PLOS ONE RESEARCH ARTICLE Social mobility and healthy behaviours from a gender perspective in the Spanish multicase- control study (MCC-Spain) M. Pinto-Carbó1, R. Peiró-Pérez2,3,4, A. Molina-Barceló ID1*, M. Vanaclocha-Espi1, J. Alguacil4,5, G. Castaño-Vinyals4,6,7,8, C. O’Callaghan-Gordo4,6,7,9, E. Gràcia-Lavedan4,6,8, B. Pérez-Gómez4,10, V. Lope ID4,10, N. Aragonés4,11, A. J. Molina ID12, T. Fernández-Villa12, L. Gil-Majuelo13,14, P. Amiano4,13,14, T. Dierssen-Sotos4,15, I. Gómez-Acebo ID4,15, M. Guevara4,16,17, C. Moreno-Iribas16,17, M. Obón-Santacana4,18,19, M. M. Rodrı́guez- a1111111111 Suárez20,21, I. Salcedo-Bellido ID4,22,23, A. Delgado-Parrilla5, R. Marcos-Gragera ID4,24,25, M. a1111111111 D. Chirlaque4,26, M. Kogevinas4,6,7,8, M. Pollán4,10, D. Salas1,3,4 a1111111111 a1111111111 1 Cancer and Public Health Area, Foundation for the Promotion of the Research in Healthcare and a1111111111 Biomedicine (FISABIO-Salud Pública), Valencia, Valencian Community, Spain, 2 Inequalities Area, Foundation for the Promotion of the Research in Healthcare and Biomedicine (FISABIO-Salud Pública), Valencia, Valencian Community, Spain, 3 General Directorate of Public Health, Valencia, Valencian Community, Spain, 4 Consortium for Biomedical Research in Epidemiology and Public Health (CIBEResp), Madrid, Spain, 5 Centre for Health and Environmental Research, Huelva University, Huelva, Andalucia, Spain, 6 Barcelona Institute for Global Health (ISGlobal), Barcelona, Catalonia, Spain, 7 Universitat Pompeu OPEN ACCESS Fabra, Plaça de la Mercè, Barcelona, Catalonia, Spain, 8 Hospital del Mar Medical Research Institute, Barcelona, Catalonia, Spain, 9 Faculty of Health Science,Universitat Oberta de Catalunya, Barcelona, Citation: Pinto-Carbó M, Peiró-Pérez R, Molina- Catalonia, Spain, 10 Department of Epidemiology of Chronic Diseases, National Center for Epidemiology, Barceló A, Vanaclocha-Espi M, Alguacil J, Castaño- Carlos III Institute of Health, Madrid, Spain, 11 Epidemiology Section, Public Health Division, Department of Vinyals G, et al. (2021) Social mobility and healthy Health of Madrid, Madrid, Spain, 12 The Research Group in Gene—Environment and Health Interactions, behaviours from a gender perspective in the Institute of Biomedicine (IBIOMED), University of León, León, Castilla y León, Spain, 13 Ministry of Health of Spanish multicase-control study (MCC-Spain). the Basque Government, Sub-Directorate for Public Health and Addictions of Gipuzkoa, San Sebastián, PLoS ONE 16(5): e0251447. https://doi.org/ Gipuzkoa, Spain, 14 Biodonostia Health Research Institute, Group of Epidemiology of Chronic and 10.1371/journal.pone.0251447 Communicable Diseases, San Sebastián, Gipuzkoa, Spain, 15 Cantabria University, Santander, Cantabria, Spain, 16 Navarra Public Health Institute, Pamplona, Navarra, Spain, 17 Navarra Institute for Health Editor: Thomas Behrens, Ruhr University Bochum, Research (IdiSNA), Pamplona, Navarra, Spain, 18 Oncology Data Analytics Program (ODAP), Catalan GERMANY Institute of Oncology (ICO), Barcelona, Catalonia, Spain, 19 ONCOBELL Program, Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Catalonia, Spain, 20 Preventive Medicine and Public Health Area, Received: January 21, 2021 Oviedo University, Oviedo, Asturias, Spain, 21 Central University Hospital of Asturias, Public Health Service of the Principe de Asturias, Oviedo, Asturias, Spain, 22 Instituto de Investigación Biosanitaria ibs.GRANADA, Accepted: April 26, 2021 Granada, Andalucia, Spain, 23 Departamento de Medicina Preventiva y Salud Pública, Universidad de Published: May 12, 2021 Granada, Granada, Andalucia, Spain, 24 Epidemiology Unit and Girona Cancer Registry, Oncology Coordination Plan, Department of Health, Autonomous Government of Catalonia, Catalan Institute of Copyright: © 2021 Pinto-Carbó et al. This is an Oncology, Girona, Catalonia, Spain, 25 Descriptive Epidemiology, Genetics and Cancer Prevention Group open access article distributed under the terms of [Girona Biomedical Research Institute], Girona, Catalonia, Spain, 26 Department of Epidemiology, Murcia the Creative Commons Attribution License, which Regional Health Council, IMIB-Arrixaca, El Palmar, Murcia, Spain permits unrestricted use, distribution, and reproduction in any medium, provided the original * molina_anabar@gva.es author and source are credited. Data Availability Statement: The database was registered with the Spanish data protection agency, Abstract under number 210267217118. Data cannot be shared publicly because of the confidential nature There is evidence for the influence of socioeconomic status (SES) on healthy behaviours of the data imposed by the national legislation but the effect of social mobility (SM) is not yet well known. This study aims to analyse the (BOE no. 171, announcement 24716, on 16th July influence of origin and destination SES (O-SES and D-SES) and SM on healthy behaviours 2009). However, the data used in this analysis and other data from the MCC-Spain study is available and co-occurrence, from an integrated gender and age perspective. Data were obtained upon request to the Barcelona Institute for Global from the controls of MCC-Spain between 2008–2013 (3,606 participants). Healthy behav- Health (ISGlobal) institution (contact via: del iours considered: healthy diet, moderate alcohol consumption, non-smoking and physical Rosselló street, 132, Barcelona, 08036, Spain. PLOS ONE | https://doi.org/10.1371/journal.pone.0251447 May 12, 2021 1 / 15 PLOS ONE Social mobility and healthy behaviours from a gender perspective in the MCC-Spain study Telephone: +34 932 27 18 06 E-mail: activity. SM was categorized as stable high, upward, stable medium, downward or stable info@isglobal.org) or to the MCC-Spain Steering low. Binary and multinomial logistic regression models were adjusted. Those aged <65, with Committee through the study coordinators: Manolis Kogevinas (manolis.kogevinas@isglobal. a low O-SES, D-SES and stable low SM are less likely to have healthy behaviours in the org) and Marina Pollán (mpollan@isciii.es). case of both women (physically active: OR = 0.65 CI = 0.45–0.94, OR = 0.71 CI = 0.52– Funding: This research was supported by the 0.98, OR = 0.61 CI = 0.41–0.91) and men (non-smokers: OR = 0.44 CI = 0.26–0.76, OR = “Acción Transversal del Cancer”, approved by the 0.54 CI = 0.35–0.83, OR = 0.41 CI 0.24–0.72; physically active: OR = 0.57 CI = 0.35–0.92, Spanish Council of Ministers on 11th October OR = 0.64 CI = 0.44–0.95, OR = 0.53 CI = 0.23–0.87). However, for those aged �65, this 2007, by the Instituto de Salud Carlos III-FEDER probability is higher in women with a low O-SES and D-SES (non-smoker: OR = 8.09 CI = [grant number:PI08/1770, PI08/0533, PI08/1359, PS09/00773-Cantabria, PS09/01286-León, PS09/ 4.18–15.67, OR = 4.14 CI = 2.28–7.52; moderate alcohol consumption: OR = 3.00 CI = 01903-Valencia, PS09/02078-Huelva, PS09/ 1.45–6.24, OR = 2.83 CI = 1.49–5.37) and in men with a stable low SM (physically active: 01662-Granada, PI11/01403, PI11/01889-FEDER, OR = 1.52 CI = 1.02–1.26). In the case of men, the same behaviour pattern is observed in PI11/00226, PI11/01810, PI11/02213, PI12/00488, those with a low O-SES as those with upward mobility, with a higher probability of co-occur- PI12/00265, PI12/01270, PI12/00715, PI12/00150, PI14/01219, PI14/0613, PI15/00069, PI15/00914, ring behaviours (three-to-four behaviours: OR = 2.00 CI = 1.22–3.29; OR = 3.13 CI = 1.31– PI15/01032, PI11/01810, PI14/01219, PI11/02213, 7.48). The relationship of O-SES, D-SES and SM with healthy behaviours is complex and PIE16/00049, PI17/01179, PI17-00092], by the differs according to age and gender. Fundación Marqués de Valdecilla [grant number: API 10/09], by the ICGC International Cancer Genome Consortium CLL (The ICGC CLL-Genome Project is funded by Spanish Ministerio de Economı́a y Competitividad (MINECO) through the Instituto de Salud Carlos III (ISCIII)), by the Red Introduction Temática de Investigación del Cáncer (RTICC) del Social determinants of health are the conditions in which people are born, grow up, work and ISCIII [grant number: RD12/0036/0036], by the Junta de Castilla y León [grant number: LE22A10- live that affect their values, preferences and access to resources, and therefore their health 2], by the Consejerı́a de Salud of the Junta de behaviours and health outcomes [1]. Thus, health behaviours are socially determined and Andalucı́a [grant number: PI-0571-2009, PI-0306- result in health inequalities, with gender and socioeconomic status (SES) being key social 2011, salud201200057018tra], by the Conselleria determinants [2]. Some of the most important healthy behaviours for management of chronic de Sanitat of the Generalitat Valenciana [grant diseases include a diet rich in fruits and vegetables, the absence of smoking, responsible alcohol number: AP_061/10], by the Recercaixa [grant consumption and physical activity [3]. number: 2010ACUP00310], by the Regional Government of the Basque Country, by the It has been observed that populations with a lower SES have more unhealthy behaviours Consejerı́a de Sanidad de la Región de Murcia, by [4–8]. Gender inequalities in health-related behaviours have also been found, with alcohol the European Commission [grant number: FOOD- consumption being the most common unhealthy behaviour in men and physical inactivity in CT-2006-036224-HIWATE], by the Spanish women [9]. Moreover, taking into account that the worst health indicators are seen in women Association Against Cancer (AECC) Scientific with a lower SES, it is important to explore how the intersection between these two axes of Foundation [grant number: GCTRA18022MORE], by the Catalan Government-Agency for inequality also determines health behaviours [10]. Management of University and Research Grants Health behaviours usually appear cumulatively, with a co-occurrence of two or more risk (AGAUR) [grant number: 2014SGR647, behaviours being the most common scenario [5, 9]. The bault’s cross-sectional study con- 2014SGR850 and 2017SGR723], by the Fundación cluded that, the accumulation of risk behaviours was similar between both genders although Caja de Ahorros de Asturias and by the University the greatest predisposition is observed in men with a low educational level [11]. Therefore, the of Oviedo. The funders had no role in study design, intersection between gender and educational level is also important when studying the co- data collection and analysis, decision to publish, or preparation of the manuscript. occurrence of health behaviours. There are several studies that show the influence of SES on health behaviours and health Competing interests: The authors have declared outcomes [11, 12], but the effect of social mobility is not yet well known. Social mobility can be that no competing interests exist. understood from an intragenerational