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American Journal of Public Health

Journal of Epidemiology & Community Health current issue
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Journal of Epidemiology & Community Health

The global health community continues to look to the World Health Organization (WHO) to solve current global health governance (GHG) problems. Until the 1990s, nation-states and multilateral organisations with state members governed international health, and WHO played a prominent role, coordinating worldwide efforts such as smallpox eradication with a few partner organisations. WHO also provided international reporting and handled disease outbreaks through the International Health Regulations. The world still sees WHO as the leading global health governor, and proposals abound to reform it,1–4 to use its treaty abilities more regularly and to give it enforcement powers—all in the absence of real institutional alternatives.

But today's WHO is a compromised institution; some interrogate its relevance altogether2 and WHO Director-General Margaret Chan herself questions WHO's ability to respond to global health challenges.5 On a theoretical level, WHO lacks a...


A recent analysis of the EPIC-Norfolk cohort by Barnett et al found that retirement was associated with a decline in overall levels of physical activity as decreases in occupational and transport-related activity were not compensated for by increases in household and recreational activity.1 This study adds more accurate assessment of physical activity with a larger sample size than previous studies2 and allows the breakdown of physical activity across different domains, as well as investigation of socioeconomic differences. Although the main finding has been echoed in some previous studies,3 4 a 2012 systematic review by the same authors concluded that the impacts of retirement on overall physical activity were unclear.5 This lack of clarity was due to the paucity of accurate activity assessment in included studies, a gap that this study addresses and strengthens our confidence that retirement is...


A PubMed search of articles in this journal using the text word ‘frailty’ found only two manuscripts, published in 2010 and 2012.1 2 Thus, many readers of the journal may not be familiar with the concept and public health implications of the frailty syndrome.3 4 This is notable for several reasons. First, because frailty is a frequent condition, with a prevalence of about 10% in the population over age 60 years, reaching 25% in those aged 80 years and older.5 6 Also, in a well-known prospective study among community-dwelling older persons, the most common condition leading to death was frailty (27.9%), followed by organ failure (21.4%), cancer (19.3%) and dementia (13.8%).7 Additionally, frailty shows an important social gradient, so that women and less educated persons are more likely to be frail and to have...


Background

Despite the well-established link between body mass index (BMI) and diabetes mellitus (DM), it remains unclear whether this association is more pronounced at certain levels of education. This study assessed the modifying effect of educational attainment on the associations between BMI and DM—as well as the joint associations of BMI and education with DM—in low-income countries (LICs) and middle-income countries (MICs).

Methods

The authors used cross-sectional data from 160 381 participants among 49 LICs and MICs in the World Health Survey. Overweight and obesity levels were defined using WHO's classification. Educational attainment was classified in four categories: ‘no formal education’, ‘some/completed primary school’, ‘secondary/high school completed’ and ‘college and beyond’. We used random-intercept multilevel logistic regressions to investigate the modifying influence of educational attainment on the associations of different BMI levels—as well as their joint associations—with DM.

Results

We found positive associations between excessive BMI and DM at each education level in both LICs and MICs. We found that the joint associations of BMI and education with DM were larger than the product of their separate single associations among females in LICs. With joint increases in BMI and education, males and females in LICs had similar increased odds of DM, but males had higher such odds than females in MICs.

Conclusions

BMI and education are associated with the DM, but the associations seem to differ in complex ways between LICs and MICs and by gender.


Background

To describe trends in cardiovascular risk factors and change over time across education levels, and study the influence from medicine use and gender.

Methods

Data from participants (30–74 years) of the Tromsø Study in 1994–1995 (n=22 108) and in 2007–2008 (n=11 565). Blood samples, measurements and self-reported educational level and medicine use were collected.

Results

Differences in risk factor levels across education groups were persistent for all risk factors over time, with a more unfavourable pattern in the lowest education group. The exception was cholesterol, with the reduction being largest in the lowest educated, resulting in weakened educational trends over time. While a significant educational trend in cholesterol persisted among the non-users of lipid-lowering drugs (LLD), no educational trend in cholesterol was found among the LLD users in 2007–2008.

