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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

It is widely accepted that dissemination of research results has received little attention in biomedical journals, and, clearly, a scientific discovery is worthless if not communicated. The method, for example, of isolating insulin developed by Eugène Grey and kept hidden for almost 20 years is noteworthy. In 1905 Grey injected gelatine into the pancreatic duct and waited for the pancreas to degenerate before preparing an extract.1 The concept was the same as that of Banting and Best. Had Grey published his results instead of depositing them in a sealed packet at the French Society of Biology until after the work of Banting and Best was published,2 the treatment of diabetes might have been advanced by a quarter of a century.

Pharmacology offers many examples of the role of science dissemination, in specialty journals and in the lay press, in the development and adoption of new...


Introduction

Cardiovascular disease (CVD) is currently the leading cause of death worldwide, contributing to 30% of all deaths. CVD etiology is complex, with many modifiable and non-modifiable risk factors. Epidemiological evidence generally supports an association between shiftwork and an increased risk for CVD. However, the underlying physiological mechanisms remain poorly understood. Limited research suggests that the production of cortisol may differ between shift workers and non-shift workers, resulting in physiological changes that potentially increase the risk of CVD among shift workers. This study will focus on females who comprise the largest proportion of workers in healthcare settings.

Objectives

  •  1) To describe and compare total cortisol levels and its diurnal pattern in relation to current shiftwork status, and cumulative duration of exposure to shiftwork.

  •  2) To determine if current shiftwork status and/or cumulative duration are associated with total cortisol levels, and diurnal pattern.

  • Study design and methods

    Female participants were recruited from a tertiary acute care teaching hospital in southeastern Ontario, Canada between September 2011 and February 2014 (n=330). An interview and a questionnaire were used to ascertain shiftwork exposure, and covariate information. Urine samples were provided at every void over a 48-hour period to approximate free cortisol levels. A multivariate regression model will be used to describe, and determine the significance of the effect of shiftwork on total cortisol and its diurnal pattern.

    Hypotheses

    We anticipate that the overall production of cortisol will be higher in current shift workers than non-shift workers. Cumulative duration of shiftwork exposure will be associated with higher total cortisol levels and with cortisol patterns in a dose-dependent manner.

    Relevance

    Shift work is a highly prevalent work pattern: approximately 30% of Canadians are employed in shift work positions. Determining the mechanisms through which shiftwork may influence CVD has the potential to inform interventions.


    Background and objectives

    Restless legs syndrome (RLS) is common amongst patients receiving dialysis. It is unclear how to optimally treat RLS in dialysis patients. We conducted a systematic review to identify therapies to reduce the severity of RLS.

    Methods

    We systematically searched MEDLINE and EMBASE and hand searched narrative reviews for randomized controlled trials that assessed the use of pharmacological or non-pharmacological interventions to reduce the severity of RLS among patients receiving dialysis. The primary outcome was RLS symptoms.

    Results

    Of 621 abstracts identified, 12 studies that included 13 interventions met the inclusion and exclusion criteria. All trials reported interventions that significantly improved RLS severity. The interventions included dopamine agonists (n=6), gabapentin (n=2), intradialytic exercise (n=2) intravenous iron (n=1), vitamins C and E (n=1), and clonidine (n=1). In studies that compared two interventions, ropinirole gabapentin, and intradialytic exercise with resistance were all more effective than L-dopa in comparisons. However, all studies were at high risk of bias with the most common causes due to lack of allocation concealment, high losses to follow-up, and missing data. Further, follow-up for these studies was short-term ranging from 3 days to 24 weeks.

    Conclusions

    Ropinirole, gabapentin, and intradialytic exercise appear promising to reduce RLS in dialysis patients. However, methodologically rigorous, appropriately powered, longer term RCTs are required to determine the optimal treatment strategy for RLS among dialysis patients.


    Background

    The burden of cardiovascular diseases (CVD) in low- and middle-income countries (LMIC) has increased greatly. Primary prevention of CVD has been shown to work in developed countries, and is urgently needed in LMIC.

    Objective

    This literature review aims to evaluate the effectiveness of primary prevention strategies for CVD in LMIC.

    Methods

    Studies were obtained via a detailed search using Ovid MEDLINE©, EMBASE and Global Health databases, published in English between 1946 and 2013. Included studies were primary research articles aimed at the primary prevention of CVD in LMIC participants over age 15 years. We included studies of interventions targeted to the general population or to groups with specific levels of risk for CVD.

    Results

    Of 1002 studies that were identified through the initial search, 12 studies met the inclusion criteria. The interventions at the general population level mainly consisted of health promotion and education through media, as well as policy implementation and community outreach. The risk-group focused interventions used pharmaceutical treatment of cardiovascular risk factors or CVD education and lifestyle counselling as preventive measures. All but two studies showed significant improvement in at least one cardiovascular risk factor. Primary prevention strategies used in high-risk groups showed greater benefits in reducing physiological cardiovascular risk factors when compared to population-based interventions.

    Conclusion

    Primary prevention interventions have been shown to be effective at lowering cardiovascular risk factors in LMIC. In general, the included studies indicate that health promotion and education are the most successful prevention strategies. However, due to heterogeneity between the included studies (e.g. different populations or treatment modalities), no valid conclusions on the comparative effectiveness of specific study interventions can be made.


