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American Journal of Public Health

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Journal of Epidemiology & Community Health

Most people realise that too little physical activity is bad for our health. It is less well understood that this does not just mean insufficient physical exercise, but also spending too much time being sedentary. Watching television is among the most sedentary of behaviours, and yet, screen time is now the most common waking activity for many children and may even exceed the amount of time spent asleep for some children.1 2 Wennberg et al3 demonstrate, yet again, that too much time spent watching television can have long-term consequences for health. Wennberg and colleagues found that television viewing time in adolescence and early adulthood is associated with a higher risk of metabolic syndrome in mid-life. They confirm previous research that childhood and adolescence may be a particularly sensitive time for developing long-term risk of overweight, poor fitness and the metabolic syndrome.4...


The knowledge imposes a pattern, and falsifies, for the pattern is new in every moment and every moment is a new and shocking valuation of all that we have been.

East Coker, T.S. Eliot

Medicine is not a science: it is a cultural product. As such, the way it is practiced and conceived is much affected by cultural contexts, academic traditions, politics, personal interests, the health industry, experts’ and medical bodies’ opinions, journalists and medical publishing companies. Obviously, science and research have played and will continue to play a key role in the development and progress of medical knowledge. Science, however, proceeds slowly, requires the test of time and relies on strict methodological principles and in personal integrity; briefly, good science is at stake in a world dominated by technolatry1: a self-imposed commitment for continuous innovation within an industrial culture dominated by planned obsolescence and profit increase...

Introduction

Consider the following selective evidence of human behaviour in the domain of healthcare. The numeric-cognition feeds typically provided during public vaccination campaigns are less effective than affect-based perception of risk.1 It is common to avoid seeing doctors and/or doing health checks because of anxiety and fear of receiving bad results. The latter means that a perceived ‘loss today’ in the health status has a stronger impact than a ‘gain tomorrow’, namely preventing or curing a potential disease.2 Clinicians fail to act on available knowledge and guidelines despite the intention to do so.3

Instead, consider now the following couple of examples of choice architectures capable of offsetting erroneous conducts. Recent trial studies show that it is enough to change the default settings of electronic order sets to dramatically ‘improve’ clinicians prescribing behaviours.4 A lottery-based financial incentive increased warfarin adherence and...


Background

The relative contribution of different pathways leading to health inequalities in adolescence was rarely investigated, especially in a cross-national perspective. The aim of the study is to analyse the contribution of psychosocial and behavioural factors in the explanation of inequalities in adolescent self-rated health (SRH) by family wealth in 28 countries.

Methods

This study was based on the international WHO ‘Health Behaviour in School-aged Children’ (HBSC) study carried out in 2005/2006. The total sample included 117 460 adolescents aged 11–15 in 28 European and North American countries. Socioeconomic position was measured using the Family Affluence Scale (FAS). Multilevel logistic regression models were conducted to analyse the direct (independent) and indirect contribution of psychosocial and behavioural factors on SRH.

Results

Across all countries, adolescents from low affluent families had a higher risk of reporting fair/poor SRH (OR1.76, CI 1.69 to 1.84). Separate adjustments for psychosocial and behavioural factors reduced the OR of students with low family affluence by 39% (psychosocial) and 22% (behavioural). Together, both approaches explained about 50–60% of inequalities by family affluence in adolescent SRH. Separate analyses showed that relationship to father and academic achievement (psychosocial factors) as well as physical activity and consumption of fruits/vegetables (behavioural factors) were the most important factors in explaining inequalities in SRH.

Conclusions

More than half of the inequalities by family affluence in adolescent SRH were explained by an unequal distribution of psychosocial and behavioural factors. Combining both approaches showed that the contribution of psychosocial factors was higher due to their direct (independent) and indirect impact through behavioural factors.


