Aujourd’hui, de fortes inégalités sociales de santé persistent entre les individus les plus favorisés socio-économiquement et ceux vivants dans des situations moins favorables, et l’alimentation y contribue fortement. Bien que les disparités sociales de nutrition soient bien documentées, notamment en ce qui concerne le niveau d’études, les connaissances relatives à l’influence indépendante des différents indicateurs socio-économiques sur l’alimentation et notamment ses dimensions comportementales sont insuffisantes. Par ailleurs, les mécanismes sous-jacents des disparités en nutrition sont encore mal compris. Parmi les déterminants individuels, nous manquons de connaissances sur l’influence du parcours de vie des individus sur leurs comportements alimentaires. Dans ce contexte, les objectifs de cette thèse étaient d’analyser les associations entre les facteurs socio-économiques et les comportements alimentaires, abordés sous différentes dimensions : apports en nutriments, prise des repas principaux, et pratiques de snacking (i.e. prises alimentaires différentes des repas principaux). Il s’agissait également d’évaluer l’influence d’événements de vie professionnels sur les comportements alimentaires. Les résultats montrent que les individus ayant la position socio-économique (PSE) la plus favorisée ont des apports plus élevés en nutriments recommandés (fibre, vitamine C, B9, magnésium, etc.). Le niveau d’éducation semble être un déterminant majeur des apports nutritionnels et modifie les associations entre revenus et apports en nutriments. Bien que les individus de PSE moins favorisée soient moins susceptibles d’avoir des prises de snacking, la qualité nutritionnelle de ces prises est moindre. Par ailleurs, le passage à la retraite est associé à des apports alimentaires moins favorables à la santé (qualité globale, lipides, sodium, acides gras saturés…), en particulier chez les hommes ayant les plus bas revenus avant la retraite (diminution de l’apport en produits laitiers et augmentation de l’apport en lipides). L’ensemble de ces résultats soulignent l’importance des déterminants socio-économiques ainsi que des événements de vie professionnels sur les comportements alimentaires et la nécessité de mieux adapter les politiques nutritionnelles de santé en fonction des sous-groupes de la population et des périodes et événements de la vie. / Strong health inequalities remain between socio-economically advantaged individuals and those of lower socioeconomic position. Diet appears to be an important modifiable factor, which contributes to health inequalities. Although social disparities in nutrition have been well documented, the independent influences of the different socioeconomic indicators on diet – in particular its behavioural dimensions – have not been deeply investigated. In addition, the pathways underlying these disparities are still poorly understood. Among individual determinants, there is a lack of knowledge regarding effects of life course on dietary behaviours.The objective of this Ph.D. thesis was to investigate the associations between socioeconomic factors and dietary behaviours, expressed in terms of nutrient intakes and snacking practices. The influence of occupational life events on dietary behaviours was also assessed.The results showed that individuals with high socioeconomic position (PSE) had higher intakes of recommended nutrients (fibre, vitamin C, folate, magnesium, etc.). Education appears to be a major determinant of dietary intakes and modifies the associations between income and dietary intakes. Although individuals with low socioeconomic position are less likely to snack, the nutritional quality of their snacks is lower. Moreover, retirement was associated with unhealthier dietary intakes (overall diet quality, lipids, sodium, saturated fatty acids,...), particularly in men with the lowest income before retirement (decrease in intake of dairy products and increase in intake of lipids).The results underline the importance of socioeconomic determinants and life events on dietary behaviours. The identification of life periods and events leading to changes in dietary behaviours enables on one hand to improve knowledge regarding pathways underlying socioeconomic inequalities in health related to nutrient and food intake, and on the other hand to determine target populations for interventions. Adapting nutritional public interventions among social subgroups of the population and throughout the entire life is key to improve dietary behaviours.

