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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 missing piece

The past 10 years have witnessed a remarkable rise in the visibility of the field of global mental health, which applies the core principles of global health (improving health and equity in health for all people worldwide1) to mental health. The stated goal of global mental health is to reduce the burden of mental disorders using an evidence-based and human rights approach with a focus on low and middle income countries (LMIC) as this is where inequity in mental health treatment and care is the greatest.2

The field, as witnessed by the changing nature of papers published in this journal, has moved rapidly from research into the prevalence of and risk factors for mental disorders,3 4 to randomised controlled trials (RCTs) of interventions in low-resource settings.5 There is now a small but growing evidence base of...


Background

There is a paucity of studies on socioeconomic inequalities in cancer mortality in developing countries. We examined trends in inequalities in cancer mortality by educational attainment in Colombia during a period of epidemiological transition and rapid expansion of health insurance coverage.

Methods

Population mortality data (1998–2007) were linked to census data to obtain age-standardised cancer mortality rates by educational attainment at ages 25–64 years for stomach, cervical, prostate, lung, colorectal, breast and other cancers. We used Poisson regression to model mortality by educational attainment and estimated the contribution of specific cancers to the slope index of inequality in cancer mortality.

Results

We observed large educational inequalities in cancer mortality, particularly for cancer of the cervix (rate ratio (RR) primary vs tertiary groups=5.75, contributing 51% of cancer inequalities), stomach (RR=2.56 for males, contributing 49% of total cancer inequalities and RR=1.98 for females, contributing 14% to total cancer inequalities) and lung (RR=1.64 for males contributing 17% of total cancer inequalities and 1.32 for females contributing 5% to total cancer inequalities). Total cancer mortality rates declined faster among those with higher education, with the exception of mortality from cervical cancer, which declined more rapidly in the lower educational groups.

Conclusions

There are large socioeconomic inequalities in preventable cancer mortality in Colombia, which underscore the need for intensifying prevention efforts. Reduction of cervical cancer can be achieved through reducing human papilloma virus infection, early detection and improved access to treatment of preneoplastic lesions. Reinforcing antitobacco measures may be particularly important to curb inequalities in cancer mortality.


Background

To measure the explanatory role of behavioural factors to educational and income disparities in mortality among US adults (ages 25+).

Methods

Data were from four waves of the American Changing Lives Study (N=3617). There were 1832 deaths between 1986 and 2011. Smoking, physical activity, alcohol and body mass index were examined.

Results

Those with 0–11 years of schooling had an 88% (95% CI 48% to 139%) increased risk of dying compared to those with 16+years of schooling. Behavioural factors explained 41% (95% CI 26% to 55%) and 50% (95% CI 30% to 70%) of this excess in models that treated behavioural factors as fixed (single point in time) and time varying (repeated), respectively. The lowest income group (bottom 20th centile) had a 209% (95% CI 172% to 256%) increased risk of dying relative to the highest income group (top 40th centile). Behavioural factors explained 24% (fixed, 95% CI 13% to 35%) and 39% (repeated, 95% CI 22% to 56%) of this difference. Analyses of deaths by causes indicated that behavioural factors were more consequential to disparities in cardiovascular mortality, explaining up to 83% of educational differences, compared to cancer and other death causes.

Conclusions

Behavioural factors are one of a number of factors which explain socioeconomic mortality disparities, but their estimated explanatory role depends on a number of parameters including the socioeconomic status measure examined, the cause of death and age. In this nationally representative sample, findings based on repeated measures did not warrant a re-evaluation of earlier estimates.


Background

Ecological and cross-sectional studies have indicated that conservative political ideology is associated with better health. Longitudinal analyses of mortality are needed because subjective assessments of ideology may confound subjective assessments of health, particularly in cross-sectional analyses.

Methods

Data were derived from the 2008 General Social Survey-National Death Index data set. Cox proportional analysis models were used to determine whether political party affiliation or political ideology was associated with time to death. Also, we attempted to identify whether self-reported happiness and self-rated health acted as mediators between political beliefs and time to death.