perspective, meaning, the change in an individual’s SES throughout his or her lifecourse or from an intergenerational perspective, meaning, changes in SES between two generations (progenitors-children) [13]. This study is framed from an inter- generational social mobility perspective, since it considers the SES of the parents and the participants. Campos-Matos’s study [14] shows that the upwardly mobile population, that is, those who ascend the social scale, present better health than the downwardly mobile population, that is, PLOS ONE | https://doi.org/10.1371/journal.pone.0251447 May 12, 2021 2 / 15 PLOS ONE Social mobility and healthy behaviours from a gender perspective in the MCC-Spain study those who descend it. Regarding health behaviours, another study observed that people with stable low, meaning they remain in a low social position, or downward mobility are more likely to have unhealthy behaviours [5]. Gugushvili’s study [15] shows a differential mobility pattern according to gender, with women being more influenced by their origin SES than men. These findings also coincide with other studies [16]. Considering Van Eijck’s sociological theories regarding the impact of social mobility on behaviours [17], the results of aforementioned stud- ies [15, 16] coincide with the socialization hypothesis, which puts forward that primary sociali- zation has a stronger impact on healthy behaviours than secondary socialization. Therefore, our hypothesis is that origin SES influences health behaviours to a greater extent than destina- tion SES, depending on gender and age, with different results according to the type of behav- iour studied. SES can be measured by income, occupation or educational level [18]. To analyse intergen- erational social mobility, this study used the origin SES obtained through the self-referred position of the progenitors and the destination SES obtained through the current educational level of participants, used as an approximation of their status. This study aims to analyse the influence of origin and destination SES and social mobility on healthy behaviours, as well as co-occurrence, from an integrated gender and age perspective. Materials and methods Design and study population We performed a cross-sectional design using data from men and women recruited as popula- tion-based controls in the Multicase Control study in Spain (MCC-Spain). The MCC-Spain is a case-control study on several types of cancers, namely breast, prostate, colorectal, gastric and chronic lymphocytic leukemia, carried out in 10 Spanish regions (Madrid, Catalonia, Valen- cian Community, Andalucia, Navarra, Castilla León, Murcia, Asturias, Basque Country, and Cantabria). Its main characteristics have been described elsewhere [19]. For the present study, only population without cancer (controls) was included. Selected controls were recruited between September 2008 and December 2013, and were randomly selected from the adminis- trative records of primary care health centres located within the catchment areas [19]. These controls were frequency-matched by age, sex and region, ensuring that in each region there was at least one control of the same sex and 5-year interval for each case. All controls had to be between 20–85 years of age, to have resided in the catchment area for at least 6 months before the selection and to be able to answer the epidemiological questionnaire [19]. The sample of this study consisted of 4,098 participants. Participants that were missing information on any of the study variables were excluded from this analysis (492 excluded). Therefore, the study sample included 3,606 participants aged between 24 and 85 (1,762 women and 1,844 men). Data collection Information on sociodemographic characteristics, tobacco habits and physical activity was col- lected from the epidemiological MCC-Spain questionnaire, developed by MCC-Spain researchers. Food intake and alcohol consumption were evaluated using a self-administered, semi-quantitative food frequency questionnaire (FFQ) [20] validated in Spain to include regional products. All these data were collected in a cross-sectional manner when the controls accepted partic- ipation in the study. PLOS ONE | https://doi.org/10.1371/journal.pone.0251447 May 12, 2021 3 / 15 PLOS ONE Social mobility and healthy behaviours from a gender perspective in the MCC-Spain study Ethics statement Participants who agreed to partake in the study signed an informed consent form. The MCC-Spain study protocol was approved by the Clinical Research Ethics Committee of the Municipal Health Care Institute (IMAS) in accordance with conformity to the principles of the Declaration of Helsinki. The database was registered with the Spanish data protection agency, under number 210267217118 [19]. Study variables Origin SES. We use the SES of progenitors, obtained through a self-referred question. This variable is categorized as low, medium or high. Destination SES. The participants’ current educational level is used as an indicator of the destination SES [18]. This variable is categorized as low (less than or equal to primary school level), medium (secondary studies) or high (university studies). Social mobility (intergenerational). Social mobility was categorized into five groups, tak- ing into account the origin and destination SES: 1) “stable high", which includes participants that have a high origin SES and high destination SES; 2) "stable