    Introduction

    Increasingly, a presence on social media platforms, such as Facebook and Twitter, are the cultural norm. Such activities typically involve the public sharing of personal information and viewpoints. For physicians, however, such public accessibility may affect their relationships with patients and other stakeholders.

    Objectives

    We sought to determine public expectations of the extent and manner of physicians' presence on social media.

    Methods

    A questionnaire consisting of 36 questions was created using the SurveyMonkey.com website. The link to the survey was shared widely via social media.

    Results

    There were 259 respondents, predominantly female (74%), urban (87%) and Canadian (94%). A small proportion (31%) felt that a relationship with their physician on social media would be harmful to their clinical relationship, while 56% reported that it would be neither harmful nor beneficial. The majority (55%) expressed concerns about privacy. Almost a third (29%) would be less inclined to maintain a professional relationship with their physician if their physician expressed a conflicting political view than their own on social media. A substantial proportion (46%) also felt that their family physicians should limit their visibility on social media.

    Conclusion

    As social media becomes entrenched into our everyday lives, the extent to which the rights of physicians to participate must be weighed against the perceptions of their current and potential patients.


    Introduction

    Exposure to air pollution has been linked with an increased risk for cardiovascular morbidity and mortality. Few studies have examined possible associations between air pollution and gestational hypertension (GH). The prevalence of GH in Canada is approximately 6%, translating into roughly 300 women developing GH in Halifax annually. GH disorders account for 2–8% of pregnancy complications worldwide.

    Objective

    The current study examined the relationship between exposure to air pollution during pregnancy and GH.

    Methods

    A retrospective cohort study including women residing in urban Halifax, Nova Scotia who delivered a singleton infant between 2008 and 2012. The Nova Scotia Atlee Perinatal Database was used to determine socio-demographic characteristics and pregnancy conditions. Spatial estimates of air pollution were determined from land-use regression (LUR) models and were linked to women in the Perinatal Database based on their six-digit postal code. Residential concentrations of sulfur dioxide (SO2), nitrogen dioxide (NO2), particulate matter (PM1, PM2.5, PM10), toluene, and benzene were averaged over three seasons and categorized into quartiles. Odds ratios (OR) and 95% confidence intervals (CI) were calculated using logistic regression, adjusting for potential confounders.

    Results

    Of the 11,724 singleton births analyzed, 7.7% of the cohort developed GH. When adjusted for smoking, pre-pregnancy weight, maternal age and parity a significant inverse relationship was observed for exposure to all pollutants (top quartile of exposure relative to lowest quartile); SO2 (OR: 0.75; 95% CI: 0.62, 0.92), NO2 (0.66; 0.54, 0.81), PM1 (0.71; 0.57, 0.87), PM2.5 (0.68, 0.56, 0.83), PM10 (0.71; 0.58, 0.87) toluene (0.68; 0.56, 0.83) and benzene (0.62; 0.51, 0.75).

    Conclusion

    The inverse relationships observed were contrary to what has been observed in past research. These results stress the importance of conducting more research in this field to better understand the characteristics that influence the relationship between air pollution and GH.


    Introduction

    Depressive symptoms are associated with increased risk of incident diabetes. Inflammatory mechanisms have been suggested to be involved in depression and diabetes. Specifically, increased levels of C-reactive protein (CRP), a biomarker for inflammation, is associated with depression and have also been linked to risk of developing diabetes.

    Objective

    To assess the association of both CRP and depressive symptomatology with diabetes incidence in a representative sample of English people ≥50 years old.

    Methods

    Participants were 5475 community-dwelling men and women without diabetes at baseline from the English Longitudinal Study of Ageing (ELSA). Wave 2 of ELSA was used as baseline (first assessment of CRP), with assessment of diabetes incidence at waves 3, 4, and 5. Elevated depressive symptoms were based on a score ≥4 using the 8-item Center for Epidemiologic Studies Depression (CES-D) scale, and high CRP level was defined as >3 mg/L. Diabetes incidence was indicated by self-reported doctor diagnosis. Association of diabetes incidence with baseline CRP and depressive symptomatology groups was examined using multivariate logistic regression adjusted for socio-demographic, lifestyle, metabolic, and health variables.

    Results

    In comparison to participants with normal CRP levels and low depressive symptoms, those with both high CRP and elevated depressive symptoms were more likely to develop diabetes over 6 years of follow-up (adjusted OR: 1.90, 95% CI: 1.10–3.30). Individuals with high CRP and low depressive symptoms (adjusted OR: 1.26, 95% CI: 0.89–1.78) and those with normal CRP and elevated depressive symptoms (adjusted OR: 1.55, 95% CI: 0.88–2.73) were not associated with diabetes incidence.

    Conclusion

    People with high CRP and elevated depressive symptoms are more likely to develop diabetes. Further analyses will examine the possible interactions between CRP and depression with diabetes incidence.


    Family health history is the genetic and ecological contributions and interactions, or what others may refer to as the genomic and bionomic inputs, affecting the life course of family members. The adage to ‘know your family history’ promoted in public health and clinical settings emphasises having awareness of first and second degree relatives’ health status, including causes and outcomes of morbidity and mortality. An overarching aim of promoting awareness of family health history resides in making health a public good accessible to all through informed decisions about resource allocation in personal and societal realms, including effort, time and money. Evidence of the promise associated with family health history awareness emerges in studies such as the ‘Family Healthware Impact Trial’ conducted in the USA. Findings demonstrated that risk-tailored messages associated with self-reports of personal lifestyle behaviours and familial risk for coronary heart disease, stroke, diabetes, and colorectal, breast, and...