Results

In this analysis of 32 830 participants and a total follow-up time of 498 845 person-years, we find that political party affiliation and political ideology are associated with mortality. However, with the exception of independents (adjusted HR (AHR)=0.93, 95% CI 0.90 to 0.97), political party differences are explained by the participants’ underlying sociodemographic characteristics. With respect to ideology, conservatives (AHR=1.06, 95% CI 1.01 to 1.12) and moderates (AHR=1.06, 95% CI 1.01 to 1.11) are at greater risk for mortality during follow-up than liberals.

Conclusions

Political party affiliation and political ideology appear to be different predictors of mortality.


Background

Socioeconomic inequalities are increasingly recognised as an important public health issue, although their role in the leading causes of mortality in urban areas in Europe has not been fully evaluated. In this study, we used data from the INEQ-CITIES study to analyse inequalities in cause-specific mortality in 15 European cities at the beginning of the 21st century.

Methods

A cross-sectional ecological study was carried out to analyse 9 of the leading specific causes of death in small areas from 15 European cities. Using a hierarchical Bayesian spatial model, we estimated smoothed Standardized Mortality Ratios, relative risks and 95% credible intervals for cause-specific mortality in relation to a socioeconomic deprivation index, separately for men and women.

Results

We detected spatial socioeconomic inequalities for most causes of mortality studied, although these inequalities differed markedly between cities, being more pronounced in Northern and Central-Eastern Europe. In the majority of cities, most of these causes of death were positively associated with deprivation among men, with the exception of prostatic cancer. Among women, diabetes, ischaemic heart disease, chronic liver diseases and respiratory diseases were also positively associated with deprivation in most cities. Lung cancer mortality was positively associated with deprivation in Northern European cities and in Kosice, but this association was non-existent or even negative in Southern European cities. Finally, breast cancer risk was inversely associated with deprivation in three Southern European cities.

Conclusions

The results confirm the existence of socioeconomic inequalities in many of the main causes of mortality, and reveal variations in their magnitude between different European cities.


Background

We examined indicators of job strain in relation to level and change in episodic memory in the years leading up to as well as following retirement.

Methods

Our analyses centre on 3779 individuals from the nationally representative Health and Retirement Study (baseline age 57.3 years) who reported gainful employment in an occupation for 10+ years prior to retirement, and who were assessed for episodic memory performance over up to 20 years (median 8 waves over 16 years). We used ratings from the Occupational Information Network (O*Net) to score occupations for job control and job demands, and to measure job strain (job demands/job control).

Results

Controlling for sociodemographic characteristics, depressive symptoms, and cardiovascular disease, less job control and greater job strain were not significantly associated with change in episodic memory in the period leading up to retirement, but were associated with significantly poorer episodic memory at retirement and an accelerated rate of decline in episodic memory following retirement. The results did not vary for men and women or by self-employment status.

Conclusions

Job strain expressed mainly as low job control is linked to poorer episodic memory at retirement and more decline after retirement. Job characteristics appear to have implications for cognitive ageing independent of relevant confounds.


Background

Several studies tested whether stressful work mediates the association between socioeconomic position (SEP) and health. Although providing moderate support, evidence is still inconclusive, partly due to a lack of theory-based measures of SEP and work stress, and because of methodological limitations. This contribution aims at overcoming these limitations.

Methods

We conduct pathway analysis and investigate indirect effects of SEP on mental health via stressful work. Data are derived from the first two waves of the ‘Survey of Health, Ageing and Retirement in Europe’ (SHARE) with information from employed men and women aged 50–64 across 11 European countries (N=2798). SEP is measured according to two alternative measures of occupational position: occupational class (focus on employment relations) and occupational status (focus on prestige). We assess work stress according to the effort-reward imbalance and the demand-control model (wave 1), and we use newly occurring depressive symptoms as health outcome (wave 2).

Results

Effort-reward imbalance and, less consistently, low control mediate the effect of occupational class and occupational status on depressive symptoms.

Conclusions

Our findings point to two important aspects of work stress (effort-reward imbalance and low control) in explaining socioeconomic differences in health. Further, we illustrate the significance of two alternative dimensions of occupational position, occupational class and occupational status.


Background

People in Arctic Canada are undergoing a nutritional transition and increased prevalence of chronic disease. The Healthy Foods North diet and physical activity intervention was developed in 2007–2008 while working with populations in six communities in Nunavut and the Northwest Territories, Canada.