Background: The National Health Service (NHS) aims to achieve maximum health gains with its limited resources, while also ensuring that it provides services according to need, irrespective of factors such as socioeconomic position (SEP). Aim: The aim of this thesis is to explore the relationships between SEP and various aspects of the NHS orthodontic service, including need, demand, supply, and outcomes. Methods: Three main data sources were used: two population-based surveys (the 2003 United Kingdom (UK) Children’s Dental Health Survey (CDHS) and the 2008-2009 NHS Dental Epidemiology Programme for England Oral Health Survey (OHS) in the North West) and an administrative data set (containing 2008-2012 North West NHS orthodontic activity data). The data were used to investigate levels of need and willingness to have orthodontic treatment, treatment utilisation, assessment procedures, and treatment outcomes, and the costs associated with the service. Subsequently, regression analyses were carried out to explore the associations between SEP and the various orthodontic variables. Results: Over a third of 12-year-olds had normative need for orthodontic treatment and over half had patient-defined need. Those in the most deprived groups in the North West tended to have lower levels of treatment compared to those in the least deprived group (despite the fact that normative need was not shown to vary by SEP), and they were more likely to discontinue treatment and have residual post-treatment need (RPTN). There was a great deal of variation among practices/orthodontic clinicians in terms of the percentages of patients with repeated assessments, treatment discontinuations, and RPTN. The major sources of potential inefficiency costs in the NHS orthodontic service in the North West are treatments that result in discontinuations (which cost £2.4 million per year), RPTN (which cost £1.8 million per year), and unreported treatment outcomes (which cost £13.0 million per year). Discussion: The NHS is not delivering orthodontic care equitably between SEP groups in the North West, as those from more deprived groups are more likely to fail to receive treatment, and to have poor outcomes if they do receive treatment. In addition, the wide range of process and outcome indicators between practices/orthodontic clinicians raises issues about quality of the overall service. In particular, treatment outcomes are frequently unreported, which highlights the need to improve the outcome monitoring systems in the NHS orthodontic service.

<p>This thesis described socioeconomic inequalities in fruit and vegetable consumption in Stockholm County.<strong> </strong>A comparative descriptive analysis was carried out with the use of secondary data from the 2006 Stockholm County Public Health Survey. The data was analyzed through cross tabulations that were conducted in SPSS.<strong> </strong>The findings showed that people with high socioeconomic position consumed fruit and vegetables more frequently than those of low socioeconomic position. Differences in fruit and vegetable consumption were found for the three measures of socioeconomic position; education, occupation and income. These differences were pronounced to a larger extent across different education levels compared to levels of occupation and income. Further research is needed to investigate which factors may explain the observed differences.</p>

This thesis described socioeconomic inequalities in fruit and vegetable consumption in Stockholm County. A comparative descriptive analysis was carried out with the use of secondary data from the 2006 Stockholm County Public Health Survey. The data was analyzed through cross tabulations that were conducted in SPSS. The findings showed that people with high socioeconomic position consumed fruit and vegetables more frequently than those of low socioeconomic position. Differences in fruit and vegetable consumption were found for the three measures of socioeconomic position; education, occupation and income. These differences were pronounced to a larger extent across different education levels compared to levels of occupation and income. Further research is needed to investigate which factors may explain the observed differences.

Self-reported psychological distress is quite common in the Swedish elderly population. Feelings of psychological distress may have devastating consequences. The overall aim of this study was to explore associations between socioeconomic position and work complexity during midlife with psychological distress in old age. Ordered logistic regression was used to investigate the associations between, (I) socioeconomic position during midlife and psychological distress in old age, (II) work complexity during midlife and psychological distress in old age, (III) the association between socioeconomic position and psychological distress independent of work complexity, and (IV) the association between work complexity and psychological distress independent of socioeconomic position. The results show that (I) higher socioeconomic position during midlife is associated with less psychological distress in old age (II) higher work complexity during midlife is associated with less psychological distress in old age, and that (III) higher work complexity is associated to less psychological distress independent of socioeconomic position, (IV) but the association between socioeconomic position and psychological distress diminishes adjusting for work complexity. The main conclusion from this study is that individuals with high socioeconomic position benefits from both their position in society and from their working conditions while individuals of lower socioeconomic position are more likely to also suffer the drawbacks of disadvantageous working conditions in relation to late life psychological distress.

Background: High blood pressure is the leading risk factor for disease burden worldwide, contributing to more than 9 million deaths each year. Some research suggests that the prevalence of hypertension increases as individual/household socioeconomic position (SEP) decreases. The results of multilevel studies also suggest an association between poorer neighborhood socioeconomic circumstances and hypertension. Further, at both the individual/household- and area-level, high blood pressure may be more strongly related to SEP among women than men. Most research, however, has been restricted to urban populations. There has not been much research which examines risk factors for hypertension in rural Canada and, in particular, socioeconomic risk factors. Objectives: To examine the relationship between individual/household- and area- level socioeconomic circumstances, gender, and high blood pressure in a rural Saskatchewan population. Methods: There were two data sources for this study. Individual/household-level data were from the Saskatchewan Rural Health Study (SRHS). Analyses focused on adults (n=8,261) who completed the cross-sectional baseline questionnaire. Census subdivisions were used to link SRHS data with area-level data from the 2006 Canadian census. The dependent variable was self-reported diagnosed high blood pressure. The primary independent variables were gender and four measures of socioeconomic circumstances: household income, educational attainment, arealevel material deprivation, and area-level social deprivation. Principal components analysis was used to derive the area-level measures of deprivation. Multilevel logistic regression was the primary method of analysis. Results: Four main findings emerged: 1) low educational attainment was associated with a greater odds of high blood pressure; 2) the relationship between low household income and high blood pressure was more pronounced among women than men; 3) the relationship between higher area-level social deprivation and high blood pressure was more pronounced among men than women; and 4) area-level material deprivation was not associated with high blood pressure. iii Conclusion: Study results revealed complex relationships between SEP, gender, and high blood pressure in this rural Saskatchewan population. Future research applying a longitudinal design is needed to advance understanding of the relationship between SEP and incident hypertension in rural Canada, including the identification of vulnerable subgroups. Also needed is research examining the factors which explain (i.e. mediate) associations between SEP and hypertension in rural settings, particularly at the area-level.

