Enabling the examination of long-term mortality trends by educational level for England and Wales in a time-consistent and internationally comparable manner.

BACKGROUND: Studying long-term trends in educational inequalities in health is important for monitoring and policy evaluation. Data issues regarding the allocation of people to educational groups hamper the study and international comparison of educational inequalities in mortality. For the UK, this has been acknowledged, but no satisfactory solution has been proposed. OBJECTIVE: To enable the examination of long-term mortality trends by educational level for England and Wales (E&W) in a time-consistent and internationally comparable manner, we propose and implement an approach to deal with the data issues regarding mortality data by educational level. METHODS: We employed 10-year follow-ups of individuals aged 20+ from the Office for National Statistics Longitudinal Study (ONS-LS), which include education information from each decennial census (1971-2011) linked to individual death records, for a 1% representative sample of the E&W population. We assigned the individual cohort data to single ages and calendar years, and subsequently obtained aggregate all-cause mortality data by education, sex, age (30+), and year (1972-2017). Our data adjustment approach optimised the available education information at the individual level, and adjusts-at the aggregate level-for trend discontinuities related to the identified data issues, and for differences with country-level mortality data for the total population. RESULTS: The approach resulted in (1) a time-consistent and internationally comparable categorisation of educational attainment into the low, middle, and high educated; (2) the adjustment of identified data-quality related discontinuities in the trends over time in the share of personyears and deaths by educational level, and in the crude and the age-standardised death rate by and across educational levels; (3) complete mortality data by education for ONS-LS members aged 30+ in 1972-2017 which aligns with country-level mortality data for the total population; and (4) the estimation of inequality measures using established methods. For those aged 30+ , both absolute and relative educational inequalities in mortality first increased and subsequently decreased. CONCLUSION: We obtained additional insights into long-term trends in educational inequalities in mortality in E&W, and illustrated the potential effects of different data issues. We recommend the use of (part of) the proposed approach in other contexts.

Diabetes management in the face of adversity: Experiences of asylum-seekers in Belgian reception centres.

BACKGROUND: Diabetes poses a heavy burden on patients due to its progressive and chronic nature; it requires continuous management to promote a high-quality and long life. Disease management is especially challenging in emergency settings. We examined how displaced people with diabetes experienced managing their illness before and throughout the process of fleeing their home communities and seeking resettlement in Europe. DESIGN: We designed an interview instrument with closed- and open-ended questions about diabetes diagnosis and management before fleeing the home country, during migration, stays in transit countries and reception in the European Union. We interviewed 20 asylum-seekers living in Belgian reception centres with diagnosed diabetes mellitus. RESULTS: Primary topics emerging from interviews were availability, accessibility, and quality. Belgium was described as a setting with high availability, accessibility and quality of diabetes management components (medication, tools, care) compared with other settings before and during migration. Even in Belgium, maintaining a healthy diet as an asylum-seeker was difficult. Other concerns such as safety, other health issues and the asylum request itself often outweighed diabetes management. CONCLUSIONS: Displaced people in non-Western countries need attention for nutrition and diabetes medicine, so aid agencies should consider providing for those needs. For people seeking asylum in the West and living in temporary facilities, care should be paid to the dietary options available for those with diabetes. For irregular migrants, diabetes can be deadly, and resources should be made available for their basic diabetes needs, even if they are not eligible for regular health services.

Are we really all in this together? The social patterning of mortality during the first wave of the COVID-19 pandemic in Belgium.

BACKGROUND: Belgium was one of the countries that was struck hard by COVID-19. Initially, the belief was that we were 'all in it together'. Emerging evidence showed however that deprived socioeconomic groups suffered disproportionally. Yet, few studies are available for Belgium. The main question addressed in this paper is whether excess mortality during the first COVID-19 wave followed a social gradient and whether the classic mortality gradient was reproduced. METHODS: We used nationwide individually linked data from the Belgian National Register and the Census 2011. Age-standardized all-cause mortality rates were calculated during the first COVID-19 wave in weeks 11-20 in 2020 and compared with the rates during weeks 11-20 in 2015-2019 to calculate absolute and relative excess mortality by socioeconomic and -demographic characteristics. For both periods, relative inequalities in total mortality between socioeconomic and -demographic groups were calculated using Poisson regression. Analyses were stratified by age, gender and care home residence. RESULTS: Excess mortality during the first COVID-19 wave was high in collective households, with care homes hit extremely hard by the pandemic. The social patterning of excess mortality was rather inconsistent and deviated from the usual gradient, mainly through higher mortality excesses among higher socioeconomic groups classes in specific age-sex groups. Overall, the first COVID-19 wave did not change the social patterning of mortality, however. Differences in relative inequalities between both periods were generally small and insignificant, except by household living arrangement. CONCLUSION: The social patterning during the first COVID-19 wave was exceptional as excess mortality did not follow the classic lines of higher mortality in lower classes and patterns were not always consistent. Relative mortality inequalities did not change substantially during the first COVID-19 wave compared to the reference period.