Methods

Four communities received the 1-year intervention (eg, conducting workshops, cooking classes and walking clubs) and two communities served as controls. Among the 263 adult evaluation participants, food frequency questionnaires were used to assess dietary intake at baseline and postintervention. Changes in mean nutrient intakes, nutrient density and dietary adequacy from baseline to postintervention were determined. The intervention impact on nutrient intakes was assessed through multivariate linear regression analysis.

Results

Post-intervention assessment showed a reductions in total fat, saturated, monounsaturated and polyunsaturated fatty acids, and increases in iron intake, only in the intervention group. More than a 4%-increase in the percentage of adherence to vitamins A and D recommendations was observed in the intervention group. After adjusting the regression models, respondents in the intervention communities significantly reduced their energy intake and increased their vitamins A and D intake.

Conclusions

The Healthy Foods North is an effective programme to improve dietary quality among populations of the Canadian Arctic. Long-term interventions are expected to be important factors in the prevention of diet-related chronic diseases in these communities.


Background

Persons with mental illness are over-represented in prison populations around the world. They are more vulnerable to arrest and more likely to experience repeated encounters with the criminal justice system. Whether criminal justice involvement, in and of itself, is associated with higher mortality, particularly among offenders with mental illness, is unknown.

Methods

The authors conducted a mediation analysis of mortality rates in a cohort of 79 088 offenders from British Columbia using administrative records spanning 2001–2010, where the mediating variable was the individual-level rate of criminal sentencing.

Results

During 339 506 person-years of follow-up, there were 1841 deaths. The diagnosis of mental illness had no direct association with higher mortality after adjustment for confounders (HR=0.98, 95% CI 0.86 to 1.06). However, mental illness had an indirect association with mortality that was mediated through more frequent criminal justice involvement (HR=1.02, 95% CI 1.01 to 1.04).

Conclusions

These findings support the hypothesis that offenders with mental illness experience higher mortality that is mediated by higher rates of criminal justice contact. The results of our study indicate that criminal justice diversion programmes are further warranted because they may contribute to the prevention of mortality among offenders with mental illness.


Background

Previous research suggests that first-generation immigrants have a lower suicide risk than those both born in Sweden and with both parents born in Sweden (natives), while the suicide risk in the second generation seems higher. The aim of this study was to investigate to what extent suicide risk in first-generation and second-generation (both parents born abroad) and intermediate-generation (only one parent born abroad) immigrants compared with natives is associated with sociodemographic factors, labour market marginalisation and morbidity.

Methods

A prospective population-based cohort study of 4 034 728 individuals aged 16–50 years was followed from 2005 to 2010. HRs for suicide were calculated for first-generation, intermediate-generation and second-generation immigrants compared with natives. Analyses were controlled for sociodemographic factors, morbidity and labour market marginalisation.

Results

The HR of suicide was significantly lower in first-generation immigrants (HR 0.83 CI 0.76 to 0.91), and higher in second-generation (HR 1.32, CI 1.15 to 1.52) and intermediate-generation immigrants (HR 1.20, CI 1.08 to 1.33) in comparison to natives. The excess risk was explained by differences in sociodemographics, morbidity and labour market marginalisation. In the fully adjusted models, a higher HR remained only for the Nordic second generation (HR 1.29, CI 1.09 to 1.52). There were no sex differences in HRs.

Conclusions

The risk of suicide was shown to be lower in the first generation and higher in the second generation compared with natives. The higher HR in the Nordic second generation was not explained by differences in sociodemographics, labour market marginalisation and morbidity. Further research is warranted to investigate factors underlying this excess risk.


Background

Limited health literacy is associated with worse physical function in cross-sectional studies. We aimed to determine if health literacy is a risk factor for decline in physical function among older adults.

Methods

A longitudinal cohort of 529 community-dwelling American adults aged 55–74 years were recruited from an academic general internal medicine clinic and federally qualified health centres in 2008–2011. Health literacy (Newest Vital Sign), age, gender, race, education, chronic conditions, body mass index, alcohol consumption, smoking status and exercise frequency were included in multivariable analyses. The 10-item PROMIS (Patient-Reported Outcomes Measurement Information System) physical function scale was assessed at baseline and follow-up (mean=3.2 years, SD=0.39).

