http://repub.eur.nl/res/aut/15202/ List of Publications en http://repub.eur.nl/static-eur/img/logo.png http://repub.eur.nl http://repub.eur.nl/res/pub/40020/ 2013-03-01T00:00:00Z Objectives. We examined the impact of expanding health insurance coverage on socioeconomic disparities in total and cardiovascular disease mortality from 1998 to 2007 in Colombia. Methods. We used Poisson regression to analyze data from mortality registries (633 905 deaths) linked to population census data. We used the relative index of inequality to compare disparities in mortality by education between periods of moderate increase (1998-2002) and accelerated increase (2003-2007) in health insurance coverage. Results. Disparities in mortality by education widened over time. Among men, the relative index of inequality increased from2.59 (95% confidence interval [CI] = 2.52, 2.67) in 1998-2002 to 3.07 (95% CI = 2.99, 3.15) in 2003-2007, and among women, from 2.86 (95% CI = 2.77, 2.95) to 3.12 (95% CI = 3.03, 3.21), respectively. Disparities increased yearly by 11% in men and 4% in women in 1998-2002, whereas they increased by 1% in men per year and remained stable among women in 2003-2007. Conclusions. Mortality disparities widened significantly less during the period of increased health insurance coverage than the period of no coverage change. Although expanding coverage did not eliminate disparities, it may contribute to curbing future widening of disparities. http://repub.eur.nl/res/pub/37961/ 2012-01-01T00:00:00Z Depression is one of the leading causes of disability in the developed world. Previous studies have shown varying depression prevalence rates between European countries, and also within countries, between socioeconomic groups. However, it is unclear whether these differences reflect true variations in prevalence or whether they are attributable to systematic differences in reporting styles (reporting heterogeneity) between countries and socioeconomic groups. In this study, we examine the prevalence of three depressive symptoms (mood, sleeping and concentration problems) and their association with educational level in 10 European countries, and examine whether these differences can be explained by differences in reporting styles. We use data from the first and second waves of the COMPARE study, comprising a sub-sample of 9,409 adults aged 50 and over in 10 European countries covered by the Survey of Health, Ageing and Retirement in Europe. We first use ordered probit models to estimate differences in the prevalence of self-reported depressive symptoms by country and education. We then use hierarchical ordered probit models to assess differences controlling for reporting heterogeneity. We find that depressive symptoms are most prevalent in Mediterranean and Eastern European countries, whereas Sweden and Denmark have the lowest prevalence. Lower educational level is associated with higher prevalence of depressive symptoms in all European regions, but this association is weaker in Northern European countries, and strong in Eastern European countries. Reporting heterogeneity does not explain these cross-national differences. Likewise, differences in depressive symptoms by educational level remain and in some regions increase after controlling for reporting heterogeneity. Our findings suggest that variations in depressive symptoms in Europe are not attributable to differences in reporting styles, but are instead likely to result from variations in the causes of depressive symptoms between countries and educational groups. http://repub.eur.nl/res/pub/33733/ 2011-12-01T00:00:00Z http://repub.eur.nl/res/pub/33597/ 2011-11-01T00:00:00Z Background: To investigate the association between childhood and adulthood socioeconomic position and the hospital-based incidence of hip fractures, and the contribution of health behaviours to these socioeconomic disparities. Methods: Baseline (1991) information about socioeconomic position in childhood and adulthood, behavioural factors (alcohol consumption, smoking, physical inactivity, coffee consumption) and body height of 25e74-year-old participants (n=18 810) were linked to hospital admissions for hip fractures (ICD9 code 820e821) over a follow-up period of almost 13 years. Results: During follow-up 192 hip fractures resulted in hospital admission. Childhood socioeconomic position was not associated with the incidence of hip fractures. Adjusted for body height, a lower educational level and being in a lower income proxy group were associated with an increased probability of hip fractures (HR=1.88, 95% CI 1.00 to 3.53 in the lowest education group; HR=2.39, 95% 1.46 to 3.92 in the lowest income group). Very excessive alcohol consumption, smoking and physical inactivity were associated with an increased probability of hip fractures, and contributed (10e31%) to socioeconomic disparities in hip fractures. Conclusions: The higher prevalence of unhealthy behaviour in lower socioeconomic groups in adulthood contributes moderately to socioeconomic disparities in incidence of hip fractures later in life. http://repub.eur.nl/res/pub/26433/ 2011-05-01T00:00:00Z