The strongest educational trends were found for daily smoking and Body Mass Index (BMI). In 2007–2008 the odds for being a smoker were five times higher among the lowest educated compared to the highest educated. In men, the odds for being in the highest quintile of the BMI distribution were, in 2007–2008, almost doubled in the lowest compared to the highest educated. The lowest educated women had 6.2 mm Hg higher mean systolic blood pressure than the highly educated, mean BMI of 26.4 kg/m 2 and smoking prevalence of 37.7%.

Conclusions

The difference across education groups for cholesterol levels decreased, while the educational gap persisted over time for the other risk factors. Use of LLD seemed to contribute to the reduction of social differences in cholesterol levels.


Background

Few studies have examined the relationship between stressful social relations in private life and all-cause mortality.

Objective

To evaluate the association between stressful social relations (with partner, children, other family, friends and neighbours, respectively) and all-cause mortality in a large population-based study of middle-aged men and women. Further, to investigate the possible modification of this association by labour force participation and gender.

Methods

We used baseline data (2000) from The Danish Longitudinal Study on Work, Unemployment and Health, including 9875 men and women aged 36–52 years, linked to the Danish Cause of Death Registry for information on all-cause mortality until 31 December 2011. Associations between stressful social relations with partner, children, other family, friends and neighbours, respectively, and all-cause mortality were examined using Cox proportional hazards models adjusted for age, gender, cohabitation status, occupational social class, hospitalisation with chronic disorder 1980–baseline, depressive symptoms and perceived emotional support. Modification by gender and labour force participation was investigated by an additive hazards model.

Results

Frequent worries/demands from partner or children were associated with 50–100% increased mortality risk. Frequent conflicts with any type of social relation were associated with 2–3 times increased mortality risk. Interaction between labour force participation and worries/demands (462 additional cases per 100 000 person-years, p=0.05) and conflicts with partner (830 additional cases per 100 000 person-years, p<0.01) was suggested. Being male and experiencing frequent worries/demands from partner produced 135 extra cases per 100 000 person-years, p=0.05 due to interaction.

Conclusions

Stressful social relations are associated with increased mortality risk among middle-aged men and women for a variety of different social roles. Those outside the labour force and men seem especially vulnerable to exposure.


Background

IQ is thought to explain social gradients in mortality. IQ scores are based roughly equally on Verbal IQ (VIQ) and Performance IQ tests. VIQ tests, however, are suspected to confound true verbal ability with socioeconomic status (SES), raising the possibility that associations between SES and IQ scores might be overestimated. We examined, first, whether two of the most common types of VIQ tests exhibited differential item functioning (DIF) favouring persons of higher SES and/or majority race/ethnicity. Second, we assessed what impact, if any, this had on estimates of the extent to which VIQ explains social gradients in mortality.

Methods

Data from the General Social Survey-National Death Index cohort, a US population representative dataset, was used. Item response theory models queried social-factor DIF on the Thorndike Verbal Intelligence Scale and Wechsler Adult Intelligence Scales, Revised Similarities test. Cox models examined mortality associations among SES and VIQ scores corrected and uncorrected for DIF.

Results

When uncorrected for DIF, VIQ was correlated with income, education, occupational prestige and race, with correlation coefficients ranging between |0.12| and |0.43|. After correcting for DIF, correlations ranged from |0.06| to |0.16|. Uncorrected VIQ scores explained 11–40% of the Relative Index of Inequalities in mortality for social factors, while DIF-corrected scores explained 2–29%.

Conclusions

Two of the common forms of VIQ tests appear confound verbal intelligence with SES. Since these tests appear in most IQ batteries, circumspection may be warranted in estimating the amount of social inequalities in mortality attributable to IQ.


