM: Symptoms related to colorectal cancer (CRC) are common. We investigated the value of the faecal occult blood test (FOBT), when administered in primary care, in the diagnosis of CRC. METHOD: All patients who underwent a FOBT (Hemoccult II) at 20 public primary care centres in Sörmland County, Sweden, during 2000-2005, were included (n=9048). Linkage to the Swedish Cancer Registry identified all cases of CRC. Symptoms recorded at the time of the FOBT were retrieved from the patient records. The outcome from the FOBT to diagnosis and subsequent survival was compared between patients who were FOBT negative and patients who were FOBT positive. RESULTS: One-hundred and sixty-one patients were diagnosed with CRC within 2 years after undergoing a FOBT in primary care. These comprised 18% of all 917 patients diagnosed with CRC in the county during the study period. In 41 (25.4%) of the 161 patients the test was negative. Symptoms related to CRC were documented for 158 (98%) patients at the time the FOBT was administered. The median investigation time from the FOBT test to the diagnosis of CRC was 91 days: 80 days for FOBT-positive patients and 188 days for FOBT-negative patients (P<0.001). This difference was significant independent of age, sex and site of tumour. The hazard ratio for FOBT negativity, 3 years after the FOBT, when adjusted for age and sex, was 1.47 (95% CI, 0.81-2.68). CONCLUSION: Despite having suggestive symptoms, 41 (4.5%) of 917 CRC patients had a negative FOBT result in primary care. This was associated with diagnostic delay and, potentially, a worse outcome.

Socioeconomic inequalities in the use of radiotherapy for rectal cancer: a nationwide study.

UNLABELLED: Preoperative radiotherapy (PRT) in rectal cancer reduces the risk of local recurrence by at least half but the influence of the socioeconomic status of patients on the use of PRT is little investigated in Europe. METHODS: Individually attained data on civil status, education and income were linked to the Swedish Rectal Cancer Registry 1995-2005 (n=16,713) and analysed by logistic regression. RESULTS: Forty-six percentage of the patients received PRT and the crude rate varied with age, gender, civil status, education and income as well as with sublocalisation, stage, type of hospital and health care region. In a multivariate analysis, all civil status groups had PRT to a lesser extent compared with married patients; odds ratio (OR) for unmarried patients was 0.67 (95% confidence interval (CI) 0.59-0.76). Patients with secondary and university education had PRT to the same extent as those with compulsory school (OR 1.04 (0.94-1.15) and 0.92 (0.81-1.06)). The use of PRT was associated with income; OR for patients with income Q1 versus Q4 was 0.76 (0.67-0.86). The inequalities by civil status and income remained unchanged also in groups with a relatively stronger indication for adjuvant radiotherapy, i.e. younger patients and in low rectal cancer. CONCLUSION: Unmarried and low-income patients are at increased risk for not receiving PRT in rectal cancer. Comorbidity may explain some differences but increased awareness of the role of non-medical variables for the use of PRT is warranted.

Sphincter preservation in rectal cancer is associated with patients' socioeconomic status.

BACKGROUND: Decision making regarding the choice of surgical procedure in rectal cancer is complex. It was hypothesized that, in addition to clinical factors, several aspects of patients' socioeconomic background influence this process. METHODS: Individually attained data on civil status, education and income were linked to the Swedish Rectal Cancer Registry 1995-2005 (16 713 patients) and analysed by logistic regression. RESULTS: Anterior resection (AR) was performed in 7433 patients (44.5 per cent), abdominoperineal resection (APR) in 3808 (22.8 per cent) and Hartmann's procedure in 1704 (10.2 per cent). Unmarried patients were least likely (odds ratio (OR) 0.76, 95 per cent confidence interval (c.i.) 0.64 to 0.88) and university-educated men were most likely (OR 1.30, 1.04 to 1.62) to have an AR. Patients with the highest income were more likely to undergo AR (OR 0.80, 0.85 and 0.86 respectively for first, second and third income quartiles). Socioeconomic differences in the use of AR were smallest among the youngest patients. Unmarried patients were more likely (OR 1.21, 95 per cent c.i. 1.00 to 1.48) and university-educated patients less likely (OR 0.78, 95 per cent c.i. 0.63 to 0.98) to have an APR. CONCLUSION: The choice of surgical strategy in rectal cancer is not socioeconomically neutral. Confounding factors, such as co-morbidity or smoking, may explain some of the differences but inequality in treatment is also plausible.