Abstract
Objectives
We estimated the roles of childhood socioeconomic position (ChSEP) and education attainment on chronic diseases in Chilean adults, mediated through structural determinants and health behaviors, to identify potential pro-equity interventions.
Methods
We analyzed Chile’s longitudinal Social Protection Surveys, a national sample of 14,788 adults with follow-up to 2009. Controlled direct effects (CDE) and natural effects (NDE and NIE) of ChSEP and education on number of chronic diseases were estimated with negative binomial models.
Results
CDE of low ChSEP with education fixed at 12 years showed a 12% increase with 4% indirect effects. CDEs at favorable levels of BMI, smoking, alcohol use, and physical activity were similar. CDE estimates for education adjusted for ChSEP were larger with negligible mediation. CDEs for women were generally larger.
Conclusions
Low ChSEP exerts a primarily direct effect on later chronic disease, modestly mediated by education. Education attainment showed larger direct effects with minimal mediation by behaviors. Strengthening current–early child development and education policies, particularly gender aspects, may reduce social inequalities and key pathways for reducing chronic disease inequalities in Chile.
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References
Allison P (2012) Do we really need zero-inflated models? In: Stat. Horizons. http://statisticalhorizons.com/zero-inflated-models
Alvarado ME, Garmendia ML, Acuña G et al (2009) Validez y confiabilidad de la versión chilena del alcohol use disorders identification test (AUDIT). Rev Med Chil 137:1463–1468. doi:10.4067/S0034-98872009001100008
Baron R, Kenny D (1986) The moderator–mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol 5:1173–1182
Baumeister H, Kriston L, Bengel J, Härter M (2010) High agreement of self-report and physician-diagnosed somatic conditions yields limited bias in examining mental–physical comorbidity. J Clin Epidemiol 63:558–565. doi:10.1016/j.jclinepi.2009.08.009
Ben-Shlomo Y, Kuh D (2002) A life course approach to chronic disease epidemiology: conceptual models, empirical challenges and interdisciplinary perspectives. Int J Epidemiol 31:285–293
Centro de Microdatos (2009) Encuesta de Protección Social 2002–2009. Documento metodológico, Santiago
Cummings P (2009) Methods for estimation adjusted risk ratios. Stata J 9:175–196
Di Cesare M, Khang Y-H, Asaria P et al (2013) Inequalities in non-communicable diseases and effective responses. Lancet (London, England) 381:585–97. doi:10.1016/S0140-6736(12)61851-0
Emsley R, Liu H (2013) PARAMED: Stata module to perform causal mediation analysis using parametric regression models. http://fmwww.bc.edu/repec/bocode/p/paramed.ado. Accessed 12 Jan 2016
Ernstsen L, Strand BH, Nilsen SM et al (2012) Trends in absolute and relative educational inequalities in four modifiable ischaemic heart disease risk factors: repeated cross-sectional surveys from the Nord-Trøndelag Health Study (HUNT) 1984–2008. BMC Public Health 12:266. doi:10.1186/1471-2458-12-266
Frenz P, Delgado I, Kaufman JS, Harper S (2014) Achieving effective universal health coverage with equity: evidence from Chile. Health Policy Plan 29:717–731. doi:10.1093/heapol/czt054
Galobardes B, Shaw M, Lawlor DA et al (2006) Indicators of socioeconomic position (part 1). J Epidemiol Community Health 60:7–12. doi:10.1136/jech.2004.023531
Galobardes B, Lynch JW, Smith GD (2008) Is the association between childhood socioeconomic circumstances and cause-specific mortality established? Update of a systematic review. J Epidemiol Community Health 62:387–390. doi:10.1136/jech.2007.065508