Background

Childhood living conditions have been found to predict health and mortality in midlife and in old age. This study examines the associations between social and economic childhood conditions and the onset and progression of functional health problems from midlife into old age, and the extent to which potential associations are mediated by educational attainment and smoking.

Methods

Data from the Level of Living Survey and the Swedish Panel Study of Living Conditions of the Oldest Old were merged to create a longitudinal data set with five repeated measures from 1968 to 2004 (n=1765, aged 30–50 years and free from functional health problems at baseline). Multilevel regression models were used to analyse retrospective reports of social and economic conditions in childhood (eg, conflicts or economic problems in the family) in relation to the progression of functional health problems over the 36-year period.

Results

Results showed that social and economic disadvantages in childhood were associated with an earlier onset and a faster progression of functional health problems from midlife into old age. Subsequent models showed that differences in educational attainment, but not smoking, explained much of the association between childhood disadvantages and trajectories of functional health problems.

Conclusions

According to these results, adverse social and economic conditions in childhood affect the development of functional health problems from midlife into old age indirectly through less favourable life careers, including lower education. Creating equal opportunities for educational attainment may help reduce the long-term effects of disadvantaged childhood conditions and postpone functional health problems.


Background

Early life adversities may play a role in the associations observed between neighbourhood contextual factors and health behaviours.

Methods

We examined whether self-reported adverse experiences in childhood (parental divorce, long-term financial difficulties, serious conflicts, serious/chronic illness or alcohol problem in the family, and frequent fear of a family member) explain the association between adulthood neighbourhood disadvantage and co-occurrence of behavioural risk factors (smoking, moderate/heavy alcohol use, physical inactivity). Study population consisted of 31 271 public sector employees from Finland. The cross-sectional associations were analysed using two-level cumulative logistic regression models.

Results

Childhood adverse experiences were associated with the sum of risk factors (cumulative OR 1.32 (95% CI 1.25 to 1.40) among those reporting 3–6 vs 0 adversities). Adverse experiences did not attenuate the association between neighbourhood disadvantage and risk factors; this cumulative OR was 1.52 (95% CI 1.43 to 1.62) in the highest versus lowest quartile of neighbourhood disadvantage when not including adversities, and 1.50 (95% CI 1.40 to 1.60) when adjusted for childhood adversities. In adversity-stratified analyses those reporting 3–6 adversities had 1.60-fold (95% CI 1.42 to 1.80) likelihood of risk factors if living in the neighbourhood of the highest disadvantage, while in those with fewer adversities this likelihood was 1.09–1.34-fold (95% CI 0.98 to 1.53) (p interaction 0.07).

Conclusions

Childhood adverse experiences and adulthood neighbourhood disadvantage were associated with behavioural risk factors. Childhood experiences did not explain associations between neighbourhood disadvantage and the risk factors. However, those with more adverse experiences may be susceptible for the socioeconomic conditions of neighbourhoods.


Background

Retirement is associated with an increase in recreational physical activity but its impact on other domains of activity (at home, for transport) and sedentary behaviour, such as time spent watching television (TV) is unknown. We examined the association between retirement and changes in domain-specific and overall activity and TV viewing.

Methods

Data were derived from the population-based EPIC (European Prospective Investigation into Cancer)–Norfolk cohort. Physical activity and TV viewing time were self-reported at baseline (1997–2000) and follow-up 2 (2006–2007) by 3334 participants employed at baseline, of whom 785 (24%) were retired at follow-up 1 (2002–2006). Multivariable regression models were fitted to estimate the association between retirement and changes in physical activity and weekly TV viewing time.

Results

Compared with continued employment, retirement was associated with a decline in overall activity (men: non-manual, –40.9 MET h/wk; manual, –49.6 MET h/wk; women: non-manual, –26.9 MET h/wk; manual, –31.6 MET h/wk; all p<0.001 (MET, metabolic equivalent of task)). Domain-specific activity declined for transport and occupational (p<0.001) and increased for recreational (p<0.02) and household (p≤0.002) activity. We observed significant interaction between retirement and social class in respect of overall and domain-specific activity apart from household activity. Retirement was associated with a mean increase in TV viewing time, with the largest increase among manual social classes (men: +3.9 h/wk; women: +2.8 h/wk; both p<0.001).