Results

Nearly half of the sample (48.2%) had either marginal (25.5%) or low health literacy (22.7%). Average physical function at baseline was 83.2 (SD=16.6) of 100, and health literacy was associated with poorer baseline physical function in multivariable analysis (p=0.004). At follow-up, physical function declined to 81.9 (SD=17.3; p=0.006) and 20.5% experienced a meaningful decline (>0.5 SD of baseline score). In multivariable analyses, participants with marginal (OR 2.62; 95%CI 1.38 to 4.95; p=0.003) and low (OR 2.57; 95%CI 1.22 to 5.44; p=0.013) health literacy were more likely to experience meaningful decline in physical function than the adequate health literacy group. Entering cognitive abilities to these models did not substantially attenuate effect sizes. Health literacy attenuated the relationship between black race and decline in physical function by 32.6%.

Conclusions

Lower health literacy increases the risk of exhibiting faster physical decline over time among older adults. Strategies that reduce literacy disparities should be designed and evaluated.


Background

Abdominal aortic aneurysm (AAA) is a leading cause of death in the USA. We evaluated the incidence and predictors of AAA in a prospectively followed cohort.

Methods

We calculated age-adjusted AAA incidence rates (IR) among 18 782 participants aged ≥65 years in the Southern Community Cohort Study who received Medicare coverage from 1999–2012, and assessed predictors of AAA using multivariable Cox proportional hazards models, overall and stratified by sex, adjusting for demographic, lifestyle, socioeconomic, medical and other factors. HRs and 95% CIs were calculated for AAA in relation to factors ascertained at enrolment.

Results

Over a median follow-up of 4.94 years, 281 cases were identified. Annual IR was 153/100 000, 401, 354 and 174 among blacks, whites, men and women, respectively. AAA risk was lower among women (HR 0.48, 95% CI 0.36 to 0.65) and blacks (HR 0.51, 95% CI 0.37 to 0.69). Smoking was the strongest risk factor (former: HR 1.91, 95% CI 1.27 to 2.87; current: HR 5.55, 95% CI 3.67 to 8.40), and pronounced in women (former: HR 3.4, 95% CI 1.83 to 6.31; current: HR 9.17, 95% CI 4.95 to 17). A history of hypertension (HR 1.44, 95% CI 1.04 to 2.01) and myocardial infarction or coronary artery bypass surgery (HR 1.9, 95% CI 1.37 to 2.63) was negatively associated, whereas a body mass index ≥25 kg/m2 (HR 0.72; 95% CI 0.53 to 0.98) was protective. College education (HR 0.6, 95% CI 0.37 to 0.97) and black race (HR 0.44, 95% CI 0.28 to 0.67) were protective among men.

Conclusions

Smoking is a major risk factor for incident AAA, with a strong and similar association between men and women. Further studies are needed to evaluate benefits of ultrasound screening for AAA among women smokers.


Background

Healthcare financing through out-of-pocket payments and inequities in healthcare utilisation are common in low and middle income countries (LMICs). Given the dearth of pertinent studies on these issues among older people in LMICs, we investigated the determinants of health service use, out-of-pocket and catastrophic health expenditures among older people in one LMIC, India.

Methods

We accessed data from a nationally representative, multistage sample of 2414 people aged 65 years and older from the WHO's Study on global Ageing and adult health in India. Sociodemographic characteristics, health profiles, health service utilisation and out-of-pocket health expenditure were assessed using standard instruments. Multivariate zero-inflated negative binomial regression models were used to evaluate the determinants of health service visits. Multivariate Heckman sample selection regression models were used to assess the determinants of out-of-pocket and catastrophic health expenditures.

Results

Out-of-pocket health expenditures were higher among participants with disability and lower income. Diabetes, hypertension, chronic pulmonary disease, heart disease and tuberculosis increased the number of health visits and out-of-pocket health expenditures. The prevalence of catastrophic health expenditure among older people in India was 7% (95% CI 6% to 8%). Older men and individuals with chronic diseases were at higher risk of catastrophic health expenditure, while access to health insurance lowered the risk.