Reliable estimates for differences in life expectancy (LE) by socio-economic position (SEP), that can be assessed in an international context and are comprehensive in terms of considering different SEP dimensions, are missing for the German population so far. The aim of the present study is to fill this gap by providing estimates for differences in LE by education, household income, work status and vocational class. The lack of national mortality data by SEP required an innovative methodological approach to estimate LE from survey data with a mortality followup. The main strengths of the method are the low demand on the data, its simple applicability and the estimation of a set of age-specific probabilities of dying. We employed the method to the German Life Expectancy Survey and estimated period life tables for 45 male and 32 female SEP subpopulations. The results show striking differences in LE across all analysed SEP indicators. Among men, LE at age 40 ranges by more than five years between the lowest and highest household income quartiles, more than six years between individuals with low and high education, around ten years across the work status groups, and almost 15 years across the vocational classes. The proportion of those who reach the classic pension age of 65 years also varies considerably, as does the remaining LE at this age. The corresponding differences among women are smaller, yet still notable. The results yield an interesting finding for the ongoing discussion about the various consequences of an increased pension age. Moreover, they provide policy-makers, doctors, researchers and public health workers with insights into Germany's most disadvantaged SEP subpopulations and the potential extent of their disadvantages in terms of longevity and mortality.

L’objectif général de la thèse était d’étudier le rôle des déterminants sociaux dans l’asthme avec un intérêt particulier pour des aspects méthodologiques de caractérisation du contexte social de résidence.La première partie de la thèse visait à étudier l’hypothèse d’une association entre le niveau socioéconomique (NSE) et la pollution de l’air qui est un facteur de risque important de l’asthme. Nous avons étudié spécifiquement l’association entre le NSE évalué à un niveau individuel (niveau d’études et catégorie socioprofessionnelle) et contextuel (taux de chômage du quartier de résidence) en lien avec l’exposition au dioxyde d’azote (NO2), un marqueur du trafic routier, dans 16 villes d’Europe occidentale (n=5692, 3 cohortes). Dans les analyses stratifiées par ville, nous avons observé que le NSE individuel n’était généralement pas associé au NO2, alors que l’indicateur contextuel était associé positivement et significativement au NO2 dans la majorité des villes.La deuxième partie de la thèse visait à mieux comprendre l’association entre le NSE et le contrôle de l’asthme, objectif majeur de la prise en charge thérapeutique. Ce travail a d’abord porté sur des aspects méthodologiques d’évaluation du contexte social de résidence dans la cohorte E3N (Etude Epidémiologique auprès des femmes de la Mutuelle Générale de l’Education Nationale). La comparaison de trois indices de désavantage (n=63888) a mis en évidence l’intérêt de l’indice FDep (French Deprivation Index) pour caractériser le contexte de résidence de cette cohorte spécifique de femmes âgées avec un NSE relativement élevé comparé à celles de la population générale française. Ce travail a ensuite porté sur l’étude de l’association entre le NSE, individuel et contextuel, et le contrôle de l’asthme dans l’étude Asthma-E3N, une étude cas-témoin sur la santé respiratoire, nichée dans la cohorte E3N. Parmi les 2258 femmes avec un asthme actuel, les femmes avec un niveau d’études moyen (OR= 1.2 (1.0 ; 1.6)) ou bas (1.9 (1.4 ; 2.6)) avaient significativement un moins bon contrôle de leur asthme que celles avec un niveau d’études élevé (≥Bac+3). Les femmes qui résidaient dans les quartiers les plus désavantagés avaient plus fréquemment un asthme non contrôlé, quel que soit leur niveau d’études.Ces résultats montrent l’importance de prendre en compte le niveau socioéconomique au niveau individuel et contextuel dans l’étude des facteurs de risque de l’asthme. / The general aim of the thesis was to study the role of social determinants in asthma with a particular focus on methodological aspects to characterize neighborhood social context.The first part of the thesis aimed to investigate the hypothesis of a differential exposure to air pollution, an important risk factor for asthma. Specifically, we studied the association between socioeconomic position (SEP) assessed at individual-level (educational level and occupational status) and neighborhood-level (unemployment rate) and exposure to nitrogen dioxide (NO2), a marker of traffic exhaust, in 16 western European cities. In stratified analyses, including 5692 participants from three European cohorts, association between individual SEP and NO2 were generally weak and inconsistent in direction. The neighborhood unemployment rate was positively and significantly associated with NO2 in most of the cities studied.The second part of the thesis aimed to better understand the association between socioeconomic position and asthma control, the main target of asthma management. We first focused on methodological aspects to characterize neighborhood social context in the E3N cohort. We compared three indices of deprivation and showed that the French Deprivation Index was the most appropriate to measure neighborhood social context in this specific cohort composed of elderly women with higher socioeconomic profile than the elderly women in the general French population. We then investigated the association between SEP, at individual- and area-level, and asthma control in Asthma-E3N, a case-control study on asthma nested in the E3N cohort. Including 2258 women with current asthma, the analysis showed that women with medium and low educational level had more often uncontrolled asthma than women with high educational level. Women living in deprived neighborhood had more often uncontrolled asthma independently of their educational level.