Background

Few population-based studies from low-income and middle-income countries have addressed adolescent drinking onset and its association with adult alcohol-related adverse outcomes. The aims of this study were to: (1) estimate the rate of adolescent drinking onset and its trend over time among men (2) describe demographic and socioeconomic factors associated with adolescent drinking onset; and (3) examine the association between adolescent drinking onset and adverse outcomes in later life, including hazardous or harmful alcohol use, heavy episodic drinking, alcohol dependence, injuries and psychological distress.

Methods

Population-based survey of men (n=1899) from rural and urban communities in northern Goa, India. Analysis addressed age of drinking onset among those who reported ever drinking in their lifetime, and drinking patterns and consequences among current drinkers.

Results

Adolescent drinking onset showed an increasing trend over time (p<0.001), from 19.5% for those born between 1956 and 1960 to 74.3% for those born between 1981 and 1985. Urban residence, Christian religion and low standard of living were associated with adolescent drinking onset. Adolescent drinking onset was associated with psychological distress (OR 2.82; 95% CI 1.41 to 5.63), alcohol dependence (OR 2.56; 95% CI 1.79 to 3.68), lifetime history of alcohol related injuries (OR 3.07; 95% CI 1.16 to 8.14), alcohol related injuries during the past year (OR 3.04; 95% CI 1.35 to 6.81), and a Alcohol Use Disorder Identification Test score ≥8 indicating hazardous or harmful alcohol use (OR 1.9; 95% CI 1.17 to 3.08) in adulthood.

Conclusions

This study among men in Goa, India suggests a substantial increase in adolescent drinking onset in more recent birth cohorts. Consistent with other countries, adolescent drinking onset increased the likelihood of lifetime alcohol dependence, hazardous or harmful alcohol use, alcohol related injuries and psychological distress. These findings highlight the need for policies and programmes to delay drinking onset in India.


Background

Accumulating evidence suggests that television (TV) viewing is associated with cardio-metabolic risk, but little is known about how this relationship unfolds over the life course. This study employs a life course epidemiological framework by examining the potential cumulative effect of frequent TV viewing during adolescence and young adulthood on the prevalence of metabolic syndrome in mid-adulthood; and whether TV viewing during adolescence constitutes a sensitive period for the development of the metabolic syndrome in mid-adulthood.

Methods

We used data from the Northern Swedish Cohort, a nationally representative cohort comprising 855 participants (80% of the baseline sample). Data were collected during 1981–2008 and analysed in 2013. Logistic regression was applied to examine the associations between TV viewing at ages 16, 21 and 30 years, and the metabolic syndrome at age 43 years.

Results

Cumulative frequent TV viewing was associated with subsequent prevalence of the metabolic syndrome after adjustment for potential confounders (p for trend=0.026). Watching ‘several shows a day’ compared with ‘one show/week’ or less at age 16 years was associated with the metabolic syndrome at age 43 years after adjustment for later exposure (TV viewing at ages 21 and 30 years) and potential confounders (OR 1.86, 95% CI 1.06 to 3.27).

Conclusions

The number of life periods of frequent TV viewing during adolescence and early adulthood influenced cardio-metabolic risk in mid-adulthood in a dose-dependent manner, corresponding to a cumulative risk life course model. Additionally, TV viewing in adolescence may constitute a sensitive period for the metabolic syndrome in mid-adulthood.


Background

Knowledge on the long-term development of adiposity throughout childhood/adolescence and its prenatal determinants and health sequelae is lacking. We sought to (1) identify trajectories of Body Mass Index (BMI) from 1 to 18 years of age, (2) examine associations of maternal gestational smoking and early pregnancy overweight with offspring BMI trajectories and (3) determine whether BMI trajectories predict health outcomes: asthma, lung function parameters (forced expiratory volume in one second (FEV1)/forced vital capacity (FVC) ratio), and blood pressure, at 18 years.