    Background

    The Global Lipids Genetics Consortium identified 95 common loci that explained 12.2% (LDL-C), 12.1% (HDL-C) and 9.6% (triglycerides [TG]) of total variance in plasma lipid traits in the Framingham Heart Study. Since adiposity is associated with plasma levels of TG and HDL-C, we hypothesized that the predictive value of common risk variants for these lipid traits would differ for obese versus lean subjects.

    Methods

    The study population consisted of two independent cohorts of subjects of European de-scent, genotyped on the Affymetrix 6.0 array with 1000G imputation. 1) OBLE: 959 obese/869 lean. 2) CC (healthy elderly subjects recruited as con-trols for a CAD study) 830 obese/1,044 lean. A genetic predisposition score was calculated for each individual as a sum across SNPs of the number of risk alleles at that SNP multiplied by the effect size of the SNP.

    Results

    In the OBLE cohort, a genetic risk score explained a greater percentage of the total TG variance in obese vs lean (beta GRS=0.154 mmol/L (p<2e-16) vs 0.094 mmol/L (p=5.8e-10); adjusted R2=0.090 vs 0.042), a finding that was replicated in the CC cohort for obese vs lean (beta GRS=0.153 mmol/L (p=1.5e-7) vs 0.102 mmol/L (p=4.2e-6); adjusted R2=0.044 vs 0.024). A similar but less significant trend was noted for LDL-C. In addition, the genetic risk score predicted variability in TG better than sex/age for obese subjects. In contrast a genetic risk score for HDL-C was a better predictor of this trait in lean versus obese subjects in both the OBLE and CC cohorts. Genetic risk scores for each lipid trait showed no association with BMI (P>0.2) indicating that the above findings are not due to possible overlap between genetic loci for BMI and lipid traits.

    Conclusions

    Genetic predisposition to elevated plasma triglycerides and LDL-C and low HDL-C is highly sensitive to extremes of BMI.


    Introduction

    In order to evaluate the diet-disease association, valid dietary assessment tools that accurately assess nutritional intake are critical. Childhood is a critical window for intervention to delineate the risk of many nutrition-related diseases later in life. Limited validated tools exist to assess dietary intake in children aged less than 10 years in the Middle East and North Africa Region and in Lebanon.

    Objectives

    The main objectives of this study were to develop and validate a Food Frequency Questionnaire (FFQ) to assess dietary intake among Lebanese children aged 5–10 years.

    Methods

    Children were recruited from public and private schools in the Lebanese capital Beirut. Mothers (used as proxy) completed the FFQ (FFQ-1) in the first visit. During the following 4 weeks, 4 Multiple Pass 24 hour recalls (MPRs) were collected. At Week 4, the FFQ (FFQ-2) was completed a second time. Validity tested the developed FFQ against the mean of the MPRs. It was assessed by spearman correlation coefficients and Bland Altman plots. The Intraclass Correlation Coefficient (ICC) and kappa statistic were used to test reliability between FFQ-1 and FFQ-2.

    Results

    120 children completed the study. Spearman correlation coefficients for energy, protein and total fat intakes were 0.60, 0.40 and 0.60, respectively. Other nutrients' coefficients ranged between 0.20–0.65. Bland-Altman's Limits of Agreement showed acceptable agreement.

    ICCs for energy, protein and total fat intakes were 0.87, 0.85 and 0.85, respectively. Other nutrients' ICC ranged between 0.18–0.90. The kappa coefficients between FFQ-1 and FFQ-2 ranged between substantial and moderate agreement.

    Conclusions

    This study's findings indicated that the developed FFQ is valid and reliable among Lebanese children aged 5–10 years. This validated questionnaire will be a useful tool for assessing Lebanese children's dietary intakes. It will also be an asset that other researchers in the region can use or adapt to suit their study populations.


    Introduction

    Sedentary behaviour is gaining attention as an important cardiometabolic risk factor. Studies of sedentary behavior and cardiometabolic risk have not considered sleep duration, although there is evidence that sleep duration may be related to both sedentary behaviour and cardiometabolic risk.

    Objective

    The purpose of this study is to determine if sedentary behaviour is related to the metabolic syndrome (MetS) while controlling for sleep duration.

    Methods

    This cross-sectional study is based on the 2003–2006 National Health and Nutrition Examination Survey. A sample of 1371 adults over the age of 20 were studied. Average daily sedentary time and sleep duration were determined via 7-day accelerometry. Screen time was determined via questionnaire. The MetS was determined using standard criteria. Analysis of variance was used to examine relationships among sedentary time and screen time with sleep duration. Multiple logistic regression was used to examine associations between total sedentary time, screen time, and sleep duration with the MetS after controlling for several covariates.

    Results

    Sedentary time and screen time did not vary across the sleep quartiles (p=0.08 and p=0.87, respectively). Participants in the highest quartile of sedentary time were significantly more likely to have the MetS than participants in the lowest quartile (odds ratio=1.60, 95% CI:1.05–2.45). The odds of the MetS was higher in participants in the highest screen time tertile as compared to the lowest tertile (odds ratio=1.67, 95% CI:1.13–2.48). Sleep duration was not independently related to the MetS.

    Conclusion

    Highly sedentary individuals and individuals with a high screen time are more likely to have the MetS.