This study examined whether physical, social, cultural and economical environmental factors are associated with obesogenic dietary behaviours and overweight/obesity among adults. Literature searches of databases (i.e. PubMed, CSA Illumina, Web of Science, PsychInfo) identified studies examining environmental factors and the consumption of energy, fat, fibre, fruit, vegetables, sugar-sweetened drinks, meal patterns and weight status. Twenty-eight studies were in-scope, the majority (n= 16) were conducted in the USA. Weight status was consistently associated with the food environment; greater accessibility to supermarkets or less access to takeaway outlets were associated with a lower BMI or prevalence of overweight/obesity. However, obesogenic dietary behaviours did not mirror these associations; mixed associations were found between the environment and obesogenic dietary behaviours. Living in a socioeconomically-deprived area was the only environmental factor consistently associated with a number of obesogenic dietary behaviours. Associations between the environment and weight status are more consistent than that seen between the environment and dietary behaviours. The environment may play an important role in the development of overweight/obesity, however the dietary mechanisms that contribute to this remain unclear and the physical activity environment may also play an important role in weight gain, overweight and obesity. © 2010 The Authors. obesity reviews http://repub.eur.nl/res/pub/26481/ 2011-04-15T00:00:00Z Although Americans make up just 5% of the world's population, they represent more than half of every medical dollar expended on the planet. Yet, American life expectancy appears near the bottom of rankings by the Organization for Economic Cooperation and Development, and American adults live in poorer health than most Europeans. In this issue of the Journal, Martinson et al. (Am J Epidemiol. 2011;173(8):870) provide us with further evidence of the generality of this phenomenon, showing a pattern of poorer health in the United States relative to England across the entire life course. Recent research points at single risk factors such as smoking as potential explanations, but such hypotheses are of limited scope to explain the pervasive US health disadvantage across the entire life course. In this commentary, a potentially promising line of inquiry based upon differences in social policy contexts is proposed. Life in the United States can be distinguished from that of the rest of the member countries of the Organization for Economic Cooperation and Development in terms of the weakness of its social safety nets, the magnitude of social inequalities, and the harshness of poverty. The authors argue that broadening the scope of their inquiry to include the social and policy contexts of nations might help to solve the puzzle of the US health disadvantage. http://repub.eur.nl/res/pub/23315/ 2011-02-17T00:00:00Z Introduction: Lower social class has higher lung cancer incidence, largely attributable to higher smoking prevalence among the lower social classes. We assessed the magnitude and time dimension of potential impact of targeted interventions on smoking on socioeconomic inequalities in lung cancer. Methods: Using population dynamic modelling, we projected lung cancer incidence up to 2050 in lowest and highest socioeconomic groups under two intervention scenarios (annual 10% increase in cigarette prices and health advertisement) and compared this to a scenario of no intervention. For the analysis we retrieved smoking prevalence data from the General Household Survey of England and Wales between 1980 and 2006 and cancer incidence data from the national cancer registry. Results: By 2050, the model projected that lung cancer incidence inequality would almost double (Incidence Rate Ratio (IRR) = 4.2 in 2050 vs. 2.5 in 2005) in men and slightly decrease (IRR = 2.4 in 2050 vs. 2.7 in 2005) in women compared to what was observed in 2005. If annual increase in cigarette price targeting the lowest socioeconomic group was implemented, socioeconomic inequality in lung cancer incidence in 2050 might be largely reduced (IRR = 1.5 and 1.4 among men and women, respectively). If in addition to annual price increase (targeted to the lowest socioeconomic group) health advertisement was implemented and successfully reduced smoking prevalence in the highest socioeconomic group, the lung cancer gap between the socioeconomic groups would be reduced by 78% and 58% in men and women by 2050. Conclusion: Even under the best scenarios, inequality in lung cancer was not fully eliminated within 45 years period. Though the process is lengthy, rigorous interventions may reduce the expected widening of the future inequalities in lung cancer. Modelling exercise such as ours relies heavily on the quality of the input data and the assumptions, thus caution is needed in interpretation of our findings and should consider all the assumptions taken in the analysis. http://repub.eur.nl/res/pub/28420/ 2010-12-01T00:00:00Z Objective: To determine the impact of ill health on exit from