Breast cancer by migrant background in Belgium: Lower risk, but worse survival in women of non-European origin.

Foreign and native populations differ in terms of breast cancer outcomes. Studies rarely distinguish between premenopausal and postmenopausal breast cancer, although the risk profile is different; nor between migrants of the first and second generation (FG and SG), which is crucial to examine genetic and environmental influences on breast cancer. This research fills these gaps by investigating patterns in breast cancer incidence and survival in different migrant groups by menopausal and migrant generational status, taking various risk factors into account. To this end, individually linked data from the 2001 census, the Belgian Cancer Registry and the Crossroads Bank for Social Security are used. Age-standardised incidence rates and incidence rate ratios are calculated by migrant background group, stratified according to ages 30-50 (premenopausal) and 50-70 (postmenopausal). Incidence rate ratios are examined with and without taking reproductive factors and socioeconomic position (SEP) into account. Relative survival percentages and relative excess risks of dying among premenopausal and postmenopausal patients are computed with and without controlling for the stage at diagnosis and SEP. Premenopausal breast cancer is further examined by migrant generational status. Breast cancer incidence is lower among non-European migrants compared to Belgians. Keeping SEP and known risk factors constant reduces much, but not all of the observed discrepancies. A risk convergence between SG migrants and Belgians for the development of premenopausal breast cancer is observed. Premenopausal breast cancer survival is worse among Moroccan patients due to a higher stage at diagnosis. This disadvantage is concentrated in the FG.

Breast cancer screening and migrants: exploring targeted messages for Moroccan migrant women in Brussels.

Objectives: This study explored views of Moroccan migrant women on barriers and facilitators to the organized breast cancer screening program in Brussels (Belgium), and the potential of targeted printed invitations to increase this population's attendance to the program. Methods: We conducted one expert interview with the breast cancer screening program coordinator on current practices and challenges with regards to inviting Moroccan migrant women in Brussels for screening. Secondly, we held focus groups with Moroccan women aged 26-66. Sessions focused on perspectives on breast cancer screening and the existing generic program invitations. Directed content analysis of transcripts was based on the Health Belief Model. Alternative communication packages were developed based on barriers and suggestions from the focus groups. A second round of focus groups looked at the alternative communication packages and their potential to encourage Moroccan migrant women in Brussels to participate in the organized breast cancer screening program. Results: Alternative packages were appreciated by some, but a number of adjustments did not catch participants' attention. Printed communication delivered by post does not appear to be the preferred means of communication to encourage breast cancer screening for Moroccan migrant women in Brussels, nor does it seem appropriate to address the barriers to screening found in this study. Conclusions: The benefit of targeted postal invitation packages for Moroccan migrant women in Brussels seems limited for a variety of reasons. For future research, a large-scale study analyzing the topic in a cross-cultural perspective is warranted.

Trends in educational inequalities in smoking-attributable mortality and their impact on changes in general mortality inequalities: evidence from England and Wales, Finland, and Italy (Turin).