medium", which includes par- ticipants that have a medium origin SES and medium destination SES; 3)"stable low", which includes participants that have a low origin SES and low destination SES; 4) "upward", which includes participants that have a low origin SES and medium/high destination SES, or that have medium origin SES and high destination SES; and 5) "downward", which includes partici- pants that have a high origin SES but have medium/low destination SES, or that have a medium origin SES but now have low destination SES. Healthy behaviours. We studied four healthy behaviours: 1) healthy diet, considered as the consumption of �400 g/d of fruits and vegetables [21]. Intake from previous years was evaluated.; 2) tobacco consumption, grouping the responses into smokers (former and current smokers) and non-smokers (never smoked before); 3) alcohol consumption, measured as the number of glasses consumed per day and categorized in Standard Drinking Units (SDU). According to the recommendations of the Dietary Guidelines for Americans [22], moderate consumption is considered as �one SDU/day for women and � two SDU/day for men; 4) physical activity, evaluated using metabolic equivalents (METs), establishing adequate physical activity as a weekly energy expenditure in physical activities higher than 8 METs hour per week [23], that is to say, consuming 8 times the energy consumed at rest. Physical activity referred to a long period of time (approximately 10 years). Co-occurrence of healthy behaviours. This refers to the coexistence of behaviours and was categorized into: none, one, two, three and four healthy behaviours. Three groups were established for the analysis: none-to-one, two and three-to-four. These categories allowed us to compare extreme groups, i.e., few healthy behaviours (none-to-one) versus many healthy behaviours (three-to-four). Statistical analysis Information on age, origin and destination SES, social mobility, healthy behaviours and co-occurrence was obtained for the entire sample and expressed in frequencies and percentages. Logistic regression models were used to study the association between origin and destina- tion SES and social mobility (explanatory variables) for each of the healthy behaviours studied (outcome variables). These models were first calculated for total sample (adjusted by age, gen- der, interaction age� gender and region) and stratified by age and gender groups later on (adjusted by region). Age, gender and region were considered as confounding factors. The PLOS ONE | https://doi.org/10.1371/journal.pone.0251447 May 12, 2021 4 / 15 PLOS ONE Social mobility and healthy behaviours from a gender perspective in the MCC-Spain study sample was stratified by gender as gender roles can lead to inequalities in health behaviours. The age stratification used two categories: under 65 and over 65. The population aged under 65 was born in the 50s, and therefore achieved social and economic independence around the 70s when political, social and economic changes took place in Spain towards greater democra- tization which improved gender and social equity. This social transformation may have reduced social and gender inequalities, and may also have influenced the health behaviour pat- terns of the population. Multinomial logistic regression models were used to study the association between origin and destination SES and social mobility (explanatory variables) with the co-occurrence of healthy behaviours (outcome variables) (category of reference: none-to-one behaviours). All models were adjusted by region and stratified by gender and age to control their role as con- founding factors. Results were presented in terms of the odds ratio and a 95% confidence interval. Statistical analysis was performed using SPSS Statistics V21. Results In Table 1, the characteristics of study participants can be seen. In both genders, the most rep- resented social mobility category is stable low, and the least represented category is upward. The most frequent healthy behaviour in women is moderate alcohol consumption and the least frequent is being physically active. In men, the most frequent is moderate alcohol con- sumption and the least frequent is being a non-smoker. Both genders are most likely to present co-occurrence of three-to-four behaviours (Table 1). In the logistic regression models for the entire sample (Table 2) it is observed that the popu- lation with low origin and destination SES (OR = 1.23 CI = 1.01–1.50, OR = 1.40 CI = 1.11– 1.76), as well as those with stable medium mobility (OR = 1.38 CI = 1.09–1.75), are more likely to be non-smoker. In addition, this table shows that, regardless of origin and destination SES and social mobility, sex influences all healthy behaviors (p <0.05), that age in turn impacts healthy diet and physical activity and finally, that the interaction between sex and age has an impact on be non-smoker. Stratifying by sex and age, as detailed in Table 3, women under 65 with a low origin and destination SES and stable low mobility are more likely to be non-smokers (OR = 1.83 CI = 1.26–2.66, OR = 1.63 CI = 1.18–2.24, OR = 1.69 CI = 1.14–2.51) and less likely to be phys- ically active (OR = 0.65 CI = 0.45–0.94, OR = 0.71 CI = 0.52–0.98, OR = 0.61 CI = 0.41–0.91). Women over 65 with a low origin and destination SES are more likely to be non-smokers (OR = 8.09 CI = 4.18–15.67, OR = 4.14 CI = 2.28–7.52) and those with a low