paid employment in Europe among older workers. Methods: Participants of the Survey on Health and Ageing in Europe (SHARE) in 11 European countries in 2004 and 2006 were selected when 50-63 years old and in paid employment at baseline (n=4611). Data were collected on self-rated health, chronic diseases, mobility limitations, obesity, smoking, alcohol use, physical activity and work characteristics. Participants were classified into employed, retired, unemployed and disabled at the end of the 2-year follow-up. Multinomial logistic regression was used to estimate the effect of different measures of ill health on exit from paid employment. Results: During the 2-year follow-up, 17% of employed workers left paid employment, mainly because of early retirement. Controlling for individual and work related characteristics, poor self-perceived health was strongly associated with exit from paid employment due to retirement, unemployment or disability (ORs from 1.32 to 4.24). Adjustment for working conditions and lifestyle reduced the significant associations between ill health and exit from paid employment by 0-18.7%. Low education, obesity, low job control and effort-reward imbalance were associated with measures of ill health, but also risk factors for exit from paid employment after adjustment for ill health. Conclusion: Poor self-perceived health was strongly associated with exit from paid employment among European workers aged 50-63 years. This study suggests that the influence of ill health on exit from paid employment could be lessened by measures targeting obesity, problematic alcohol use, job control and effort-reward balance. http://repub.eur.nl/res/pub/27802/ 2010-09-01T00:00:00Z Background Reduced hand-grip strength predicts disability, morbidity and mortality, but whether it is shaped by socio-economic experiences is yet unknown. The authors examined the association of education, occupation, income and wealth with grip strength in older Europeans.Methods Data came from the Survey of Health, Ageing and Retirement in Europe comprising 27 351 participants ages 50+ in 11 countries. Grip strength was objectively measured using a handheld ynamometer. Estimates were obtained based on multivariate linear regression controlling for a wide set of confounders, demographics, health and disability measures, and behavioural risk factors.Results In the total sample, education, occupational class, income and wealth predicted grip strength among men, whereas only education and wealth predicted grip strength among women While education and income effects were inconsistent in most countries, wealth consistently p edicted grip strength in each country. A one-point increase in the log of wealth was associated with 0.38 kg (95% CI 0.31 to 0.45) higher grip strength in men and 0.18 kg (95% CI 0.15 to 0.21) higher grip strength in women. While education, income and occupation effects disappeared after adjustment for health measures, log of wealth effects remained significant in both men (0.22, 95% CI 0.15 to 0.29) and women (0.08, 95% CI 0.05 to 0.11). Wealth effects were particularly evident in the two lowest quintiles. Conclusion Old-agesocio-economic and financial circumstances as measured by wealth are associated with grip strength, particularly among the least wealthy, while circumstances defined earlier in life as me sured by education, income and occupation do not consistently predict grip strength. http://repub.eur.nl/res/pub/28496/ 2010-06-01T00:00:00Z This Review examined socioeconomic inequalities in intakes of dietary factors associated with weight gain, overweight/obesity among adults in Europe. Literature searches of studies published between 1990 and 2007 examining socioeconomic position (SEP) and the consumption of energy, fat, fibre, fruit, vegetables, energy-rich drinks and meal patterns were conducted. Forty-seven articles met the inclusion criteria. The direction of associations between SEP and energy intakes were inconsistent. Approximately half the associations examined between SEP and fat intakes showed higher total fat intakes among socioeconomically disadvantaged groups. There was some evidence that these groups consume a diet lower in fibre. The most consistent evidence of dietary inequalities was for fruit and vegetable consumption; lower socioeconomic groups were less likely to consume fruit and vegetables. Differences in energy, fat and fibre intakes (when found) were small-to-moderate in magnitude; however, differences were moderate-to-large for fruit and vegetable intakes. Socioeconomic inequalities in the consumption of energy-rich drinks and meal patterns were relatively under-studied compared with other dietary factors. There were no regional or gender differences in the direction and magnitude of the inequalities in the dietary factors examined. The findings suggest that dietary behaviours may contribute to socioeconomic inequalities in overweight/obesity in Europe. However, there is only consistent evidence that fruit and vegetables may make an important contribution to inequalities in weight status across European regions. http://repub.eur.nl/res/pub/24843/ 