    Purpose/Rationale for the project

    How important are early childhood predictors in the presence of later childhood and early adolescent predictors when examining several late adolescent health and education outcomes? How well do the models work? A sibling design examines a set of time-varying predictors on two health outcomes (ADHD/Conduct Disorders, asthma) between ages 14 and 18 and one education outcome (failure to graduate high school), controlling for a variety measures.

    Methods

    Multi-level modeling of a sample of randomly selected consecutive siblings and twins (n=29,444) born in Manitoba, Canada between 1984 and 1989 allowed comparing family and individual level characteristics. Extensive sensitivity testing involved comparison with a population sample (n=62,820). This analysis uses files from the Population Health Research Data Repository at the Manitoba Centre for Health Policy (MCHP), linked across ministries, which include information on individual level health and education. Census data on neighborhood household income, education and so forth, were also incorporated.

    Results/Next steps

    Although several 0–3 variables were significant for the education outcome, very few were significant for the health outcomes indicating that early childhood variables are not particularly important in predicting late adolescent health and education outcomes. Time-varying predictors in early childhood were markedly less important when including later childhood (4–8) and early adolescent (9–13) health predictor; however, events in early childhood might be important in embedding specific outcomes in later life. Using a life course approach provided an excellent fit for the externalizing mental conditions model (c-statistic=0.826) and a reasonable fit for failure to graduate high school (c-statistic=0.793) and asthma (c-statistic=0.798) models. This paper adds to the growing literature that suggests a stronger focus be put on adolescence as a "second sensitive developmental period" when examining late adolescent and adult outcomes. Future research should be less concerned with birth and early childhood predictors and put a stronger focus on the late childhood and early adolescent time periods, as they bring with them a period of rapid brain maturation that can significantly modify childhood trajectories.


    Introduction

    Prenatal depression is a serious maternal-child health concern; risk factors and health consequences appear more prevalent in Aboriginal communities and ethnic minority groups. However, research on these populations is limited. We examined the following questions: A) How do pregnant Aboriginal women, ethnic minority women and White/Caucasian women compare on levels of depressive symptoms, and on major risk and protective factors? B) Is non-dominant race associated with higher depressive symptoms? C) Through what pathways may race operate to contribute to depressive symptoms?

    Methods

    Data were from the All Our Babies study (n=3354 pregnant women from Alberta recruited between 2008–2011). Depressive symptoms were measured with the Edinburgh Postnatal Depression Scale (EPDS). Descriptive statistics and multivariable regression methods were used to assess the following hypotheses: We hypothesized that Aboriginal and ethnic minority women would have significantly higher mean EPDS score estimates relative to White/Caucasian women. The association between race and EPDS score was hypothesized to be partially mediated by risk factors such as socioeconomic factors, health background factors, discrimination, domestic violence, and psychosocial stress. Potential confounders were age, marital status, and parity. Diet and social support were hypothesized as protective buffers between stress and depressive symptoms.

    Results

    White/Caucasian women appeared to have higher income, better employment and higher social support, and have significantly lower depressive symptoms. The association between race and depressive symptoms appeared partially mediated by socioeconomic factors and psychosocial stress; the attenuation with addition of stress in the model was particularly striking. However, race remained highly statistically significant as a predictor. Social support appeared to moderate the association between stress and depressive symptoms.

    Conclusion

    Mental health disparities between pregnant White/Caucasian women and other women are driven by social disparities. A better understanding of the determinants of prenatal depression in specific populations may facilitate more effective public health and clinical interventions.


    In Southern Ontario, climate change has resulted in an increased occurrence of heat waves, causing heat stress among humans and livestock, with potentially fatal consequences. Heat waves are defined as three consecutive days of temperatures greater than or equal to 32°C. Maps visualizing the distribution of heat stress can provide information about related health risks and insight for control strategies.

    Weather data were collected from weather stations throughout Southern Ontario for dry bulb temperature and dew point temperature. The Dairy Cow Heat Stress Index (HSI) was estimated by averaging the first three days for three heat waves, during 2010, 2011 and 2012. Geostatistical kriging was used to map three-day averages of maximum heat stress over periods involving a heat wave and control periods three weeks prior to and following heat waves.

    Average HSI for each period across Southern Ontario ranged from 55 to 78 during control periods, and from 65 to 84 during heat waves, surpassing levels where mortality is known to increase substantially. Heat stress followed a consistent geographic pattern with the most affected areas in the southern region of the study area, surrounding major metropolitan areas.

    These HSI maps indicate areas which are less optimal for dairy farming within the study boundary. Thus, some areas currently used for dairy farming and at high-risk for heat stress mortality may require heat abatement strategies to sustain dairy cow production as heat waves become more frequent and intense due to climate change.


    Introduction

    Urinary incontinence (UI) negatively impacts quality of life, potentially contributing to depression, urinary tract infection, and renal impairment. Early treatment includes behavioural modification and anticholinergics. Among the general population, ~40% of patients with overactive bladder do not improve with such treatment. Diapers, pads, and intermittent catheterization may also be used. When earlier options fail, surgery is considered. Botox was approved by Health Canada for UI due to neurogenic detrusor overactivity (NDO), resulting from neurogenic bladder associated with multiple sclerosis or subcervical spinal cord injury in adults who had an inadequate response to or are intolerant of anticholinergic medications.

    Botox is a sterile form of botulinum neurotoxin type A, derived from the anaerobic bacterium Clostridium botulinum. It is believed to prevent muscle contractions by temporarily blocking nerve impulses to the bladder muscle.