origin and desti- nation SES and stable low mobility consume moderate amounts of alcohol (OR = 3.00 CI = 1.45–6.24, OR = 2.83 CI = 1.49–5.37 OR = 3.97 CI = 1.81–8.70). For men, those under 65 with a low origin and destination SES and stable low mobility are less likely to be non-smokers (OR = 0.44 CI = 0.26–0.76, OR = 0.54 CI = 0.35–0.83, OR = 0.41 CI = 0.24–0.72) and be physically active (OR = 0.57 CI = 0.35–0.92, OR = 0.64 CI = 0.44–0.95 OR = 0.53 CI = 0.23–0.87). Those with a low origin SES and upward mobility are less likely to consume moderate amounts of alcohol (OR = 0.33 CI = 0.20–0.55, OR = 0.35 CI = 0.19–0.66). Men over 65 with stable low mobility are more likely to be physically active (OR = 1.52 CI = 1.02–1.26) (Table 3). On the other hand, as shown in the multinomial regression models (Table 4), women over 65 with a low origin and destination SES and stable low mobility are more likely to have three- to-four behaviours (OR = 6.54 CI = 2.38–17.97, OR = 3.92 CI = 1.69–9.09, OR = 6.19 CI = 2.09–18.34) vs. none-to-one than those with a high origin and destination SES and stable high mobility. PLOS ONE | https://doi.org/10.1371/journal.pone.0251447 May 12, 2021 5 / 15 PLOS ONE Social mobility and healthy behaviours from a gender perspective in the MCC-Spain study Table 1. Characteristics of the participants (2008–2013, Spain). Women Men Total n % n % n % 1,762 48.9 1,844 51.1 3,606 100 Age <65 1,076 61.1 724 39.3 1,800 49.9 �65 686 38.9 1,120 60.7 1,806 50.1 Geographical area Madrid 324 18.4 318 17.2 642 17.8 Catalonia 404 22.9 586 31.8 990 27.5 Valencian Community 52 3.0 57 3.1 109 3.0 Andalucia 83 4.7 173 9.4 256 7.1 Navarra 158 9.0 81 4.4 239 6.6 León 204 11.6 235 12.7 439 12.2 Murcia 12 0.7 28 1.5 40 1.1 Asturias 113 6.4 102 5.5 215 6.0 Basque Country 250 14.2 94 5.1 344 9.5 Cantabria 162 9.2 170 9.2 332 9.2 Origin SES High 302 17.7 282 16.2 584 16.9 Medium 873 51.1 868 49.7 1,741 50.4 Low 534 31.2 595 34.1 1,129 32.7 Destination SES High 379 21.5 393 21.3 772 21.4 Medium 545 30.9 511 27.7 1,056 29.3 Low 838 47.6 940 51.0 1,778 49.3 Social mobility Stable high 278 16.3 270 15.5 584 15.9 Upward 113 6.6 119 6.8 232 6.7 Stable medium 500 29.2 474 27.2 974 28.2 Downward 297 17.4 292 16.7 589 17.0 Stable low 521 30.5 590 33.8 1,111 32.2 Healthy eating� (Yes) 1,243 70.5 1,130 61.3 2,373 65.8 Non-smoker� (Yes) 1,072 60.8 527 28.6 1,599 44.3 Moderate alcohol consumption� (Yes) 1,478 83.9 1,215 65.9 2,693 74.7 Physically active� (Yes) 809 45.9 1,007 54.6 1,816 50.4 Co. Healthy behaviours� None-to-one 247 14.0 533 28.9 780 21.6 Two 523 29.7 634 34.4 1157 32.1 Three-to-four 992 56.3 677 36.7 1669 46.3 � The table shows the percentage of participants that practised each behaviour, out of the total number of participants. https://doi.org/10.1371/journal.pone.0251447.t001 For men, those under 65 with a low origin SES and upward or stable low mobility are less likely to have three-to-four behaviours (OR = 0.36 CI = 0.19–0.66, OR = 0.27 CI = 0.13–0.59, OR = 0.39 CI = 0.21–0.73) vs. none-to-one than those with a high origin SES and stable high mobility. Men over 65 with a low origin SES and upward or stable low mobility are more likely to have three-to-four healthy behaviours (OR = 2.00 CI = 1.22–3.29, OR = 3.13 CI = 1.31–7.48, OR = 2.04 CI = 1.23–3.39). PLOS ONE | https://doi.org/10.1371/journal.pone.0251447 May 12, 2021 6 / 15 PLOS ONE Social mobility and healthy behaviours from a gender perspective in the MCC-Spain study Table 2. Logistic regression models for each of the healthy behaviours and interaction tests with age and sex for the whole sample (2008–2013, Spain). Healthy diet Non-smoker Moderate alcohol Physically active consumption OR CI (95%) OR CI (95%) OR CI (95%) OR CI (95%) Origin SES High 1 1 1 1 Medium 0.93 0.76–1.14 0.88 0.72–1.08 0.91 0.72–1.13 0.84 0.70–1.00 Low 1.05 0.86–1.27 1.23 1.01–1.50� 1.00 0.81–1.24 0.90 0.75–1.09 Sex Men 1 1 1 1 Women 1.89 1.50–2.32� 2.47 2.00–3.04� 9.94 7.85–12.57� 0.74 0.61–0.89� Age (years) <65 1 1 1 1 �65 1.75 1.40–2.14� 1.01 0.82–1.26 0.85 0.69–1.03 1.49 1.23–1.81� Interaction sex-age 0.96 0.71–1.29 4.89 3.57–6.72� 1.27 0.89–1.79 0.97 0.74–1.28 Destination SES High 1 1 1 1 Medium 0.91 0.74–1.11 0.99 0.81–1.22 0.88 0.70–1.11 0.89 0.74–1.08 Low 1.13 0.90–1.42 1.40 1.11–1.76� 1.00 0.77–1.28 0.88 0.71–1.08 Sex Men 1 1 1 1 Women 1.93 1.57–2.37� 2.39 1.93–2.95� 9.99 7.87–12.69� 0.72 0.59–0.88� Age (years) <65 1 1 1 1 � �65 1.75 1.42–2.14 1.05 0.84–1.30 0.83 0.67–1.01 1.41 1.16–1.72� � Interaction sex-age 0.90 0.66–1.22 4.69 3.40–6.47 1.29 0.91–1.84 1.01 0.76–1.34 Social mobility Stable high 1 1 1 1 Upward 0.88 0.64–1.22 1.12 0.80–1.56 0.82 0.57–1.19 1.12 0.82–1.54 Stable medium 1.13 0.90–1.44 1.38 1.09–1.75� 0.97 0.75–1.25 0.87 0.70–1.08 Downward 0.88 0.68–1.14 1.10 0.85–1.43 0.88 0.66–1.17 0.88 0.69–1.13 Stable low 0.91 0.73–1.14 0.89 0.71–1.13 0.85 0.66–1.10 0.89 0.72–1.10 Sex Men 1 1 1 1 Women 1.93 1.57–2.37� 2.40 1.94–2.97� 10.0 7.88–12.71� 0.72 0.59–0.88� Age (years) <65 1 1 1 1 �65 1.74 1.42–2.14� 1.04 0.84–1.29 0.82 0.67–1.01 1.43 1.17–1.75� Interaction sex-age 0.90 0.66–1.22 4.64 3.36–6.39� 1.29 0.91–1.84 1.02 0.77–1.35 � Statistically significant results (p<0.05). Logistic regression model adjusted by region, sex, age and interaction sex-age. https://doi.org/10.1371/journal.pone.0251447.t002 Discussion This study shows that there are gender and age inequalities in terms of the impact of origin and destination