2009-12-01T00:00:00Z OBJECTIVES: To examine the role of sex and marital status in the distribution and consequences of cardiovascular risk factors for stroke. DESIGN: Longitudinal cohort. SETTING: U.S. national sample, community based. PARTICIPANTS: U.S. adults aged 50 and older and their spouses. MEASUREMENTS: Health and Retirement Study (HRS) participants born between 1900 and 1947 (N=22,818), aged 50 and older, and stroke-free at baseline were followed an average of 9.4 years for self- or proxy-reported stroke (2,372 events). Financial resources, behavioral risk factors, and cardiovascular conditions were used to predict incident stroke in Cox proportional hazard models stratified according to sex and marital status (married, widowed, divorced or separated, or never married). RESULTS: Women were less likely to be married than men. The distribution of risk factors differed according to sex and marital status. Men had higher incident stroke rates than women, even after full risk factor adjustment (hazard ratio (HR)=1.22, 95% confidence interval (CI)=1.11-1.34). For both sexes, being never married or widowed predicted greater risk, associations that were attenuated after adjustment for financial resources. Widowed men had the highest risk (HR=1.40, 95% CI=1.12-1.74 vs married women). Lower income and wealth were associated with similarly high risk across subgroups, although this risk factor especially affected unmarried women, with this group reporting the lowest income and wealth levels. Most other risk factors had similar HRs across subgroups, although moderate alcohol use did not predict lower stroke risk in unmarried women. CONCLUSION: Stroke incidence and risk factors vary substantially according to sex and marital status. It is likely that gendered social experiences, such as marriage and socioeconomic disadvantage, mediate pathways linking sex and stroke. http://repub.eur.nl/res/pub/27080/ 2009-12-01T00:00:00Z http://repub.eur.nl/res/pub/25306/ 2009-10-01T00:00:00Z We use cross-national, longitudinal data to explore the impact of educational level on changes in health outcomes among Europeans aged over 50. Our analyses are performed separately for Northern, Western and Southern Europe, as these regions broadly represent different welfare state regimes. We find that low education is associated with higher incident events - over a two-year period - of poor health, chronic diseases and disability, but it is less consistently associated with new events of long-standing illness. Net of behavioural risk factors, educational effects are more consistent in Western and Southern Europe than in the Nordic welfare states. In Northern Europe, lower education is associated with less financial and employment disadvantage than in Southern or Western Europe. After controlling for educational differences in these factors, effects of educational level on health deterioration remain significant for most outcomes in Western and Southern Europe, whereas they are weaker and non-significant after adjustment in Northern Europe. http://repub.eur.nl/res/pub/17395/ 2009-09-21T00:00:00Z Background. Substantial research has documented variations in the magnitude of relative socioeconomic differences in health across European countries, and within countries, across different age groups. The aim of this paper is to examine to what extent these variations are determined by differences in the overall rate or prevalence of a health outcome across countries and age-groups in the total population. Methods. Three surveys (European Social Survey, and two different population census-mortality registry linked longitudinal data) were used. We plotted rates of mortality and prevalence of poor self-rated health against ratios of mortality and morbidity prevalence associated with educational level. We calculated Pearson coefficients to examine the magnitude of correlations. Results. We found a significant negative correlation between total mortality rates and associated rate ratios of mortality by education in the SEDHA study (r = -0.40, p = 0.04), but not in the HUNT study (r = -0.37, p = 0.06). There was a weaker but significant negative correlation between the prevalence of poor health and associated prevalence ratios by education in the European social survey (r = -0.22, p = 0.00). Correlations increased as underlying prevalence and rates increased, while they were weaker or null at low prevalence or rates. Conclusion. We found some evidence that the magnitude of relative inequalities in mortality and morbidity is negatively correlated with underlying morbidity prevalence and mortality rates. Although correlations are moderate, underlying morbidity prevalence and mortality rates should be taken into account in the interpretation of variations in relative health inequalities among populations. http://repub.eur.nl/res/pub/24841/ 2009-03-01T00:00:00Z OBJECTIVES: To determine whether cognitive test scores and cognitive decline predict incidence of first diagnosed stroke. DESIGN: Stroke-free Health and Retirement Study participants were followed on average 7.6 years for self- or