    Objective

    To evaluate whether the benefit in urinary incontinence patients with neurogenic detrusor overactivity treated with Botox provides good value for Ontario public funding.

    Methods

    A Markov model was used to estimate population outcomes and costs for NDO patients, receiving either Botox or best supportive care (oxybutynin). A Cost Utility Analysis was conducted, using 3 month cycles with a 2 year time horizon (discounted at 5%), plus one-way and probabilistic sensitivity analyses.

    Results

    From the incremental cost-effectiveness ratio (ICER) of $9,710/QALY, Botox is more cost-effective compared to oxybutynin. From the cost-effectiveness acceptability curve (CEAC), at a maximum acceptable ceiling ratio of $50,000/QALY, the probability that Botox is cost-effective compared to oxybutynin is 0.987.

    Conclusion

    Based on ICER and CEAC, Botox appears to be a cost-effective intervention for urinary incontinence due to neurogenic detrusor overactivity compared with anticholinergic.


    Introduction

    Absence of shelter may adversely affect the health of post-disaster populations. When shelters are inadequate or not provided, overcrowded ad hoc communities may form and encourage the spread of infectious disease. Shelter evaluation is therefore necessary to promote post-disaster population health. Even in cases where evaluations are carried out, standardized evaluation indicators do not exist.

    Objectives

    To determine what indicators are being used and which should be used to evaluate shelter assistance following natural disasters.

    Methodology

  •  1. Review: Using systematic review methods, electronic databases and the grey literature were searched for publications that evaluated shelter assistance following natural disasters in developing countries. Indicators used to evaluate shelter assistance were extracted and the most common indicators were identified.

  •  2. Interviews: Based on the indicators extracted, a preliminary evaluation instrument was designed to evaluate shelter assistance. Six shelter experts were interviewed to establish validity of the indicators and evaluation questions. The transcripts from the interviews were analyzed using rigorous qualitative research methodology.

  • Results

  •  1. Review: A total of 1480 indicators were extracted from 181 publications. Indicators most commonly evaluated in the field were: community involvement in shelter planning (n=108), quality and labour of construction (n=107), and scale of assistance provided (n=99).

  •  2. Interviews: Shelter experts felt that the correct indicators had been extracted; however, they expressed the need for more health related indicators. They also felt that the questions evaluating the indicators measured output and should be rephrased to evaluate outcome and impact.

  • Conclusions

    This evaluation instrument, directly based on the most important indicators in the literature and validated by shelter experts, will enable aid agencies to better assess and meet the shelter and health needs of populations impacted by disasters.


    Introduction

    Canadians eat at fast food restaurants more regularly than in the past. Fast foods are higher in energy, saturated fats, and sodium than most other foods, and the portion sizes are often very large. Thus, excessive fast food consumption contributes to an unhealthy diet and a host of adverse health effects.

    Individuals with a low socioeconomic status (SES) and ethnic minorities are at increased risk for excessive fast food consumption. Another determinant of fast food consumption is the density of fast food restaurants in the environment. There is a greater density of fast food restaurants in poorer neighbourhoods and neighbourhoods with larger ethnic minority populations. Disparities may also exist in the extent to which fast food restaurants are associated with fast food consumption. However, this relationship has not been examined in young Canadians.

    Objectives

    To examine the associations between fast food restaurant density in the home neighbourhood and fast food consumption within youth, and to determine whether this association is modified by SES and ethnicity.

    Methods

    Data are from the 2009/2010 Canadian Health Behaviour in School-Aged Children survey, which is a nationally representative sample of 26,078 grade 6–10 students. Frequency of fast food consumption, SES, ethnicity, home postal code, and several confounders were assessed by self-report. Density of chain fast food restaurants within 1 km of each participant's home postal code was determined using computerized geographic information systems (GIS). A multilevel logistic regression model will be used to determine the relationship between neighbourhood fast food restaurant density and excessive fast food consumption (>2 times/week). Regression models will test for SES and ethnicity interactions and will control for several confounding variables.

    Results and conclusion

    To be presented at conference (work in progress).


    Background

    Actual or perceived status, such as housing tenure, may impact on health through stress-inducing social comparisons. Studies of how status change impacts mental health change are rare but important because they are less prone to confounding.

    Methods

    We used data from the British Household Panel Survey to compare psychological distress in local authority renters who opted to buy their home under the UK's Right to Buy (RTB) policy versus those who continued to rent the same (social non-mover (SNM)) or a different (social mover (SM)) local authority property or who bought privately (owner mover (OM)). General Health Questionnaire (GHQ-12) scores before and after any change in tenure and/or address were compared across groups using a difference-in-difference approach.

    Results

    Individuals who moved house (bought or rented) were younger while those who bought (the same or different house) were better off, more likely to be employed, and had higher educational qualifications. Individuals who bought their home (under RTB or privately) had lower distress scores from the outset. Individuals who moved house (bought or rented) experienced a rise in distress prior to moving that was no longer evident 1 year after the move. There was no evidence that changing tenure reduced psychological distress comparing (difference (95% CI)) average GHQ score 2 years preaddress and 1 year postaddress/tenure change in RTB vs SNM, SM, OM: –0.08 (–0.68 to 0.51), 0.16 (–0.70 to 1.01) and –0.17 (–1.28 to 0.94), respectively).