Granstrom F, Garvin P, Molarius A, Kristenson M (2014) The mediating role of material/structural factors in explaining educational inequalities in psychosocial factors—analysis of data from a Swedish population survey from 2008 using structural equation modelling: Fredrik Granstrom. Eur J Public Heal 24:cku166.086. doi:10.1093/eurpub/cku166.086
Guimarães JMN, Werneck GL, Faerstein E et al (2014) Early socioeconomic position and self-rated health among civil servants in Brazil: a cross-sectional analysis from the Pró-Saúde cohort study. BMJ Open 4:e005321. doi:10.1136/bmjopen-2014-005321
Helmke I (2011) A decade towards better health in Chile. Bull World Health Organ 89:710–711. doi:10.2471/BLT.11.041011
Hilbe JM (2011) Negative binomial regression. Public Adm Rev 70:1–6. doi:10.1111/j.1540-6210.2010.02207.x
Huntley AL, Johnson R, Purdy S et al (2012) Measures of multimorbidity and morbidity burden for use in primary care and community settings: a systematic review and guide. Ann Fam Med 10:134–141. doi:10.1370/afm.1363
Jones A, Mitchel D, Goza F (2014) Lifecourse socioeconomic status and cardiovascular illness in Latin America. Curr Sociol 62:1055–1078
Kaufman JS, MacLehose RF (2013) Which of these things is not like the others? Cancer 119:4216–4222. doi:10.1002/cncr.28359
Krieger N, Williams DR, Moss NE (1997) Measuring social class in US public health research: concepts, methodologies, and guidelines. Annu Rev Public Health 18:341–378. doi:10.1146/annurev.publhealth.18.1.341
Krieger N, Okamoto A, Selby JV (1998) Adult female twins’ recall of childhood social class and father’s education: a validation study for public health research. Am J Epidemiol 147:704–708
Kuh D, Lynch J, Hallqvist J, Power C (2003) Life course epidemiology. J Epidemiol Commun Health 57:778–783
Kuhn Barrientos L, Castillo Riquelme M (2013) Atención primaria de salud en Chile: mecanismos de financiamiento y consideraciones de equidad. Econ y Salud 7:14–21
Lash TL, Fox MP, Fink AK (2009) Applying quantitative bias analysis to epidemiologic data. Springer, New York
Levesque J-F, Harris MF, Russell G (2013) Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health 12:18. doi:10.1186/1475-9276-12-18
Loucks EB, Almeida ND, Taylor SE, Matthews KA (2011) Childhood family psychosocial environment and coronary heart disease risk. Psychosom Med 73:563–571. doi:10.1097/PSY.0b013e318228c820
Mackenbach JP, Karanikolos M, McKee M (2013) The unequal health of Europeans: successes and failures of policies. Lancet 381:1125–1134. doi:10.1016/S0140-6736(12)62082-0
McKenzie SK, Carter KN, Blakely T, Ivory V (2011) Effects of childhood socioeconomic position on subjective health and health behaviours in adulthood: how much is mediated by adult socioeconomic position? BMC Public Health 11:269. doi:10.1186/1471-2458-11-269
Ministerio de Desarrollo Social (2013) Casen 2013. Género Síntesis de resultados. http://observatorio.ministeriodesarrollosocial.gob.cl/documentos/Casen2013_Genero.pdf. Accessed 24 Jan 2016
Ministerio de Salud (2008) Informe Final Estudio Carga de Enfermedad y Carga Atribuible
MINSAL (2010) Encuesta Nacional de Salud ENS Chile 2009–2010. Santiago
Montez JK (2015) Educational attainment and adult health: under what conditions is the association causal? Soc Sci Med 127:1–7
Nandi A, Glymour MM, Subramanian SV (2014) Association among socioeconomic status, health behaviors, and all-cause mortality in the United States. Epidemiology 25:170–177. doi:10.1097/EDE.0000000000000038
OECD (2014) Social and welfare issues, Society at a Glance. http://www.oecd.org/social/societyataglance.htm. Accessed 11 Jun 2015
Orsini N, Belloco R, Bottai M et al (2008) A tool for deterministic and probabilistic sensitivity analysis of epidemiologic studies. Stata J 8:29–48
Pollitt RA, Rose KM, Kaufman JS (2005) Evaluating the evidence for models of life course socioeconomic factors and cardiovascular outcomes: a systematic review. BMC Public Health 5:7. doi:10.1186/1471-2458-5-7