SES and social mobility on the prevalence and co-occurrence of healthy behav- iours, with different results depending on the type of behaviour. Those aged under 65 are less likely to have healthy behaviours if they have stable low social mobility, and the opposite is PLOS ONE | https://doi.org/10.1371/journal.pone.0251447 May 12, 2021 7 / 15 PLOS ONE Social mobility and healthy behaviours from a gender perspective in the MCC-Spain study Table 3. Logistic regression models for each of the healthy behaviours stratified by gender and age (2008–2013, Spain). Aged under 65 Healthy diet Non-smoker Moderate alcohol Physically active consumption OR CI (95%) OR CI (95%) OR CI (95%) OR CI (95%) Women, origin SES High 1 1 1 1 Medium 0.97 0.71–1.32 1.06 0.79–1.43 1.24 0.82–1.87 0.72 0.54–0.98� � Low 1.38 0.93–2.06 1.83 1.26–2.66 1.73 0.99–3.02 0.65 0.45–0.94� Women, destination SES High 1 1 1 1 Medium 0.98 0.72–1.34 0.98 0.73–1.33 0.94 0.65–1.38 0.70 0.52–0.95� � Low 1.00 0.72–1.40 1.63 1.18–2.24 1.16 0.76–1.77 0.71 0.52–0.98� Women, social mobility Stable high 1 1 1 1 Upward 0.78 0.48–1.29 1.18 0.73–1.90 1.17 0.63–2.17 0.88 0.54–1.43 Stable medium 0.96 0.68–1.37 0.95 0.68–1.33 1,02 0.68–1.55 0.64 0.45–0.89� Downward 0.67 0.42–1.04 1.45 0.94–2.23 1.22 0.69–2.16 0.84 0.55–1.30 Stable low 1.23 0.80–1.88 1.69 1.14–2.51� 1.28 0.76–2.16 0.61 0.41–0.91� Men, origin SES High 1 1 1 1 Medium 0.81 0.53–1.23 0.61 0.40–0.94� 0.51 0.33–0.76� 0.66 0.43–0.99� Low 1.00 0.60–1.62 0.44 0.26–0.76� 0.33 0.20–0.55� 0.57 0.35–0.92� Men, destination SES High 1 1 1 1 Medium 0.98 0.72–1.34 0.55 0.36–0.84� 1.05 0.71–1.57 0.76 0.51–1.11 Low 1.00 0.72–1.40 0.54 0.35–0.83� 0.97 0.65–1.44 0.64 0.44–0.95� Men, social mobility Stable high 1 1 1 1 Upward 0.66 0.36–1.21 0.66 0.34–1.25 0.35 0.19–0.66� 0.70 0.38–1.28 Stable medium 0.74 0.47–1.17 0.51 0.32–0.82� 0.68 0.42–1.11 0.64 0.41–1.00 Downward 1.43 0.81–2.53 0.65 0.36–1,15 0.68 0.38–1.22 0.62 0.36–1.08 � Stable low 1.10 0.67–1.82 0.41 0.24–0.72 0.82 0.48–1.40 0.53 0,23–0,87� Aged 65 or older Healthy diet Non-smoker Moderate alcohol Physically active consumption OR CI (95%) OR CI (95%) OR CI (95%) OR CI (95%) Women, origin SES High 1 1 1 1 Medium 0.66 0.32–1.34 2.19 1.21–3.96� 1.48 0.74–2.97 1.23 0.70–2.17 Low 0.86 0.42–1.75 8.09 4.18–15.67� 3.00 1.45–6.24� 1.14 0.65–1.99 Women, destination SES High 1 1 1 1 Medium 0.89 0.41–1.95 1.43 0.74–2.78 1.61 0.77–3.38 1.83 0.98–3.43 Low 0.69 0.35–1.37 4.14 2.28–7.52� 2.83 1.49–5.37� 1.26 0.74–2.17 Women, social mobility Stable high 1 1 1 1 Upward 0.74 0.16–3.32 0.99 0.28–3.59 0,93 0,24–3,56 0,83 0,25–2,80 Stable medium 0.83 0.35–1.98 4.22 2.30–7.77� 2,00 0,87–4,62 1,71 0,86–3,41 (Continued ) PLOS ONE | https://doi.org/10.1371/journal.pone.0251447 May 12, 2021 8 / 15 PLOS ONE Social mobility and healthy behaviours from a gender perspective in the MCC-Spain study Table 3. (Continued) Aged under 65 Healthy diet Non-smoker Moderate alcohol Physically active consumption Downward 0.46 0.20–1.06 1.22 0.68–2.20 1,38 0,64–2,97 1,23 0,64–2,38 � Stable low 0.73 0.33–1.61 1.55 0.27–1.15 3,97 1,81–8,70 1,28 0,68–2,39 Men, origin SES High 1 1 1 1 Medium 1.13 0.77–1.65 1.06 0.71–1.60 1.05 0.72–1.55 1.33 0.92–1.91 Low 1.46 0.99–2.16 1.32 0.87–1.98 1.30 0.89–1.92 1.41 0.97–2.04 Men, destination SES High 1 1 1 1 Medium 0.96 0.64–1.44 0.97 0.64–1.49 1.00 0.67–1.49 1.18 0.80–1.73 Low 1.13 0.79–1.61 1.03 0.71–1.48 1.08 0.77–1.53 1.11 0.80–1.56 Men, social mobility Stable high 1 1 1 1 Upward 1.60 0.77–3.29 1.27 0.65–2.47 1.29 0.64–2.60 2.60 1.28–5.29� Stable medium 1.12 0.72–1.75 1.20 0.84–1.71 1.09 0.70–1.70 1.45 0.94–2.22 Downward 1.20 0.75–1.92 1.04 0.68–1.59 1.03 0.65–1.62 1.24 0.79–1.94 Stable low 1.40 0.92–2.13 1.00 0.62–1.60 1.24 0.82–1.87 1.52 1.02–1.26� � Statistically significant results (p<0.05). All logistic regression models adjusted by region. https://doi.org/10.1371/journal.pone.0251447.t003 true in women and men over 65. Moreover, the same age trend was observed in the co-occur- rence of healthy behaviours in men with a low origin SES and those with upward social mobility. Some studies have observed that the absence of tobacco use and moderate alcohol con- sumption occur more frequently in women than men [24, 25]. From a gender perspective, these inequalities can be interpreted by the fact that, in traditional societies with a clear gender division of labour, both behaviours were only socially accepted in the productive, public and power spheres, which were historically occupied by men [26, 27]. The results of this study are in line with these studies [24, 25] and could indicate that traditional gender stereotypes are still evident in the population. In this study, it is observed that women with low SES, regardless of their origin and destina- tion, show healthy smoking and alcohol consumption behaviours. This is in line with others studies [27]. These results can also be explained by the influence of traditional gender roles, which are mainly present in women from low social groups. In addition, this connection is stronger in older women and could be due to the social changes that occurred in Spain during the 70s. In this decade, women were gradually incorporated into education and the labour market, which reduced socioeconomic and gender inequalities not only between men and women, but also between women themselves. As a consequence of this social transformation, women acquired behaviours associated with the