Conclusions

Reducing out-of-pocket health expenditure among older people is an important public health issue, in which social as well as medical determinants should be prioritised. Enhanced public health sector performance and provision of publicly funded insurance may protect against catastrophic health expenses and healthcare inequities in India.


Demey D, Berrington A, Evandrou M, et al. Living alone and psychological well-being in mid-life: does partnership history matter?. J Epidemiol Community Health 2014;68:410. This article now includes the CC BY-NC licence.


Jahangir et al1 provided a fascinating analysis showing, among older people, a higher risk of abdominal aortic aneurysm (AAA) in those with normal body mass index (BMI), those who smoke and in men. Although AAA is relatively rare, ruptured AAA has a high mortality rate, so prevention, based on reversible risk factors, is important. The observed association of normal BMI with AAA may be an artefact of weight loss due to ill-health in older people. Men often have higher rates than women of cardiovascular disease, for reasons which have not been clearly explained. Smoking undoubtedly causes AAA and is a major modifiable target of intervention.

Alternatively, a more comprehensive unifying hypothesis providing aetiology based insight for further interventions could be constructed. Unexpectedly, recent promotion of testosterone replacement among older men has highlighted that testosterone plays a role in cardiovascular disease.2 Consistent with this insight in...


Developmental disabilities affect millions of people and have a great impact on their lives, their families and the societies where they live. The prevalence of disorders such as autism, attention deficit hyperactivity disorder as well as subclinical decrements in brain function cannot be explained solely as genetic diseases. Exposures to environmental chemicals, especially during prenatal and early postnatal life, are one likely explanation for some of the decrements. The current chemical risk assessment approach is typically based on the toxicity caused by a single chemical on a variety of organs without acknowledging additional exposures to other chemicals also affecting the same organ or system. We identified more than 300 chemicals allowed in food that may have potential harmful effects on the developing brain. Each individual chemical may or may not have a harmful effect if it were the only one present, but we know next to nothing about their cumulative biological effects on the brain. An expanded cumulative risk assessment approach is needed, and it should focus on health outcomes, like developmental disabilities, arising from the accumulation of effects of multiple chemicals on the brain. The laws regulating the safety of additives already require that regulators in Europe and the USA consider cumulative effects; so far, they seem to have neglected the mandate. We must move beyond treating chemical exposures as isolated incidents and look at their cumulative biological effects on organs and their role in the onset of chronic diseases. The time has come to overhaul chemical risk assessment.


Background

Previous observational studies have claimed that birth weight and childhood wheezing disorders are associated although the results remained inconsistent. One systematic review and two systematic reviews that included meta-analyses reported inconsistent results. We aimed to conduct a systematic review and meta-analysis to investigate this.

Methods

An online search of published papers linking childhood asthma and wheezing disorders with birth weight up to February 2014 was carried out using EMBASE and Medline medical research databases. Summary ORs were estimated using random-effects models. Subgroup meta-analyses were performed to assess the robustness of risk associations and between-study heterogeneity.

Results

A total of 37 studies comprising 1 712 737 participants were included in our meta-analysis. The unadjusted summary ORs for risk of childhood wheezing disorders associated with low birth weight (<2.5 kg) were 1.60 (95% CI 1.39 to 1.85, p<0.001) and 1.37 (95% CI 1.05 to 1.79, p=0.02) when compared with ≥2.5 and 2.5–4.0 kg birthweight groups, respectively. The overall summary OR for high birth weight (>4 kg) as compared to the 2.5–4.0 kg birthweight group was 1.02 (95% CI 0.99 to 1.04, p=0.13). There was substantial heterogeneity in the unadjusted low birth weight risk estimates which was not accounted for by predefined study characteristics. There was no significant heterogeneity in the high birth weight risk estimates. There was some evidence of funnel plot asymmetry and small study effects in the low birth weight (2.5 vs ≥2.5 kg and <2.5 vs 2.5–4 kg) OR estimates.

Conclusions

Our results suggest that low birth (<2.5 kg) is an independent risk factor for wheezing disorders during childhood and adolescence although there was substantial heterogeneity among the risk estimates. However, we found no significant association of high birth weight with wheezing disorders.