    Conclusions

    Changing tenure under RTB did not, on average, impact psychological distress, suggesting that this status change did not change mental health.


    Background

    Existing research points towards physical and mental health gains from housing improvements, but findings are inconsistent and often not statistically significant. The detailed characteristics and variability of housing improvement works are problematic and studies are often small, not experimental, with short follow-up times.

    Methods

    A quasi-experimental design was used to assess the impact on physical health and mental health (using SF-12v2 Physical and Mental health component summary scales) of four types of housing improvement works—central heating, ‘Secured By Design’ front doors, fabric works, kitchens and bathrooms—both singly and in pairwise combinations. A longitudinal sample of 1933 residents from 15 deprived communities in Glasgow, UK was constructed from surveys carried out in 2006, 2008 and 2011. Sociodemographic characteristics and changes in employment status were taken into account.

    Results

    Fabric works had positive associations with physical health (+2.09, 95% CI 0.13 to 4.04) and mental health (+1.84, 95% CI 0.04 to 3.65) in 1–2 years. Kitchens and bathrooms had a positive association with mental health in 1–2 years (+2.58, 95% CI 0.79 to 4.36). Central heating had a negative association with physical health (–2.21, 95% CI –3.74 to –0.68). New front doors had a positive association with mental health in <1 year (+5.89, 95% CI 0.65 to 11.14) and when provided alongside kitchens and bathrooms (+4.25, 95% CI 1.71 to 6.80). Gaining employment had strong associations with physical health (+7.14, 95% CI 4.72 to 9.55) as well as mental health (+5.50, 95% CI 3.27 to 7.73).

    Conclusions

    Fabric works may provide insulation benefits and visual amenity benefits to residents. Front doors may provide important security benefits in deprived communities. Economic regeneration is important alongside property-led regeneration.


    Background

    Mortality in Scotland is higher than in the rest of west and central Europe and is improving more slowly. Relative to England and Wales, the excess is only partially explained by area deprivation. We tested the extent to which sociodemographic, behavioural, anthropometric and biological factors explain the higher mortality in Scotland compared with England.

    Methods

    Pooled data from 18 nationally representative cohort studies comprising the Health Surveys for England (HSE) and the Scottish Health Survey (SHS). Cox regression analysis was used to quantify the excess mortality risk in Scotland relative to England with adjustment for baseline characteristics.

    Results

    A total of 193 873 participants with a mean of 9.6 years follow-up gave rise to 21 345 deaths. The age-adjusted and sex-adjusted all-cause mortality HR for Scottish respondents compared with English respondents was 1.40 (95% CI 1.34 to 1.47), which attenuated to 1.29 (95% CI 1.23 to 1.36) with the addition of the baseline socioeconomic and behavioural characteristics. Cause-specific mortality HRs attenuated only marginally to 1.43 (95% 1.28 to 1.60) for ischaemic heart disease, 1.37 (95% CI 1.15 to 1.63) for stroke, 1.41 (95% CI 1.30 to 1.53) for all cancers, 3.43 (95% CI 1.85 to 6.36) for illicit drug-related poisoning and 4.64 (95% CI 3.55 to 6.05) for alcohol-related mortality. The excess was greatest among young adults (16–44 years) and was observed across all occupational social classes with the greatest excess in the unskilled group.

    Conclusions

    Only a quarter of the excess mortality among Scottish respondents could be explained by the available baseline risk factors. Greater understanding is required on the lived experience of poverty, the role of social support, and the historical, environmental, cultural and political influences on health in Scotland.


    Objectives

    In the first decade of the 21st century, the Mexican life expectancy changed from a long trend of increase to stagnation. These changes concur with an increase in deaths by homicides that the country experienced in that decade, and an obesity epidemic that had developed over the last decades of the 20th century. We quantify the impact of causes of death on life expectancy from 2000 to 2010.

    Methods

    Two approaches to analyse causes of death are used: the number of life years lost due to each of the causes of death in a given year, and cause-decomposition techniques for comparisons of life expectancy from 2000 to 2010.

    Results

    The apparent stagnation in life expectancy is the result of an increase in deaths by homicides and diabetes mellitus on the one hand, and the positive improvements observed in other causes of death on the other. The negative impact of homicides is particularly observed for ages 15 and 50, and for that of diabetes mellitus at ages above 45 years.

    Conclusions

    There is little basis for optimism regarding the future scenarios of the health of the Mexican population based on the first decade of the 21st century. Male life expectancy would have increased by 2 years if deaths by homicides and diabetes mellitus had been avoided.


    Background

    While studies have attributed the favourable birth outcomes of Mexico-born mothers in the USA to a ‘healthy immigrant effect’ that confers protection to immigrants, a comparison of immigrants with the source population in Mexico has been lacking. We compared preterm delivery (PTD) rates of Mexico-born immigrants who delivered in California with Mexico-born women who delivered in Mexico (WIMX) and with a subgroup who delivered in the five top immigrant sending states in Mexico.

    Methods

    Using 2009 birth records, we selected all live-born singletons of primiparous WIMX (699 129) and immigrants in California (33 251). We examined the unadjusted and adjusted association between place of delivery and any PTD (<37 weeks gestation), including PTD subcategories (early, moderate, late), using relative risks (RR) and 95% CIs. Multivariate models controlled for demographic and health system characteristics.