Background: To throw light on the under-researched association between socioeconomic position (SEP) and health in Cuba, this study examined SEP gradients in health and their underlying mechanisms among urban Cuban adults aged 18-65. Methods: By applying linear regressions to data from the 2010 National Survey on Risk Factors and Chronic Diseases, the analysis explored the SEP-health gradient along three SEP dimensions-education, occupation, and skin colour-using ten health measures: Self-reported health (SRH), general and abdominal obesity, hypertension, high glucose, high cholesterol, high triglycerides, low high-density lipoprotein cholesterol, metabolic syndrome, and cumulative risk factors. Regressions also included behaviours and health-related risk perceptions (tobacco and alcohol consumption, diet, physical activity, and risk-related behaviours). It thus investigated the SEP-health gradient and its underlying mechanisms via both behaviours and health-related risk perceptions. Results: Once controlling for gender, age, marital status, region and provincial dummies, the analysis detected educational gradients in SRH (estimated coefficient [95% CI]: Middle-level education = 3.535 [1.329, 5.741], p < 0.01; high-level education = 5.249 [3.050, 7.448], p < 0.01) that are partially explainable by both health-affecting behaviours (tobacco and alcohol consumption, diet, physical and sedentary activity) and risk perceptions. Using objective measures of health, however, it found no SEP-health gradients other than hypertension among people identified as having Black skin color (adjusted for demographic variables, 0.060 [0.018, 0.101], p < 0.01) and high cholesterol among those identified as having Mulatto or Mestizo skin color (adjusted for demographic variables,-0.066 [-0.098,-0.033], p < 0.01). Conclusions: In terms of objective health measures, the study provides minimal evidence for an SEP-health gradient in Cuba, results primarily attributable to the country's universal healthcare system-which offers full coverage and access and affordable medications- A nd its highly developed education system.

no / Background Almost all studies in health research control or investigate socioeconomic position (SEP) as exposure or confounder. Different measures of SEP capture different aspects of the underlying construct, so efficient methodologies to combine them are needed. SEP and ethnicity are strongly associated, however not all measures of SEP may be appropriate for all ethnic groups. Methods We used latent class analysis (LCA) to define subgroups of women with similar SEP profiles using 19 measures of SEP. Data from 11,326 women were used, from eight different ethnic groups but with the majority from White British (40%) or Pakistani (45%) backgrounds, who were recruited during pregnancy to the Born in Bradford birth cohort study. Results Five distinct SEP subclasses were identified in the LCA: (i) "Least socioeconomically deprived and most educated" (20%); (ii) "Employed and not materially deprived" (19%); (iii) "Employed and no access to money" (16%); (iv) "Benefits and not materially deprived" (29%) and (v) "Most economically deprived" (16%). Based on the magnitude of the point estimates, the strongest associations were that compared to White British women, Pakistani and Bangladeshi women were more likely to belong to groups: (iv) "benefits and not materially deprived" (relative risk ratio (95% CI): 5.24 (4.44, 6.19) and 3.44 (2.37, 5.00), respectively) or (v) most deprived group (2.36 (1.96, 2.84) and 3.35 (2.21, 5.06) respectively) compared to the least deprived class. White Other women were more than twice as likely to be in the (iv) "benefits and not materially deprived group" compared to White British women and all ethnic groups, other than the Mixed group, were less likely to be in the (iii) "employed and not materially deprived" group than White British women. Conclusions LCA allows different aspects of an individual’s SEP to be considered in one multidimensional indicator, which can then be integrated in epidemiological analyses. Ethnicity is strongly associated with these identified subgroups. Findings from this study suggest a careful use of SEP measures in health research, especially when looking at different ethnic groups. Further replication of these findings is needed in other populations.