Conclusions

Interventions should aim to promote household and transport as well as recreational activity. Further research on the impact of retirement on sedentary behaviour is needed.


Background

The Rose Angina Questionnaire (RAQ) was constructed in the 1960s for assessing the population burden of angina. Studies have found that screening positivity by RAQ conferred an elevated risk of coronary heart disease (CHD). It is, however, not clear to what extent Rose angina represents early CHD in relatively young adults who are free of known CHD. If representing CHD, Rose angina is expected to carry prognostic information in addition to the risk conferred by other risk factors.

Methods

The Tromsø Study is a population-based cohort study in Northern Norway. All men aged 20–54 years (n=8238) and women aged 20–49 years (n=8001), free of known cardiovascular disease (CVD), who participated in a survey 1979–1980, were followed throughout 2010 for incident myocardial infarction (MI), and for incident MI or stroke used as proxy for incident CVD. HRs were estimated using a Cox proportional hazard regression model.

Results

In age-adjusted analyses, Rose angina predicted MI and CVD in both sexes. The excess risk was substantially accounted for by CVD risk factors, leaving no significantly elevated MI risk above the risk explained by these factors (adjusted HR 1.31; 95% CI 0.95 to 1.80 in men, HR 1.20; 95% CI 0.69 to 2.10 in women). A similar pattern was seen for CVD (adjusted HR 1.16; 95% CI 0.87 to 1.55 in men and 1.30; 95% CI 0.82 to 2.06 in women).

Conclusions

Rose angina predicted MI and CVD in a 29-years’ follow-up of a relatively young population. Established CVD risk factors were important mediators.


Background

The majority of research documenting the public health impacts of natural disasters focuses on the well-being of adults and their living children. Negative effects may also occur in the unborn, exposed to disaster stressors when critical organ systems are developing and when the consequences of exposure are large.

Methods

We exploit spatial and temporal variation in hurricane behaviour as a quasi-experimental design to assess whether fetal death is dose-responsive in the extent of hurricane damage. Data on births and fetal deaths are merged with Parish-level housing wreckage data. Fetal outcomes are regressed on housing wreckage adjusting for the maternal, fetal, placental and other risk factors. The average causal effect of maternal exposure to hurricane destruction is captured by difference-in-differences analyses.

Results

The adjusted odds of fetal death are 1.40 (1.07–1.83) and 2.37 (1.684–3.327) times higher in parishes suffering 10–50% and >50% wreckage to housing stock, respectively. For every 1% increase in the destruction of housing stock, we observe a 1.7% (1.1–2.4%) increase in fetal death. Of the 410 officially recorded fetal deaths in these parishes, between 117 and 205 may be attributable to hurricane destruction and postdisaster disorder. The estimated fetal death toll is 17.4–30.6% of the human death toll.

Conclusions

The destruction caused by Hurricanes Katrina and Rita imposed significant measurable losses in terms of fetal death. Postdisaster migratory dynamics suggest that the reported effects of maternal exposure to hurricane destruction on fetal death may be conservative.


Background

Depression and obesity are significant health concerns currently facing adolescents worldwide. This paper investigates the associations between obesity and related risk behaviours and depressive symptomatology in an Australian adolescent population.

Methods

Data from the Australian Capital Territory It's Your Move project, an Australian community-based intervention project were used. In 2012, 800 students (440 females, 360 males) aged 11–14 years (M=13.11 years, SD=0.62 years), from 6 secondary schools were weighed and measured and completed a questionnaire which included physical activity, sedentary behaviour and dietary intake. Weight status was defined by WHO criteria. A cut-off score ≥10 on the Short Mood and Feelings Questionnaire indicated symptomatic depression. Logistic regression was used to test associations.