Methods

The Isle of Wight birth cohort, a population-based sample of 1456 infants born between January 1989 and February 1990, was prospectively assessed at ages 1, 2, 4, 10 and 18 years. Group-based trajectory modelling was applied to test for the presence of latent BMI trajectories. Associations were assessed using log-binomial and linear regression models.

Results

Four trajectories of BMI were identified: ‘normal’, ‘early persistent obesity’, ‘delayed overweight’, and ‘early transient overweight’. Risk factors for being in the early persistent obesity trajectory included maternal smoking during pregnancy (RR 2.16, 95% CI 1.02 to 4.68) and early pregnancy overweight (3.16, 1.52 to 6.58). When comparing the early persistent obesity to the normal trajectory, a 2.15-fold (1.33 to 3.49) increased risk of asthma, 3.2% (0.4% to 6.0%) deficit in FEV1/FVC ratio, and elevated systolic 11.3 mm Hg (7.1 to 15.4) and diastolic 12.0 mm Hg (8.9 to 15.1) blood pressure were observed at age 18 years.

Conclusions

Maternal prenatal exposures show prolonged effects on offspring's propensity towards overweight-obesity. Distinct morbid BMI trajectories are evident during the first 18 years of life that are associated with higher risk of asthma, reduced FEV1/FVC ratio, and elevated blood pressure.


Background

The association between maternal ethnicity and newborn weight is understood. Less is known about the additional influence of paternal ethnicity and neighbourhood ethnic composition.

Methods

We studied 692 301 singleton live births of parents of Canadian, Bangladeshi, Sri Lankan, Pakistani, Indian, Filipino, Vietnamese, Korean, Hong Kong or Chinese birthplace. We used multivariable regression to calculate mean (95% CI) birthweight differences between infants of two Canadian-origin parents and (1) foreign-born mother and Canadian-born father, (2) Canadian-born mother and foreign-born father or (3) two foreign-born parents from the same country. We also stratified by high versus low same-ethnic concentration of the parent’s residence. We adjusted for gestational age at birth, maternal age, parity, marital status and income quintile.

Results

Compared with male and female infants of two Canadian-born parents, those of same-country foreign-born parents weighed 6.2% (–218 g, 95% CI –214 g to –223 g) and 5.6% (–192 g, 95% CI –187 g to –196 g) less, respectively. The largest mean weight difference was among male (8.4% (–297 g, 95% CI –276 g to –319 g)) and female (8.2% (–279 g, 95% CI –262 g to –296 g)) infants of two Bangladeshi parents. Infants of a foreign-born mother and Canadian-born father had weights closest to those of two Canadian-born parents. Residing in an area of high (vs low) same-ethnic concentration was associated with lower birthweight among infants of mixed union couples, but not among those of parents originating from the same country.

Conclusions

Paternal and maternal ethnic origin influence newborn weight, which is modified by settlement in a high same-ethnic concentration area only among parents of mixed union.


Background

Levels of paid employment in two parent and lone parent families have increased in the UK but evidence of its impact on child socioemotional behaviour is limited and inconsistent.

Methods

We conducted a longitudinal analysis using the first four sweeps of the Millennium Cohort Study (9 months, 3 years, 5 years and 7 years) to investigate the influence of family employment trajectories in the early years on socioemotional behaviour at 7 years, unadjusted and adjusted for covariates. In addition, mothers’ employment was investigated separately.

Results

Children from families where no parent was employed for one or more sweeps were at a greater risk of socioemotional problem behaviour compared with those where a parent was continuously employed, even after adjustment for covariates. Children of mothers who were non-employed for one or more sweeps were at greater risk of problem behaviour compared with mothers who were employed at all sweeps. Adjustment for covariates fully attenuated the excess risk for children whose mothers had moved into employment by the time they were 7 years. In contrast, the elevated risk associated with continuous non-employment and a single transition out of employment was attenuated after adjustment for early covariates, fathers’ employment, household income and mothers’ psychological distress at 7 years, but remained significant.