    Results

    PTD rates were higher among immigrants in California (6.7%) than WIMX (5.8%) and compared to women in the sending states (5.5%). The unadjusted risk of any PTD (RR=1.17 (1.12 to 1.22)), early/moderate PTD (<34 weeks gestation; RR=1.27 (1.18 to 1.38)) and late PTD (34–36 weeks; RR=1.14 (1.08 to 1.19)) was higher for immigrants than for WIMX and remained higher when controlling for age, education and healthcare variables. Birth weight <1500 g was also higher among immigrants (RR=1.27 (1.14 to 1.44)). Similar patterns were observed when comparing women in the sending states.

    Conclusions

    We found no evidence of a ‘healthy immigrant effect’. Further research must assess the comparability of gestational-age data in Mexican and Californian birth certificates.


    Background

    Several hypotheses predict that faltering fetal growth is an antecedent for common non-communicable diseases. This is the first systematic review of an emerging literature linking antenatal fetal measurements to postnatal outcomes.

    Methods

    Electronic databases (OVID, EMBASE and Google Scholar) and cohort study websites were searched in July 2014. Studies were selected which examined associations between antenatal fetal ultrasound measurements and postnatal outcomes. Neonatal outcomes, e.g. premature delivery, were not included.

    Results

    There were 23 papers identified from cohorts in Western countries, including 11 from a single cohort. Four papers reported outcomes in children aged over 6 years. Small, but not large, for gestational age (SGA) was associated with adverse outcomes except for one study where individuals with the lightest or heaviest estimated fetal weight risk were at increased risk for autistic spectrum disorder. The magnitude of associations was modest, e.g. each z score reduction in fetal size was associated with 10–20% increased risk for delayed development or a 1 mm Hg increase in blood pressure. Both growth acceleration and deceleration were both associated with adverse outcomes.

    Conclusions

    There is consistency for antenatal SGA and growth deceleration being associated with adverse outcomes determined in early childhood. Accelerating fetal growth was associated with both advantageous and disadvantageous outcomes, and this is consistent with the concept of predictive adaptive responses where exposure to a postnatal environment which was not anticipated predisposes the fetus to adverse health.


    Background

    Teenage pregnancy is a known social problem which has been previously described using a number of deprivation measures. This study aimed to explore the temporal patterns of teenage pregnancy in Aberdeen, Scotland and to assess the discriminating ability of three measures of socioeconomic status.

    Methods

    This was a population-based study from 1950 to 2010, using data from the Aberdeen Maternity Neonatal Databank (AMND). The main outcome variable was conceptions occurring in women aged less than 20 years. This study used two area-based measures, the Scottish Index of Multiple Deprivation (SIMD) and the Carstairs index, and one individual-based measure the Social Class based on Occupation (SCO). These measures were compared for their association with teenage conceptions using logistic regression models. The models were used to determine receiver operating characteristic (ROC) curves showing the discriminating ability of the measures.

    Results

    There was an overall decline in teenage conceptions over the 60-year period, but an increase in the rate ratio for deprived areas. All the measures of socioeconomic status were highly associated with teenage pregnancy. The adjusted OR of SIMD and teenage conception was 5.72 (95% CI 4.62 to 7.09), which compared the most deprived decile with the least deprived decile. The use of ROC curves showed that socioeconomic measures performed better than chance at determining teenage conceptions (2=21.67, p≤0.0001). They further showed that the SIMD had the largest area under the curve (AUC) with a value of 0.81 (95% CI 0.80 to 0.82), followed by the Carstairs index with an AUC of 0.80 (95% CI 0.78 to 0.80), then by SCO with an AUC of 0.79 (95% CI 0.78 to 0.80).

    Conclusions

    Despite a slight decline in teenage pregnancies over the past decades, there is still an evident association between deprivation and teenage pregnancy. This study shows that all the measures of socioeconomic status were highly associated with teenage pregnancy, with the SIMD having the greatest discriminatory effect.


    Background

    There is increasing interest on whether the current global economic uncertainties have an influence on the population's mental health. In this paper, we examined the association of negative socioeconomic changes, job loss and household income reductions with incident mental disorders. The moderating effect of gender was assessed.

    Methods

    Data come from the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2), a representative population-based, longitudinal study. Individuals with a paid job and without a 12-month mental disorder at baseline were selected and reassessed 3 years later (2007–2009/2010–2012). Substantial household income reductions and not being at a paid job anymore were self-reported at follow-up. Multivariate logistic models were utilised to investigate the association between these negative socioeconomic changes and the incidence of mood, anxiety and substance use Diagnostic and Statistical Manual-IV disorders assessed by the Composite International Diagnostic Interview 3.0.

    Results

    After 3 years, 6% had lost their job, 11% had a substantial household income reduction and 12.2% had developed a mental disorder. Household income reductions increased the risk of any mental disorder (aOR=1.77), particularly the risk of mood (aOR=2.24). Job loss increased the risk of mood disorders (aOR=2.02). Gender modified the relationship: job loss increased the risk of any mental disorder among men (aOR=3.04) and household income reductions did so among women (aOR=2.32).

    Conclusions

    Negative socioeconomic changes occurring within a short time period significantly increased the risk of incident mental disorders, particularly of mood disorders. Effective interventions to alleviate the public mental health impact of negative socioeconomic changes on men and women are needed.


    Background

    Sleep plays an important role in health and varies by social determinants. Little is known, however, about geographic variations in sleep and the role of individual-level and neighbourhood-level factors.