proxy-reported first stroke (1,483 events). Predictors included baseline performance on a modified Telephone Interview for Cognitive Status (Mental Status) and Word Recall test and decline between baseline and second assessment in either measure. Hazard ratios (HRs) were estimated using Cox proportional hazards models for the whole sample and stratified according to five major cardiovascular risk factors. SETTING: National cohort study of noninstitutionalized adults with a mean baseline age of 64±9.9. PARTICIPANTS: Health and Retirement Study participants (n=19,699) aged 50 and older. RESULTS: Word Recall (HR for 1 standard deviation difference=0.92, 95% confidence interval (CI)=0.86-0.97)) and Mental Status (HR=0.89, 95% CI=0.84-0.95) predicted incident stroke. Mental Status predicted stroke risk in those with (HR=0.93, 95%=0.87-0.99) and without (HR=0.81, 95% CI=0.72-.91) one or more vascular risk factors. Word Recall declines predicted a 16% elevation in subsequent stroke risk (95% CI=1.01-1.34). Declines in Mental Status predicted a 37% elevation in stroke risk (95% CI=1.11-1.70). CONCLUSION: Cognitive test scores predict future stroke risk, independent of other major vascular risk factors. http://repub.eur.nl/res/pub/25291/ 2009-03-01T00:00:00Z Background and Purpose-Most stroke incidence studies use geographically localized (community) samples with few national data sources available. Such samples preclude research on contextual risk factors, but national samples frequently collect only self-reported stroke. We examine whether incidence estimates from clinically verified studies are consistent with estimates from a nationally representative US sample assessing self-reported stroke. Methods-Health and Retirement Study (HRS) participants (n= 17 056) age 50+ years were followed for self- or proxy-reported first stroke (1293 events) from 1998 to 2006 (average, 6.8 years). We compared incidence rates by race, sex, and age strata with those previously documented in leading geographically localized studies with medically verified stroke. We also examined whether cardiovascular risk factor effect estimates in HRS are comparable to those reported in studies with clinically verified strokes. Results-The weighted first-stroke incidence rate was 10.0 events/1000 person-years. Total age-stratified incidence rates in whites were mostly comparable with those reported elsewhere and were not systematically higher or lower. However, among blacks in HRS, incidence rates generally appeared higher than those previously reported. HRS estimates were most comparable with those reported in the Cardiovascular Health Study. Incidence rates approximately doubled per decade of age and were higher in men and blacks. After demographic adjustment, all risk factors predicted stroke incidence in whites. Smoking, hypertension, diabetes, and heart disease predicted incident stroke in blacks. Conclusions-Associations between known risk factors and stroke incidence were verified in HRS, suggesting that misreporting is nonsystematic. HRS may provide valuable data for stroke surveillance and examination of classical and contextual risk factors. http://repub.eur.nl/res/pub/32651/ 2009-03-01T00:00:00Z Objectives. We compared the health of older US, English, and other European adults, stratified by wealth. Methods. Representative samples of adults aged 50 to 74 years were interviewed in 2004 in 10 European countries (n=17481), England (n=6527), and the United States (n=9940). We calculated prevalence rates of 6 chronic diseases and functional limitations. Results. American adults reported worse health than did English or European adults. Eighteen percent of Americans reported heart disease, compared with 12% of English and 11% of Europeans. At all wealth levels, Americans were less healthy than were Europeans, but differences were more marked among the poor. Health disparities by wealth were significantly smaller in Europe than in the United States and England. Odds ratios of heart disease in a comparison of the top and bottom wealth tertiles were 1.94 (95% confidence interval [CI]=1.69, 2.24) in the United States, 2.13 (95% CI=1.73, 2.62) in England, and 1.38 (95% CI=1.23, 1.56) in Europe. Smoking, obesity, physical activity levels, and alcohol consumption explained a fraction of health variations. Conclusions. American adults are less healthy than Europeans at all wealth levels. The poorest Americans experience the greatest disadvantage relative to Europeans. http://repub.eur.nl/res/pub/14152/ 2008-12-01T00:00:00Z http://repub.eur.nl/res/pub/15114/ 2008-12-01T00:00:00Z Objective: Self-rated health (SRH) is widely used to compare population health across countries, but comparability is often hampered by the use of different versions of this item. This study compares the WHO recommended version (ranging from 'very good' to 'very bad') with the US version (ranging from 'excellent' to 'poor') in European countries. Methods: Data came from the Survey of Health, Ageing and Retirement in Europe (SHARE). Both the WHO and US versions of SRH were measured in representative samples of Europeans aged 50+ (n = 11,643) in five countries. Concordance between the two SRH versions and differences in their associations with demographics, chronic diseases, functioning and depression were assessed using ordered probit regression. Results: The US version has a more symmetric distribution and larger variance than the WHO version. Although the WHO version discriminates better at the positive end, the US version shows better discrimination at the positive end of the scale. Sixty-nine percent of respondents provided literally concordant answers, while only about one-third provided relatively concordant answers. Overall, however, less than 10% of respondents were discordant in either sense. The two versions were strongly correlated (polychoric correlation = 0.88), had similar associations with demographics and health indicators, and showed a similar pattern of international variation. Conclusion: Health levels based on different measurements of SRH are not directly comparable and require rescaling of items. However, both versions represent parallel assessments of the same latent health variable. We did not find evidence that the WHO version is preferable to the US version as standard measure of SRH in European countries. http://repub.eur.nl/res/pub/30165/ 2008-12-01T00:00:00Z Purpose: Some previous studies found excess stroke rates among black subjects persisted after adjustment for socioeconomic status (SES), fueling speculation regarding racially patterned genetic predispositions to stroke. Previous research was hampered by incomplete SES assessments, without measures of childhood conditions or adult wealth. We assess the role of lifecourse SES in explaining stroke risk and stroke disparities. Methods: Health and Retirement Study participants age 50+ (n = 20,661) were followed on average 9.9 years for self- or proxy-reported first stroke (2175 events). Childhood social conditions (southern state of birth, parental SES, self-reported fair/poor childhood health, and attained height), adult SES (education, income, wealth, and occupational status) and traditional cardiovascular risk factors were used to predict first stroke onset using Cox proportional hazards models. Results: Black subjects had a 48% greater risk of first stroke incidence than whites (95% confidence interval, 1.33-1.65). Childhood conditions predicted stroke risk in both blacks and whites, independently of adult SES. Adjustment for both childhood social conditions and adult SES measures attenuated racial differences to marginal significance (hazard ratio, 1.13; 95% CI, 1.00-1.28). Conclusions: Childhood social conditions predict stroke risk in black and White American adults. Additional adjustment for adult SES, in particular wealth, nearly eliminated the disparity in stroke risk between black and white subjects. http://repub.eur.nl/res/pub/29800/ 2008-09-01T00:00:00Z Background: Few prospective studies have investigated the relationship between spousal cigarette smoking and the risk of incident stroke. Methods: Stroke-free participants in the U.S.-based Health and Retirement Study (HRS) aged ≥50 years and married at baseline (n=16,225) were followed, on average, 9.1 years between 1992 and 2006) for proxy or self-report of first stroke (1130 events). Participants were stratified by gender and own smoking status (never-smokers, former smokers, or current smokers), and the relationship assessed between the spouse's smoking status and the risk of incident stroke. Analyses were conducted in 2007 with Cox proportional hazards models. All models were adjusted for age; race; Hispanic ethnicity; Southern birthstate; parental education; paternal occupation class; years of education; baseline income; baseline wealth; obesity; overweight; alcohol use; and diagnosed hypertension, diabetes, or heart disease. Results: Having a spouse who currently smoked was associated with an increased risk of first stroke among never-smokers (hazard ratio=1.42, 95% CI=1.05, 1.93) and former smokers (hazard ratio=1.72, 95% CI=1.33, 2.22). Former smokers married to current smokers had a stroke risk similar to respondents who themselves smoked. Conclusions: Spousal smoking poses important stroke risks for never-smokers and former smokers. The health benefits of quitting smoking likely extend to both the individual smoker and his or her spouse. http://repub.eur.nl/res/pub/29436/ 2008-08-08T00:00:00Z http://repub.eur.nl/res/pub/29492/ 2008-06-01T00:00:00Z The current study estimated the contribution of job characteristics to socioeconomic inequalities in incidence of myocardial infarction (MI) during a 12-year follow-up period. Data were from the working population (aged 25-64 years) in the Netherlands longitudinal GLOBE study (N = 5757). Self-reported information was available from baseline measurement (in 1991) for education, occupation, job demand, job control, fear of becoming unemployed, adverse physical working conditions, and smoking and alcohol use. Information on hospital admissions for MI among study participants was available until 2003, and was linked to baseline data via record linkage. Cox regression analyses were performed