traditional male role, such as the consumption of tobacco and alcohol, and social and gender inequalities in health behaviours reduced [28]. However, this increased equity may have had a lower impact on the older women in our sam- ple, who seems to maintain traditional gender roles. In contrast to women, some studies show that younger men with low SES are less likely to be non-smokers [29, 30], in line with our results. Traditionally speaking, tobacco consumption was associated with male behaviour as a symbol of power. However, this stereotype began to PLOS ONE | https://doi.org/10.1371/journal.pone.0251447 May 12, 2021 9 / 15 PLOS ONE Social mobility and healthy behaviours from a gender perspective in the MCC-Spain study Table 4. Multinomial regression models with the reference category “none- to-one healthy behaviour” stratified by gender and age (2008–2013, Spain). Aged under 65 Two behaviours Three or four behaviours OR CI (95%) OR CI (95%) Women, origin SES High 1 1 Medium 0.69 0.45–1.06 0.70 0.46–1.07 Low 0.72 0.40–1.27 1.13 0.66–1.95 Women, destination SES High 1 1 � Medium 0.62 0.41–0.95 0.69 0.45–1.04 Low 0.65 0.41–1.04 0.96 0.61–1.50 Women, social mobility Stable high 1 1 Upward 1.20 0.59–2.44 0.96 0.47–1.95 Stable medium 0.63 0.40–1.02 0.64 0.40–1.02 Downward 0.61 0.33–1.12 0.70 0.39–1.26 Stable low 0.69 0.38–1.23 0.99 0.61–1.89 Men, origin SES High 1 1 Medium 0.61 0.36–1.04 0.33 0.20–0.57� Low 0.65 0.35–1.19 0.36 0.19–0.66� Men, destination SES High 1 1 Medium 0.71 0.45–1.13 0.50 0.31–0.79� Low 1.04 0.65–1.66 0.63 0.39–1.66 Men, social mobility Stable high 1 1 Upward 0.50 0.24–1.05 0.27 0.13–0.59� Stable medium 0.57 0.32–1.00 0.32 0.18–0.56� Downward 0.97 0.48–1.93 0.53 0.26–1.05 Stable low 0.68 0.37–1.27 0.39 0.21–0.73� Aged 65 or older Two behaviours Three or four behaviours OR CI (95%) OR CI (95%) Women, origin SES High 1 1 Medium 1.35 0.52–3.49 1.91 0.79–4.60 Low 3.09 1.05–9.06� 6.54 2.38–17.97� Women, destination SES High 1 1 Medium 1.94 0.65–5.84 3.00 1.08–8.27� Low 2.17 0.87–5.34 3.92 1.69–9.09� Women, social mobility Stable high 1 1 Upward 0.42 0.06–2.75 0.58 0.11–3.00 Stable medium 1.90 0.55–6.59 3.27 1.02–10.48� Downward 0.95 0.32–2.81 1.31 0.48–3.60 (Continued ) PLOS ONE | https://doi.org/10.1371/journal.pone.0251447 May 12, 2021 10 / 15 PLOS ONE Social mobility and healthy behaviours from a gender perspective in the MCC-Spain study Table 4. (Continued) Aged under 65 Two behaviours Three or four behaviours OR CI (95%) OR CI (95%) Stable low 2.49 0.88–8.81 6.19 2.09–18.34� Men, origin SES High 1 1 Medium 0.99 0.63–1.57 1.54 0.95–2.49 Low 1.03 0.63–1.67 2.00 1.22–3.29� Men, destination SES High 1 1 Medium 0.82 0.50–1.32 1.09 0.68–1.75 Low 1.04 0.69–1.59 1.24 0.82–1.89 Men, social mobility Stable high 1 1 Upward 1.08 0.42–2.77 3.13 1.31–7.48� Stable medium 0.80 0.48–1.35 1.49 0.87–2.54 Downward 1.20 0.70–2.05 1.37 0.77–2.43 Stable low 1.04 0.64–1.69 2.04 1.23–3.39� � Statistically significant results. Logistic regression model adjusted by region. https://doi.org/10.1371/journal.pone.0251447.t004 change in the 80s due to public health policies against this unhealthy behaviour [31]. From this point, the number of non-smokers gradually increased, but consumption remained unchanged in men with a low SES. It should be noted that this study shows the same trend of healthy behaviour in relation to alcohol in both younger men with low origin SES and those with upward mobility. Taking this into account, we could suppose that men with upward mobility maintain the behaviours of the origin SES. This finding is in line with the socialization hypothesis, confirming the strong impact of primary socialization on men’s healthy behaviour patterns [17]. There is possibly a negative relationship between women with downward mobility and healthy diet, regardless of age. Bonaccio et al’s study [32] shows that the increase in the price of healthy food decreases access to these types of products, especially in the low-income popula- tion. Considering that 91.91% of the women in our sample with downward mobility have gone from a medium to a low SES, the results seem to indicate that the process of social mobility leads to the incorporation of lifestyle habits from the achieved SES, coinciding with the results of another study [33]. Most published studies observe that men and women with a low SES are less physically active, regardless of age [34–36]. This is in line with our results for younger women and men, but not for older men. This may be due to the fact that occupation is acting as a confounder. Manual occupations such as masonry or agriculture are typical of the population with a low educational level, which implies physical activity and, possibly, later retirement [37]. Regarding the co-occurrence of behaviours, studies have reported that men accumulate more risk behaviours than women [9, 11, 38], in line with our results showing that women accumulate a greater number of healthy behaviours. These differences can again be explained by the impact of traditional gender roles, which influence men and women’s different concep- tion of health and, therefore, the related behaviours [39]. Traditionally speaking, women’s PLOS ONE | https://doi.org/10.1371/journal.pone.0251447 May 12, 2021 11 / 15 PLOS ONE Social mobility and healthy behaviours from a gender perspective in the MCC-Spain study behaviours are influenced by the role of the female caregiver, which