Results

After controlling for potential confounders, results showed significantly higher odds of depressive symptomatology in males (OR=1.22, p<0.05) and females (OR=1.12, p<0.05) who exceeded guidelines for daily screen-time leisure sedentary activities. Higher odds of depressive symptoms were seen in females who consumed greater amounts of sweet drink (OR=1.18, p<0.05), compared to lower female consumers of sweet drinks, and males who were overweight/obese also had greater odds of depressive symptoms (OR=1.83, p<0.05) compared to male normal weight adolescents.

Conclusions

This study demonstrates the associations between obesogenic risks and depression in adolescents. Further research should explore the direction of these associations and identify common determinants of obesity and depression. Mental health outcomes need to be included in the rationale and evaluation for diet and activity interventions.


Background

Most research on dietary patterns and health outcomes does not include longitudinal exposure data. We used an innovative technique to capture dietary pattern trajectories and their association with haemoglobin A1c (HbA1c), homeostasis model of insulin resistance (HOMA-IR) and prevalence of newly diagnosed diabetes.

Methods

We included 4096 adults with 3–6 waves of diet data (1991–2006) and biomarkers measured in 2009 from the China Health and Nutrition Survey. Diet was assessed with three 24-h recalls and a household food inventory. We used a dietary pattern previously identified with reduced rank regression that positively predicted diabetes in 2006 (high in wheat products and soy milk and low in rice, legumes, poultry, eggs and fish). We estimated a score for this dietary pattern for each subject at each wave. Using latent class trajectory analysis, we grouped subjects with similar dietary pattern score trajectories over time into five classes.

Results

Three trajectory classes were stable over time, and in two classes the diet became unhealthier over time (upward trend in dietary pattern score). Among two classes with similar scores in 2006, the one with the lower (healthier) initial score had an HbA1c 1.64% lower (–1.64 (95% CI –3.17 to –0.11)) and non-significantly a HOMA-IR 6.47% lower (–6.47 (–17.37 to 4.42)) and lower odds of diabetes (0.86 (0.44 to 1.67)).

Conclusions

Our findings suggest that dietary pattern trajectories with healthier scores longitudinally had a lower HbA1c compared with those with unhealthier scores, even when the trajectories had similar scores in the end point.


Background

Many chronic diseases are characterised by low-grade systemic inflammation. Oestrogens may promote immune response consistent with sex-specific patterns of diseases. In vitro culture and animal experiments suggest oestrogens are anti-inflammatory and might thereby protect against low-grade systemic inflammation. Evidence from epidemiological studies is limited. Using a Mendelian randomisation analysis with a separate-sample instrumental variable (SSIV) estimator, we examined the association of genetically predicted 17β-estradiol with well-established systemic inflammatory markers (total white cell count, granulocyte and lymphocyte count).

Methods

A genetic score predicting 17β-estradiol was developed in 237 young Chinese women (university students) from Hong Kong based on a parsimonious set of genetic polymorphisms (ESR1 (rs2175898) and CYP19A1 (rs1008805)). Multivariable linear regression was used to examine the association of genetically predicted 17β-estradiol with systemic inflammatory markers among 3096 older (50+ years) Chinese women from the Guangzhou Biobank Cohort Study.

Results

Predicted 17β-estradiol was negatively associated with white blood cell count (–6.3 103/mL, 95% CI –11.4 to –1.3) and granulocyte count (–4.5 103/mL, 95% CI –8.5 to –0.4) but not lymphocyte count (–1.5 103/mL, 95% CI –3.4 to 0.4) adjusted for age only. Results were similar further adjusted for education, smoking, use of alcohol, physical activity, Body Mass Index, waist-hip ratio, age of menarche, age at menopause, use of hormonal contraceptives and hormone replacement therapy.