to estimate the hazard of MI in different socioeconomic groups before and after adjustment for job characteristics and health-related behaviours. Lower educated and manual workers had a higher risk of MI during follow-up, after adjusting for age, sex and marital status than higher educated and non-manual workers, respectively. After adjustment for occupation, the lowest educated still had an elevated risk of MI. After adjustment for education, no significant association of occupation with MI was observed. Job control and adverse physical working conditions were not significantly associated with MI after adjustment for socioeconomic position. These results suggest that the reduction of the socioeconomic position-MI association after adjustment for the two specific job characteristics reflect the effect of other unobserved factors closely related to both socioeconomic position and job characteristics. The results of this study point toward education as being the stronger predictor of hospital admitted MI, compared to occupational position and job characteristics, in the Dutch working population. http://repub.eur.nl/res/pub/29034/ 2008-05-01T00:00:00Z BACKGROUND AND PURPOSE-: This study examines the independent effect of wealth, income, and education on stroke and how these disparities evolve throughout middle and old age in a representative cohort of older Americans. METHODS-: Stroke-free participants in the Health and Retirement Study (n=19 565) were followed for an average of 8.5 years. Total wealth, income, and education assessed at baseline were used in Cox proportional hazards models to predict time to stroke. Separate models were estimated for 3 age-strata (50 to 64, 65 to 74, and ≥75), and incorporating risk factor measures (smoking, physical activity, body mass index, hypertension, diabetes, and heart disease). RESULTS-: 1542 subjects developed incident stroke. Higher education predicted reduced stroke risk at ages 50 to 64, but not after adjustment for wealth and income. Wealth and income were independent risk factors for stroke at ages 50 to 64. Adjusted hazard ratios comparing the lowest decile with the 75th-90th percentiles were 2.3 (95% CI 1.6, 3.4) for wealth and 1.8 (95% CI 1.3, 2.6) for income. Risk factor adjustment attenuated these effects by 30% to 50%, but coefficients for both wealth (HR=1.7, 95% CI 1.2, 2.5) and income (HR=1.6, 95% CI 1.2, 2.3) remained significant. Wealth, income, and education did not consistently predict stroke beyond age 65. CONCLUSIONS-: Wealth and income are independent predictors of stroke at ages 50 to 64 but do not predict stroke among the elderly. This age patterning might reflect buffering of the negative effect of low socioeconomic status by improved access to social and health care programs at old ages, but may also be an artifact of selective survival. http://repub.eur.nl/res/pub/29464/ 2008-01-01T00:00:00Z http://repub.eur.nl/res/pub/35217/ 2007-09-01T00:00:00Z BACKGROUND AND PURPOSE - Most Stroke Belt studies define exposure based on residence at stroke onset. We assessed whether residence in the Stroke Belt during childhood confers extra stroke risk in adulthood, even among people who left the region. METHOD - Stroke-free Health and Retirement Study participants (n=18 070) followed up (average, 8.4 years) for first stroke (1452 events) were classified as living in 1 of 7 Stroke Belt states in childhood or at study enrollment (average age, 63 years). We used Cox proportional-hazards models to compare stroke risk for people who had never lived in the Stroke Belt with those who had lived there at both ages, in childhood only, or in adulthood only. RESULTS - Compared with never having lived in the Stroke Belt, the hazard ratio for Stroke Belt residence in both childhood and adulthood was 1.23 (95% CI, 1.06, 1.43) and for Stroke Belt residence in childhood only was 1.25 (95% CI, 1.02, 1.55). Stroke Belt residence at enrollment but not during childhood was not significantly related to stroke risk (hazard ratio=1.01; 95% CI, 0.70, 1.46), but the small sample in this group resulted in wide CIs. Results changed little after risk factor adjustment, including comprehensive adult socioeconomic measures. Subgroup analyses found similar patterns by sex and birth cohort. In contrast, blacks who had lived in the Stroke Belt in childhood only did not appear to have significantly elevated stroke risk compared with blacks who had never lived in the Stroke Belt. CONCLUSIONS - The excess stroke risk for people who had lived in Stroke Belt states during childhood implicates early life exposures in the etiology of the Stroke Belt. http://repub.eur.nl/res/pub/12511/ 2007-01-01T00:00:00Z Despite increased recognition of the importance of investigating socio-economic inequalities in health from a life course perspective, little is known about the influence of childhood socio-economic position (SEP) on cancer incidence. The authors studied the association between father's occupation and adult cancer incidence by linking information from the longitudinal GLOBE study with the regional population-based Eindhoven Cancer Registry (the