Conclusions

Family and mothers’ employment were associated with a lower risk of problem behaviour for children in middle childhood, in part explained by sociodemographic characteristics of families and the apparent psychological and socioeconomic benefits of employment. Results for mothers’ transitions in or out of the labour market suggest that child problem behaviour is influenced by current status, over and above diverse earlier experiences of employment and non-employment.


Background

Short and very long interbirth intervals are associated with worse perinatal, infant and immediate maternal outcomes. Accumulated physiological, mental, social and economic stresses arising from raising children close in age may also mean that interbirth intervals have longer term implications for the health of mothers and fathers, but few previous studies have investigated this.

Methods

Discrete-time hazards models were estimated to analyse associations between interbirth intervals and mortality risks for the period 1980–2008 in complete cohorts of Norwegian men and women born during 1935–1968 who had had two to four children. Associations between interbirth intervals and use of medication during 2004–2008 were also analysed using ordinary least-squares regression. Covariates included age, year, education, age at first birth, parity and change in coparent since the previous birth.

Results

Mothers and fathers of two to three children with intervals between singleton births of less than 18 months, and mothers of twins, had raised mortality risks in midlife and early old age relative to parents with interbirth intervals of 30–41 months. For parents with three or four children, longer average interbirth intervals were associated with lower mortality. Short intervals between first and second births were also positively associated with medication use. Very long intervals were not associated with raised mortality or medication use when change of coparent since the previous birth was controlled.

Conclusions

Closely spaced and multiple births may have adverse long-term implications for parental health. Delayed entry to parenthood and increased use of fertility treatments mean that both are increasing, making this a public health issue which needs further investigation.


Background

Mortality amenable to healthcare interventions has increasingly been used as an indirect indicator of the effect of healthcare on health inequalities. Studies have consistently shown socioeconomic differences in amenable mortality, but evidence on the joint effects of multiple socioeconomic and demographic factors is limited. We examined whether income and living arrangements have an independent effect on amenable mortality taking into account other dimensions of social position.

Methods

The longitudinal and yearly updated individual level data were derived from different administrative registers and obtained from Statistics Finland. The data set includes an 11% random sample of all individuals aged 25–74 years at the end of 1999 and an 80% oversample of deaths in the follow-up period between 2000 and 2007. We used Cox proportional hazard regression with appropriate weights.

Results

We found twofold to threefold differences in amenable mortality between the top and bottom income quintiles. These differences were found to be largely attenuated by economic activity and living arrangements. We also found differences in amenable mortality by living arrangements suggesting that those living alone, as well as lone parents and those cohabiting have higher amenable mortality. These differences were largely independent of our indicators of socioeconomic position and economic activity.

Conclusions

While our results give indirect support to the hypothesis that income differences in amenable mortality may be at least partially due to barriers in access to care, the large independent effects of living arrangements on amenable mortality suggest that seeking care may also have an impact.


Background

People with comorbid mental and physical illness (PI) experience worse health, inadequate care and increased mortality relative to those without mental illness (MI). The role of gender in this relationship is not fully understood. This study examined gender differences in onset of mental health service usage among people with physical illness (COPD, asthma, hypertension and type II diabetes) compared with a control cohort.

Methods

We used a unique linked dataset consisting of the 2000–2001 Canadian Community Health Survey and medical records (n=17 050) to examine risk of onset of MI among those with and without PI among Ontario residents (18–74 years old) over a 10-year period (2002–2011). Adjusted COX proportional survival analysis was conducted.

Results

Unadjusted use of MI medical services in the PI cohort was 55.6% among women and 44.7% (p=0.0001) among men; among controls 48.1% of the women and 36.7% of the men used MI medical services (p=0.0001). The relative risk of usage among women in the PI group relative to controls was 1.16. Among men, the relative risk was 1.22. Women were 1.45 times more likely to use MI medical services relative to men (HR=1.45, CI 1.35 to 1.55). Respondents in the PI cohort were 1.32 times more likely to use MI medical services (HR=1.32, CI 1.23 to 1.42) relative to controls. Women in the PI cohort used MI medical services 6.4 months earlier than PI males (p=0.0059). In the adjusted model, women with PI were most likely to use MI medical services, followed by women controls, men with PI and men controls. There was no significant interaction between gender and PI cohort.

