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Cited by 1,065Health disparities and outcomesPublic Health and Social InequalitiesCardiovascular Health and Risk Factors

Association of socioeconomic position with health behaviors and mortality

Open access
Stringhini, Silvia·2010·JAMA
DOI 10.1001/jama.2010.297PMC PMC2918905
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Abstract

CONTEXT: Previous studies may have underestimated the contribution of health behaviors to social inequalities in mortality because health behaviors were assessed only at the baseline of the study. OBJECTIVE: To examine the role of health behaviors in the association between socioeconomic position and mortality and compare whether their contribution differs when assessed at only 1 point in time with that assessed longitudinally through the follow-up period. DESIGN, SETTING, AND PARTICIPANTS: Established in 1985, the British Whitehall II longitudinal cohort study includes 10 308 civil servants, aged 35 to 55 years, living in London, England. Analyses are based on 9590 men and women followed up for mortality until April 30, 2009. Socioeconomic position was derived from civil service employment grade (high, intermediate, and low) at baseline. Smoking, alcohol consumption, diet, and physical activity were assessed 4 times during the follow-up period. MAIN OUTCOME MEASURES: All-cause and cause-specific mortality. RESULTS: A total of 654 participants died during the follow-up period. In the analyses adjusted for sex and year of birth, those with the lowest socioeconomic position had 1.60 times higher risk of death from all causes than those with the highest socioeconomic position (a rate difference of 1.94/1000 person-years). This association was attenuated by 42% (95% confidence interval [CI], 21%-94%) when health behaviors assessed at baseline were entered into the model and by 72% (95% CI, 42%-154%) when they were entered as time-dependent covariates. The corresponding attenuations were 29% (95% CI, 11%-54%) and 45% (95% CI, 24%-79%) for cardiovascular mortality and 61% (95% CI, 16%-425%) and 94% (95% CI, 35%-595%) for noncancer and noncardiovascular mortality. The difference between the baseline only and repeated assessments of health behaviors was mostly due to an increased explanatory power of diet (from 7% to 17% for all-cause mortality, respectively), physical activity (from 5% to 21% for all-cause mortality), and alcohol consumption (from 3% to 12% for all-cause mortality). The role of smoking, the strongest mediator in these analyses, did not change when using baseline or repeat assessments (from 32% to 35% for all-cause mortality). CONCLUSION: In a civil service population in London, England, there was an association between socioeconomic position and mortality that was substantially accounted for by adjustment for health behaviors, particularly when the behaviors were assessed repeatedly.

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  • Mechanisms linking psychosocial factors to increased CVD risk include unhealthy lifestyle, increased healthcare utilization, and low adherence to behaviour-change recommendations or cardiac medications.

    “Mechanisms that link psychosocial factors to increased CVD risk include unhealthy lifestyle (more frequent smoking, unhealthy food choice, and less physical exercise), increased healthcare utilization, and low adherence to behaviour-change recommendations or cardiac medications.88,90,116 -119”

    From European Guidelines on cardiovascular disease prevention in clinical practice (version 2012) (2012) · cites this paper as [88]

  • Low socio-economic status is associated with increased all-cause and CVD mortality risk (RR 1.3-2.0).

    “Multiple prospective studies have shown that men and women with low socio-economic status, defined as low educational level, low income, holding a low-status job, or living in a poor residential area, have an increased all-cause as well as CVD mortality risk [relative risk (RR) 1.3 -2.0].87 -91”

    From European Guidelines on cardiovascular disease prevention in clinical practice (version 2012) (2012) · cites this paper as [88]

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Authors
Stringhini, S.
Affiliations
Inserm (FR)
Corresponding author
Stringhini, Silvia
ORCID
Stringhini, Silvia
Venue
JAMA
Publisher
American Medical Association (AMA)
Published
2010-03-24
Volume
303
Issue
12
Pages
1159
ISSN
  • 0002-9955 (ISSN-L)
  • 0098-7484
DOI
10.1001/jama.2010.297
PMC
PMC2918905
OpenAlex
W2050761447
Cited by
1,065
References
53
Citations by year
2026: 40 · 2025: 49 · 2024: 51 · 2023: 56 · 2022: 54 · 2021: 95 · 2020: 73 · 2019: 72 · 2018: 76 · 2017: 81 · 2016: 63 · 2015: 75 · 2014: 56 · 2013: 68 · 2012: 78
FWCI
71.43
Type
journal article
Language
en
Open access
Locations
  • JAMA (publishedVersion)
  • PubMed (publishedVersion)
  • Archive ouverte UNIGE (University of Geneva) (publishedVersion, other-oa)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
  • HAL (submittedVersion, other-oa)
  • UCL Discovery (University College London) (submittedVersion)
  • IRIS (submittedVersion)
  • SERVAL (Université de Lausanne) (submittedVersion)
  • Archive ouverte UNIGE (University of Geneva) (submittedVersion, cc-by)
Funders
  • National Institute for Health and Care Research
  • British Heart Foundation (R01 AG013196, R01AG034454)
  • European Science Foundation
  • Health and Safety Executive
  • Medical Research Council (R01AG034454)
  • National Institute on Aging (R01AG034454, R01AG013196)
  • National Heart, Lung, and Blood Institute (R01HL036310)
Topics
  • Social Sciences › Health › Health disparities and outcomes
  • Social Sciences › Health › Public Health and Social Inequalities
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Health and Risk Factors
Keywords
socioeconomic position, health behavior, mortality, health disparities, smoking, alcohol consumption, diet, physical activity, cardiovascular mortality, time-varying covariates, mediation, Whitehall II cohort, public sector employees, all-cause mortality, non-cancer mortality, confounding by indication
MeSH terms
Adult, Aged, Female, Follow-Up Studies, Health Status, Humans, London, Male, Middle Aged, Mortality, Social Class, Health Behavior, Outcome Assessment, Health Care, Health Status Disparities

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