Netherlands) over a period of 14 years. In 1991, 18,973 participants (response rate 70.1%) of this study responded to a postal questionnaire, including questions on SEP in youth and adulthood. Respondents above the age of 24 were included (N = 12,978). Cox regression was used to calculate hazard ratios (HR) for all cancers as well as for the five most frequently occurring cancers by respondent's educational level or occupational class, and by father's occupational class (adjusted for respondent's education and occupation). Respondents with a low educational level showed an increased risk of all cancers, lung and breast cancer (in women). Respondents with a low adult occupational level showed an increased risk of lung cancer and a reduced risk of basal cell carcinoma. After adjustment for adult education and occupation, respondents whose father was in a lower occupational class showed an increased risk of colorectal cancer as compared to those with a father in the highest social class. In contrast, respondents whose father was in a lower occupational class, showed a decreased risk of basal cell carcinoma as compared to those with a father in the highest occupational class. The association between childhood SEP and cancer incidence is less consistent than the association between adult SEP and cancer incidence, but may exist for colorectal cancer and basal cell carcinoma. http://repub.eur.nl/res/pub/22543/ 2006-12-08T00:00:00Z The aim of the thesis was to examine the magnitude and explanation of socioeconomic differences in stroke across different world populations. Data from several sources were used including mortality statistics merged with national census data, population cohort studies and general practice registration data. Results indicate that socioeconomic status is associated with higher stroke mortality in many Western populations. Whereas socioeconomic disparities in stroke mortality are similar across Western Europe, there is a north-south gradient in socioeconomic disparities in ischaemic heart disease mortality. Stroke mortality has declined in all socioeconomic groups since the 1980s, but socioeconomic disparities in stroke mortality have persisted during the last decades in Western Europe. Our in-depth studies indicate that socioeconomic differentials in stroke result from the combination of multiple risk factors: Conventional cardiovascular risk factors such as ! hypertension and smoking explain about half of socioeconomic disparities in stroke. Furthermore, psychosocial factors such as depression and social networks additionally contribute to these disparities. Nonetheless, explanations are not uniform in all countries: For instance, whereas smoking plays a major role in explaining stroke disparities in Northern Europe, hypertension seems to be a more prominent factor in Southern European countries. Overall, results indicate that general practitioners provide stroke preventive care of a similar quality to patients from different socioeconomic groups in the Netherlands. Results from this thesis indicate that socioeconomic disparities in stroke are a major public health problem that requires combined interventions and policies. Reducing these disparities is essential to sustain the stroke mortality decline in Western populations. http://repub.eur.nl/res/pub/13285/ 2004-02-01T00:00:00Z BACKGROUND AND PURPOSE: Variations between countries in occupational differences in stroke mortality were observed among men during the 1980s. This study estimates the magnitude of differences in stroke mortality by educational level among men and women aged >or=30 years in 10 European populations during the 1990s. METHODS: Longitudinal data from mortality registries were obtained for 10 European populations, namely Finland, Norway, Denmark, England/Wales, Belgium, Switzerland, Austria, Turin (Italy), Barcelona (Spain), and Madrid (Spain). Rate ratios (RRs) were calculated to assess the association between educational level and stroke mortality. The life table method was used to estimate the impact of stroke mortality on educational differences in life expectancy. RESULTS: Differences in stroke mortality according to educational level were of a similar magnitude in most populations. However, larger educational differences were observed in Austria. Overall, educational differences in stroke mortality were of similar size among men (RR, 1.27; 95% CI, 1.24 to 1.30) and women (RR, 1.29; 95% CI, 1.27 to 1.32). Educational differences in stroke mortality persisted at all ages in all populations, although they generally decreased with age. Eliminating these differences would on average reduce educational differences in life expectancy by 7% among men and 14% among women. CONCLUSIONS: Educational differences in stroke mortality were observed across Europe during the 1990s. Risk factors such as hypertension and smoking may explain part of these differences in several countries. Other factors, such as socioeconomic differences in healthcare utilization and childhood socioeconomic conditions, may have contributed to educational differences in stroke mortality across Europe