Conclusions

Further, gender-based research focusing on onset of usage of MI services among those with and without chronic health problems will enable better understanding of gender-based health disparities to improve healthcare quality, delivery and public health policy.


Background

Previous evaluations of area-based initiatives have not compared intervention areas with the full range of areas from top to bottom of the social spectrum to evaluate their health inequalities impact.

Setting

Deprived areas subject to the New Deal for Communities (NDC) intervention, local deprivation-matched comparator areas, and areas drawn from across the socioeconomic spectrum (representing high, medium and low deprivation) in England between 2002 and 2008.

Data

Secondary analysis of biannual repeat cross-sectional surveys collected for the NDC National Evaluation Team and the Health Survey for England (HSE).

Methods

Following data harmonisation, baseline and time trends in six health and social determinants of health outcomes were compared. Individual-level data were modelled using regression to adjust for age, sex, ethnic and socioeconomic differences among respondents.

Results

Compared with respondents in HSE low deprivation areas, those in NDC intervention areas experienced a significantly steeper improvement in education, a trend towards a steeper improvement in self-rated health, and a significantly less steep reduction in smoking between 2002 and 2008. In HSE high deprivation areas, significantly less steep improvements in five out of six outcomes were seen compared with HSE low deprivation areas.

Conclusions

Although unable to consider prior trends and previous initiatives, our findings provide cautious optimism that well-resourced and constructed area-based initiatives can reduce, or at least prevent the widening of, social inequalities for selected outcomes between the most and least deprived groups of areas.


Background

Childhood poverty is associated with poorer food consumption but longitudinal data are limited. The objective was to assess if food consumption differs depending on age (6, 7, 10 and 12 years) and pattern of poverty.

Methods

Participants were from the 1998–2010 ‘Quebec Longitudinal Study of Child Development’ birth cohort. Poverty was defined as income below the low-income thresholds established by Statistics Canada which adjusts for household size and geographic region. Multiple imputation was used for missing data, and latent class growth analysis identified poverty trajectories. Multivariable ordinal logistic regression assessed the association between poverty and greater consumption of milk, cheese, fruits, vegetables, sweets and sugar-sweetened beverages (SSB).

Results

Four poverty trajectories were identified: 1 reference category (stable non-poor) and 3 higher-risk categories (stable poor, increasing and decreasing risk). The probability of more frequent consumption was lower among children from stable poor households compared to children from stable non-poor households for fruit (6, 10 and 12 years), milk and vegetables (6, 7, 10 and 12 years) but was higher for SSB (10 and 12 years). Among children from increasing and decreasing poverty households compared to stable non-poor households, the probability of greater consumption of fruits and vegetables was lower and greater consumption of SSB was higher by the age of 12 years.

Conclusions

While experiencing continual exposure to poverty has detrimental effects on food consumption throughout childhood, the association for milk, fruits and vegetables does not differ across age. Intermittent exposure to poverty may also have long-lasting effects.


Background

Previous research has demonstrated elevated mortality following release from prison. We contrasted the risk of opioid overdose death with the risk of suicide in a cohort of adults released from prison in Queensland, Australia over a 14-year-period. We examine risk factors for suicide in the cohort, and make comparisons with the general population.

Method

We constructed a retrospective cohort of all adults released from prison between 1994 and 2007 and linked this to the National Death Index for deaths up to 31 December 2007.