predisposes them to take care of their health and that of their relatives while men tend to have fewer healthy behaviours due to the influence of masculine stereotypes [40]. Inequalities in the co-occurrence of healthy behaviours were observed in both genders and age groups by origin and destination SES and social mobility. Older women are more likely to have co-occurrence if they have a low SES, independently of it is origin or destination SES. This could be explained by the fact that, as observed in the analysis of each healthy behaviour, older women with a low SES are more likely to be non-smokers and consume moderate amounts of alcohol, which may be due to the impact traditional gender roles have had on older women. In the case of men, the same behaviour pattern is observed in those with a low origin SES as those with upward mobility, regardless of age. These results once again confirm the socializa- tion hypothesis [17]. This study provides an approach to the analysis of the impact of origin and destination SES and social mobility on healthy behaviours due to the intersection of age and gender. The results reinforce the idea that health and health behaviours are socially determined and strongly linked to the specific values, norms and social resources of each social strata. The study on social mobility has provided a complex vision of the influence of origin and destina- tion SES on the assumption of healthy behaviours. It has shown that in men, healthy behav- iours from the low social position of origin are maintained when there is social mobility. One of the limitations of this study could be the social desirability bias, meaning that partic- ipants respond according to what is considered socially correct or expected, overestimating healthy behaviours in all social strata. However, the fact that the questionnaire is administered by qualified interviewers who are continuously learning and that the FFQ questionnaire was validated in Spain reduces this type of bias [19, 41]. On the other hand, an effect of reverse causality could be present, common in studies with a cross-sectional design. Taking other studies [14] into account, the association between health and SES is bidirectional, since healthy behaviours could also influence the population’s social mobility. It is important to take into account the possible confounding factors behind SES and healthy behaviours. In this article, only the confounding factors of sex, age and region are con- trolled through adjustment or stratification, but other possible confounding factors could affect our results (such as occupation, marital status, Body Mass Index etc.). Despite this, they provide an approximation of how origin and destination SES and social mobility impact healthy behaviours. Despite the fact that the sample was randomly selected in each of the regions taking part in the study and that this aspect reduced selection bias, age may be represented unequally between men and women. To overcome this limitation, the sample was stratified by age and sex. Although the results obtained coincide with the findings of recently published studies on this topic, it would be advisable to replicate this study in younger cohorts. Conclusion This study shows that the impact of origin and destination SES and social mobility on the prev- alence and co-occurrence of healthy behaviours differs by gender and age. These differences justify the importance of pursing a health-focused approach in all policies based on the princi- ple of health promotion [42, 43], as well as interventions adapted to the needs of each social group in order to improve equity in health [44]. PLOS ONE | https://doi.org/10.1371/journal.pone.0251447 May 12, 2021 12 / 15 PLOS ONE Social mobility and healthy behaviours from a gender perspective in the MCC-Spain study Author Contributions Conceptualization: M. Pinto-Carbó, R. Peiró-Pérez, A. Molina-Barceló. Data curation: R. Peiró-Pérez, A. Molina-Barceló, M. Vanaclocha-Espi, J. Alguacil, G. Cas- taño-Vinyals, C. O’Callaghan-Gordo, E. Gràcia-Lavedan, B. Pérez-Gómez, V. Lope, N. Ara- gonés, A. J. Molina, T. Fernández-Villa, L. Gil-Majuelo, P. Amiano, T. Dierssen-Sotos, I. Gómez-Acebo, M. Guevara, C. Moreno-Iribas, M. Obón-Santacana, M. M. Rodrı́guez-Suá- rez, I. Salcedo-Bellido, A. Delgado-Parrilla, R. Marcos-Gragera, M. D. Chirlaque, M. Koge- vinas, M. Pollán, D. Salas. Formal analysis: M. Pinto-Carbó, A. Molina-Barceló, M. Vanaclocha-Espi. Investigation: M. Pinto-Carbó, R. Peiró-Pérez, A. Molina-Barceló, M. Vanaclocha-Espi, J. Alguacil, G. Castaño-Vinyals, C. O’Callaghan-Gordo, E. Gràcia-Lavedan, B. Pérez-Gómez, V. Lope, N. Aragonés, A. J. Molina, T. Fernández-Villa, L. Gil-Majuelo, P. Amiano, T. Dierssen-Sotos, I. Gómez-Acebo, M. Guevara, C. Moreno-Iribas, M. Obón-Santacana, M. M. Rodrı́guez-Suárez, I. Salcedo-Bellido, A. Delgado-Parrilla, R. Marcos-Gragera, M. D. Chirlaque, M. Kogevinas, M. Pollán, D. Salas. Methodology: M. Pinto-Carbó, R. Peiró-Pérez, A. Molina-Barceló, M. Vanaclocha-Espi, D. Salas. Project administration: M. Pinto-Carbó, A. Molina-Barceló. Supervision: R. Peiró-Pérez, A. Molina-Barceló, D. Salas. Visualization: M. Pinto-Carbó. Writing – original draft: M. Pinto-Carbó. Writing – review & editing: R. Peiró-Pérez, A. Molina-Barceló, M. Vanaclocha-Espi, J. Algua- cil, G. Castaño-Vinyals, C. O’Callaghan-Gordo, E. Gràcia-Lavedan, B. 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