BACKGROUND: Socioeconomic mortality inequalities are persistent in Europe but have been changing over time. Smoking is a known contributor to inequality levels, but knowledge about its impact on time trends in inequalities is sparse. METHODS: We studied trends in educational inequalities in smoking-attributable mortality (SAM) and assessed their impact on general mortality inequality trends in England and Wales (E&W), Finland, and Italy (Turin) from 1972 to 2017. We used yearly individually linked all-cause and lung cancer mortality data by educational level and sex for individuals aged 30 and older. SAM was indirectly estimated using the Preston-Glei-Wilmoth method. We calculated the slope index of inequality (SII) and performed segmented regression on SIIs for all-cause, smoking and non-SAM to identify phases in inequality trends. The impact of SAM on all-cause mortality inequality trends was estimated by comparing changes in SII for all-cause with non-SAM. RESULTS: Inequalities in SAM generally declined among males and increased among females, except in Italy. Among males in E&W and Finland, SAM contributed 93% and 76% to declining absolute all-cause mortality inequalities, but this contribution varied over time. Among males in Italy, SAM drove the 1976-1992 increase in all-cause mortality inequalities. Among females in Finland, increasing inequalities in SAM hampered larger declines in mortality inequalities. CONCLUSION: Our findings demonstrate that differing education-specific SAM trends by country and sex result in different inequality trends, and consequent contributions of SAM on educational mortality inequalities. The following decades of the smoking epidemic could increase educational mortality inequalities among Finnish and Italian women.

The impact of estimation methods for alcohol-attributable mortality on long-term trends for the general population and by educational level in Finland and Italy (Turin).

BACKGROUND AND AIMS: This paper assesses the impact of estimation methods for general and education-specific trends in alcohol-attributable mortality (AAM), and develops an alternative method that can be used when the data available for study is limited. METHODS: We calculated yearly adult (30+) age-standardised and age-specific AAM rates by sex for the general population and by educational level (low, middle, high) in Finland and Turin (Italy) from 1972 to 2017. Furthermore the slope index of inequality and relative inequality index were computed by country and sex. We compared trends, levels, age distributions, and educational inequalities in AAM according to three existing estimation methods: (1) Underlying COD (UCOD), (2) Multiple COD (MCOD) method, and (3) the population attributable fractions (PAF)-method. An alternative method is developed based on the pros and cons of these methods and the outcomes of the comparison. RESULTS: The UCOD and MCOD approaches revealed mainly increasing trends in AAM compared to the declining trends according to the PAF approach. These differences are more pronounced when examining AAM trends by educational groups, particularly for Finnish men. Until age 65, age patterns are similar for all methods, and levels nearly identical for MCOD and PAF in Finland. Our novel method assumes a similar trend and age pattern as observed in UCOD, but adjusts its level upwards so that it matches the level of the PAF approach for ages 30-64. Our new method yields levels in-between UCOD and PAF for Turin (Italy), and resembles the MCOD rates in Finland for females. Relative inequalities deviate for the PAF-method (lower levels) compared to other methods, whereas absolute inequalities are generally lower for UCOD than all three methods that combine wholly and partly AAM. CONCLUSIONS: The choice of method to estimate AAM affects not only levels, but also general and education-specific trends and inequalities. Our newly developed method constitutes a better alternative for multiple-country studies by educational level than the currently used UCOD-method when the data available for study is limited to underlying causes of death.

Long-Term Trends in Obesity Prevalence by Socio-Economic Group in Five European Countries and the USA: The Relevance of the Diffusion of Innovations Theory.

INTRODUCTION: Cross-national comparison suggests that the timing of the obesity epidemic differs across socio-economic groups (SEGs). Similar to the smoking epidemic, these differences might be described by the diffusion of innovations theory, which states that health behaviours diffuse from higher to lower SEGs. However, the applicability of the diffusion of innovations theory to long-term time trends in obesity by SEG is unknown. We studied long-term trends in the obesity prevalence by SEG in England, France, Finland, Italy, Norway, and the USA and examined whether trends are described by the diffusion of innovations theory. METHODS: Obesity prevalence from 1978 to 2019 by educational level, sex, and age group (25+ years) from health surveys was harmonized, age-standardized, Loess-smoothed, and visualized. Prevalence rate differences were calculated, and segmented regression was performed to obtain annual percentage changes, which were compared over time and across SEGs. RESULTS: Obesity prevalence among lower educated groups has exceeded that of higher educated groups, except among American men, in all countries throughout the study period. A comparable increase across educational levels was observed until approximately 2000. Recently, obesity prevalence stagnated among higher educated groups in Finland, France, Italy, and Norway and lower educated groups in England and the USA. DISCUSSION: Recent trends in obesity prevalence by SEG are mostly in line with the diffusion of innovations theory; however, no diffusion from higher to lower SEGs at the start of the epidemic was found. The stagnation among higher SEGs but not lower SEGs suggests that the latter will likely experience the greatest future burden.

Cancer risk among individuals of migrant origin in Belgium during the 2000s - Evidence of migration as a 'cancer risk transition'?