Robins J (2002) Semantics of causal DAG models and the identification of direct and indirect effects. In: Green P, Hjort N, Richardson S (eds) Highly structures stochastic systems. Oxford University Press, Oxford
Sheikh MA, Abelsen B, Olsen JA (2014) Role of respondents’ education as a mediator and moderator in the association between childhood socio-economic status and later health and wellbeing. BMC Public Health 14:1172. doi:10.1186/1471-2458-14-1172
Shonkoff JP, Garner AS (2012) The lifelong effects of early childhood adversity and toxic stress. Pediatrics 129:e232–e246. doi:10.1542/peds.2011-2663
Singh-Manoux A, Ferrie JE, Chandola T, Marmot M (2004) Socioeconomic trajectories across the life course and health outcomes in midlife: evidence for the accumulation hypothesis? Int J Epidemiol 33:1072–1079. doi:10.1093/ije/dyh224
Smith BT, Lynch JW, Fox CS et al (2011) Life-course socioeconomic position and type 2 diabetes mellitus: the Framingham Offspring Study. Am J Epidemiol 173:438–447. doi:10.1093/aje/kwq379
Smith AD, Heron J, Mishra G et al (2015) Model selection of the effect of binary exposures over the life course. Epidemiology 26:719–726. doi:10.1097/EDE.0000000000000348
Statacorp (2015) Stata statistical software: release 14
Valeri L, Vanderweele TJ (2013) Mediation analysis allowing for exposure-mediator interactions and causal interpretation: theoretical assumptions and implementation with SAS and SPSS macros. Psychol Methods 18:137–150. doi:10.1037/a0031034
VanderWeele TJ, Vansteelandt S (2014) Mediation analysis with multiple mediators. Epidemiol Method 2:95–115. doi:10.1515/em-2012-0010
World Health Organization (2008) Closing the gap in a generation: health equity through action on the social determinants of health. Geneva
World Health Organization (2015) WHO report on the global tobacco epidemic, 2015: raising taxes on tobacco. Geneva
Zajacova A, Hummer RA (2009) Gender differences in education effects on all-cause mortality for white and black adults in the United States. Soc Sci Med 69:529–537. doi:10.1016/j.socscimed.2009.06.028
Acknowledgements
The authors thank Chile’s National Fund for Health Research and Development (Fondo Nacional de Investigación y Desarrollo en Salud, FONIS. Grant no. SA13|20138) for funding this study. They also thank the Subsecretaría de Previsión Social of the Ministerio de Trabajo y Previsión Social of Chile for access to the data bases of the Social Protection Survey (Encuesta de Protección Social). The results and conclusions are the sole responsibility of the authors and in no way commit the Government of Chile. The first author gratefully acknowledges the support and setting provided by a writing residency at the Rockefeller Foundation’s Bellagio Center (2014), where the paper was first developed.
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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study, using anonymized data from the Chilean Social Protection Survey (Encuesta de Protection Social), which is publically available from Chile’s Ministry of Labor and Social Prevision (Ministerio de Trabajo y Previsión Social), was approved by the Ethics Committee for Research on Human Subjects of the Faculty of Medicine of the University of Chile.
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Informed consent was obtained from all individual participants included in the Social Protection Survey (Encuesta de Protección Social).
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Frenz, P., Kaufman, J.S., Nazzal, C. et al. Mediation of the effect of childhood socioeconomic position by educational attainment on adult chronic disease in Chile. Int J Public Health 62, 1007–1017 (2017). https://doi.org/10.1007/s00038-017-0996-z
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DOI: https://doi.org/10.1007/s00038-017-0996-z