Conclusions

Endogenous genetically predicted 17β-estradiol reduced low-grade systemic inflammatory markers (white blood cell count and granulocyte count), consistent with experimental and ecological evidence of 17β-estradiol promoting immune response. Replication in a larger sample is required.


Shortly after the shock of seeing e-cigarette adverting on television, an unsolicited e-mail arrived promoting an ‘e-cig starter kit’ (figure 1). This showed ‘Megan’ (attractive, slim, elegant, professional, confident and happy) ‘smoking’ an e-cigarette, apparently on a plane. Incongruously, the e-cigarette billows smoke. The sender's address and titles of embedded links suggest the ease of trying e-cigarettes, and that e-cigarettes are healthy and inoffensive. Ingeniously, the advert can be read as showing that holding a cigarette object is attractive and socially desirable, and that e-cigarettes are (somewhat) distinct from ‘ordinary’ cigarettes.

Emerging research raises concerns over whether e-cigarettes renormalise and reglamourise smoking and/or act as a gateway to smoking.1 2 Within present legislation, ‘Megan’ can ‘smoke’ her e-cigarette in public spaces because e-cigarettes are not subject to smoke-free regulation. They can also be advertised, although some may question whether a smoking e-cigarette...


Background

Positive greenness effects on health are increasingly reported, although studies on allergic outcomes remain limited and conflicting. We examined whether residential greenness is associated with childhood doctor diagnosed allergic rhinitis, eyes and nose symptoms and aeroallergen sensitisation using two combined birth cohorts (GINIplus and LISAplus) followed from birth to 10 years in northern and southern Germany (Ntotal=5803).

Methods

Mean residential greenness in a 500 m buffer around the 10-year home addresses was defined using the Normalized Difference Vegetation Index, a green biomass density indicator. Longitudinal associations were assessed per study area (GINI/LISA South and GINI/LISA North) using generalised estimation equations adjusted for host and environmental covariates.

Results

Despite identical study designs and statistical modelling, greenness effects differed across the two study areas. Associations were elevated for allergic rhinitis and eyes and nose symptoms in the urban GINI/LISA South area. In contrast, risk estimates were significantly below one for these outcomes and aeroallergen sensitisation in rural GINI/LISA North. Area-specific associations were similar across buffer sizes and addresses (birth and 6 years) and remained heterogeneous after air pollution and population density stratification.

Conclusions

Existing and future single-area studies on greenness and green spaces should be interpreted with caution.


Background

Respondent-driven sampling (RDS) has become a common tool for recruiting high-risk populations for HIV research. However, few studies have explored the influence of geospatial proximity and relationship-level characteristics on RDS recruitment, particularly among high-risk individuals residing in rural areas of the US.

Methods

In a social network study of 503 drug users in rural Central Appalachia, interviewer-administered questionnaires were used to collect relationship-level data (eg, duration of relationship, frequency of communication, kinship, social/financial support, trust, drug use and sex) and residential location. Demographic and drug-use similarity were also evaluated. Residential data were geocoded and road distance (km) between participants and (1) their network members and (2) the study site were computed. Seasonal patterns were assessed using node-level analysis, and dyadic analyses were conducted using generalised linear mixed models. Adjusted ORs (AORs) and 95% CIs are reported.

Results

Differences in distance to the study office by season and order of study entry were not observed (F=1.49, p=0.209 and β=0.074, p=0.050, respectively). Participants with transportation lived significantly further from the interview site than their counterparts (p<0.001). Dyadic analyses revealed no association between RDS recruitment likelihood and geographic proximity. However, kinship (AOR 1.62; CI 1.02 to 2.58) and frequency of communication (AOR 1.63; CI 1.25 to 2.13) were significantly associated with RDS recruitment.

Conclusions

In this sample, recruitment from one's network was likely non-random, contradicting a core RDS assumption. These data underscore the importance of formative research to elucidate potential recruitment preferences and of quantifying recruitment preferences for use in analysis.