Results

We identified 41 970 individuals released from prison. Of the 2158 deaths in the community, 371 were suicides (crude mortality rate (CMR) 13.7/10 000 person-years) and 396 were due to drug-related causes (CMR 14.6/10 000 person-years). We observed a spike in drug-related deaths in the first 2 weeks after release from prison but no such pattern was observed for suicide. Being married (HR 0.40) and number of prior imprisonments (HR 3.1 for ≥5 prior incarcerations compared with none) independently predicted suicide. Age, sex, Indigenous status, length of incarceration and offence history were not associated with suicide. The standardised mortality ratios indicated that released women were 14.2 times and released men 4.8 times more likely to die from suicide than would be expected in the population.

Conclusions

This study demonstrates that the rate of suicide in adults released from prison is similar to the rate of drug-related deaths. Strategies that provide support to vulnerable people after release may reduce suicide in this population.


Background

Several epidemiological studies have investigated the effect of the quantity of green space on health outcomes such as self-rated health, morbidity and mortality ratios. These studies have consistently found positive associations between the quantity of green and health. However, the impact of other aspects, such as the perceived quality and average distance to public green, and the effect of urban green on population health are still largely unknown.

Methods

Linear regression models were used to investigate the impact of three different measures of urban green on small-area life expectancy (LE) and healthy life expectancy (HLE) in The Netherlands. All regressions corrected for average neighbourhood household income, accommodated spatial autocorrelation, and took measurement uncertainty of LE, HLE as well as the quality of urban green into account.

Results

Both the quantity and the perceived quality of urban green are modestly related to small-area LE and HLE: an increase of 1 SD in the percentage of urban green space is associated with a 0.1-year higher LE, and, in the case of quality of green, with an approximately 0.3-year higher LE and HLE. The average distance to the nearest public green is unrelated to population health.

Conclusions

The quantity and particularly quality of urban green are positively associated with small-area LE and HLE. This concurs with a growing body of evidence that urban green reduces stress, stimulates physical activity, improves the microclimate and reduces ambient air pollution. Accordingly, urban green development deserves a more prominent place in urban regeneration and neighbourhood renewal programmes.


Growing concern about the global burden of child mental health disorders has generated an increased interest in population-level efforts to improve child mental health. This in turn has led to a shift in emphasis away from treatment of established disorders and towards prevention and promotion. Prevention efforts are able to draw on a substantial epidemiological literature describing the prevalence and determinants of child mental health disorders. However, there is a striking lack of clearly conceptualised and measurable positive outcomes for child mental health, which may result in missed opportunities to identify optimal policy and intervention strategies. In this paper, we propose an epidemiological approach to child mental health which is in keeping with public health principles and with the WHO definition of health, and which is grounded in current thinking about child development. Constructs such as competence offer the opportunity to develop rigorous outcome measures for epidemiological research, while broader ideas about ‘the good life’ and ‘the good society’ derived from philosophical thinking can enable us to shape policy initiatives based on normative ideas of optimal child mental health that extend beyond individuals and undoubtedly beyond the traditional boundaries of the health sector.


Purty AJ, Singh Z, Kisku KH, et al. P1-296 Case-finding and treatment of TB patients in medical colleges in pondicherry, S. India: patient and health system delays under the revised national TB control programme (RNTCP). J Epidemiol Community Health 2011;65:A149. The seventh author's name was published incorrectly as A Senthilvel. The correct name should be V Senthilvel.


Purty AJ, Mahajan P, Singh Z, et al. P2-537 Tracking progress towards elimination of iodine deficiency disorders in Puducherry (India), a school based study. J Epidemiol Community Health 2011;65:A369. The seventh author's name was published incorrectly as A Senthilvel. The correct name should be V Senthilvel.


Niclasen J, Nybo Andersen AM, Teasdale TW, et al. Prenatal exposure to alcohol, and gender differences on child mental health at age seven years. J Epidemiol Community Health 2014;68:224–32. The first author's name was published incorrectly as J Niclasen. The correct name should be Janni Niclasen.