Recent research has shown a generally lower cancer risk and mortality among migrants from less-industrialised country origin. However, while rates are usually lower for 'lifestyle-related' cancers (e.g. breast, prostate, lung, colorectal), they are typically elevated for 'infection-related' ones such as liver and stomach cancer. Although these observations appear in line with the theory of 'migration as a rapid epidemiological transition', changes in cancer risk after migration have yet to be investigated, effectively testing if migration also entails a 'rapid cancer risk transition'. This study therefore examines cancer risk among migrants in Belgium, focusing on colorectal cancer as a typically lifestyle-related cancer on the one hand, and infection-related cancers on the other hand. We subdivide migrant groups of more and less industrialised country origin according to duration of stay, and calculate absolute and relative incidence rates between 2004 and 2013. Our findings corroborate the transition assumptions for men from Turkey and Morocco, but cannot support them for women. Italian male immigrants have an in-between position: their colorectal cancer risk does not differ from that of Belgian men, but infection-related and non-cardia stomach cancer risks are higher and remain so with longer duration of stay. The fact that rates for migrants from the Netherlands and France generally do not differ from those of Belgians further strengthens support for a cancer transition among male migrants. Further examinations should focus on changes in health-related behaviour that can explain persistently low colorectal cancer risks among Turkish and Moroccan migrants and can inform preventive strategies for other population subgroups. Knowledge about the higher non-cardia stomach cancer risk among Turkish, Moroccan, and Italian men can support early detection strategies by primary care providers when patients present with gastric symptoms, especially because this cancer tends to have unfavourable prognosis.

Neighbourhood migrant composition and tobacco-related cancer mortality: A census-linked study among five origin groups in urban Belgium.

We studied the role of 'ethnic density' in the neighbourhood for tobacco-related cancer mortality among five migrant origin groups in urban Belgium. Using full population linked census data, multilevel Poisson models were applied to model effects of three linear and categorical indicators of same-origin presence for each origin group, and to test effect mediation by migrant generation and educational level. We first of all found that increased same migrant-origin presence in the neighbourhood had protective effects on tobacco-related cancer mortality for men in most groups. Second, only Turkish men had a mortality disadvantage when Turkish concentration was higher. Third, effects were not detected across all indicators of same-origin presence, nor among most groups of women. Finally, for several groups, neighbourhood effects were mediated by generational status and educational level.

The geographic pattern of Belgian mortality: can socio-economic characteristics explain area differences?

BACKGROUND: Country averages for health outcomes hide important within-country variations. This paper probes into the geographic Belgian pattern of all-cause mortality and wishes to investigate the contribution of individual and area socio-economic characteristics to geographic mortality differences in men aged 45-64 during the period 2001-2011. METHODS: Data originate from a linkage between the Belgian census of 2001 and register data on mortality and emigration during the period 2001-2011. Mortality rate ratios (MRRs) are estimated for districts and sub-districts compared to the Belgian average mortality level using Poisson regression modelling. Individual socio-economic position (SEP) indicators are added to examine the impact of these characteristics on the observed geographic pattern. In order to scrutinize the contribution of area-level socio-economic characteristics, random intercepts Poisson modelling is performed with predictors at the individual and the sub-district level. Random intercepts and slopes models are fitted to explore variability of individual-level SEP effects. RESULTS: All-cause MRRs for middle-aged Belgian men are higher in the geographic areas of the Walloon region and the Brussels-Capital Region (BCR) compared to those in the Flemish region. The highest MRRs are observed in the inner city of the BCR and in several Walloon cities. Their disadvantage can partially be explained by the lower individual SEP of men living in these areas. Similarly, the relatively low MRRs observed in the districts of Halle-Vilvoorde, Arlon and Virton can be related to the higher individual SEP. Among the area-level characteristics, both the percentage of men employed and the percentage of labourers in a sub-district have a protective effect on the individual MRR, regardless of individual SEP. Variability in individual-level SEP effects is limited. CONCLUSIONS: Individual SEP partly explains the observed mortality gap in Belgium for some areas. The percentage of men employed and the percentage of labourers in a sub-district have an additional effect on the individual MRR aside from that of individual SEP. However, these socio-economic factors cannot explain all of the observed differences. Other mechanisms such as public health policy, cultural habits and environmental influences contribute to the observed geographic pattern in all-cause mortality among middle-aged men.