    Methods

    We used a multilevel modelling approach to quantify neighbourhood variation in self-reported sleep duration (very short <5 h; short 5–6.9 h; normative 7–8.9 h; long ≥9 h) among 3591 participants of the Boston Area Community Health Survey. We determined whether geographic variations persisted with control for individual-level demographic, socioeconomic status (SES) and lifestyle factors. We then determined the role of neighbourhood SES (nSES) in geographic variations. Additional models considered individual health factors.

    Results

    Between neighbourhood differences accounted for a substantial portion of total variability in sleep duration. Neighbourhood variation persisted with control for demographics, SES and lifestyle factors. These characteristics accounted for a portion (6–20%) of between-neighbourhood variance in very short, short and long sleep, while nSES accounted for the majority of the remaining between-neighbourhood variances. Low and medium nSES were associated with very short and short sleep (eg, very short sleep OR=2.08; 95% CI 1.38 to 3.14 for low vs high nSES), but not long sleep. Further inclusion of health factors did not appreciably increase the amount of between-neighbourhood variance explained nor did it alter associations.

    Conclusions

    Sleep duration varied by neighbourhood in a diverse urban setting in the northeastern USA. Individual-level demographics, SES and lifestyle factors explained some geographic variability, while nSES explained a substantial amount. Mechanisms associated with nSES should be examined in future studies to help understand and reduce geographic variations in sleep.


    Background

    We aimed to investigate the relationship between potentially modifiable risk factors in middle age and disability after 13 years using the Framingham Offspring Study (FOS). We further aimed to develop a disability risk algorithm to estimate the risk of future disability for those aged 45–65 years.

    Methods

    FOS is a longitudinal study. We used examination 5 (1991–1995; ‘baseline’) and examination 8 (2005–2008; ‘follow-up’). We included participants aged between 45–65 years at ‘baseline’ with complete predictor and outcome measures (n=2031; mean age 53.9 years). Predictors considered were body mass index, smoking, hypertension, diabetes and dyslipidaemia. We used multinomial logistic regression to identify predictors of disability or death.We assessed external validity using Australian data.

    Results

    By examination 8, 156 participants had disability and 198 had died. Disability was associated with smoking (OR (95% CI) 1.81 (1.18 to 2.78)); obesity (2.95 (1.83 to 4.77)); diabetes 1.96 (1.11 to 3.45) and being female (OR 1.67 (1.13 to 2.45). The model performed moderately well in predicting disability and death in an Australian population. Based on our algorithm, a 45-year-old man/woman with the combined risk factors of obesity, diabetes and smoking has similar likelihood of surviving free of disability to a 65-year-old man/woman without any of the same risk factors.

    Conclusions and relevance

    The derived risk algorithm allows, for the first time, quantification of the substantial combined impact on future disability of key modifiable risk factors in mid-life. Here we demonstrated the combined impact of obesity, diabetes and smoking to be similar to 20 years of aging.


    Background

    This paper aims to assess whether 7-year-olds’ physical activity is associated with family and area-level measures of the physical and socioeconomic environments.

    Methods

    We analysed the association of environments with physical activity in 6497 singleton children from the UK Millennium Cohort Study with reliable accelerometer data (≥2 days and ≥10 h/day). Activity levels were assessed as counts per minute; minutes of moderate to vigorous activity (MVPA); and whether meeting recommended guidelines (≥60 min/day MVPA).

    Results

    Higher levels of children's physical activity were associated with households without use of a car and with having a television in a child's bedroom (for counts per minute only). Aspects of the home socioeconomic environment that were associated with more children's physical activity were lone motherhood, lower maternal socioeconomic position and education, family income below 60% national median, and not owning the home. Children's activity levels were higher when parents perceived their neighbourhood as poor for bringing up children and also when families were living in the most deprived areas. Relationships were independent of characteristics such as child's body mass index and ethnic group. When adjusted for physical and socioeconomic correlates, the factors remaining significant in all outcomes were: household car usage and maternal education.

    Conclusions

    Although physical and socioeconomic environments are associated with children’s physical activity, much of the variation appears to be determined by the child's home socioeconomic circumstances rather than the wider environment where they live.


    Background

    Evidence of an association between fine particulate matter (PM2.5) and morbidity is limited in Asia. We used a case-crossover design to evaluate the association between short-term exposure to PM2.5 and emergency ambulance dispatches (as a proxy of acute health outcomes), and to calculate the extent to which a 10 μg/m3 decrease in PM2.5 concentrations would reduce the number of ambulance dispatches.

    Methods

    We used data on emergency ambulance dispatches in Fukuoka City, Japan between 2005 and 2010. Emergency ambulance services are publicly funded and cover the entire city. After excluding ambulance dispatches related to external injuries and pregnancy/childbirth, we analysed data on the remaining 176 123 dispatches. We also collected records of daily concentrations of PM2.5 from one ambient air pollution monitoring station. ORs per 10 μg/m3 increase in PM2.5 were estimated using conditional logistic regression controlled for ambient temperature and relative humidity.

    Results

    During the study period, the average daily concentration of PM2.5 was 20.3 μg/m3. Exposure to PM2.5 was associated with emergency ambulance dispatches in general (lag0–1; OR=1.008 (95% CI 1.002 to 1.014)) and with dispatches due to respiratory diseases (lag0–1; OR=1.027 (1.007 to 1.048)). No association was observed for dispatches due to cardiovascular diseases. We estimated that a 10 μg/m3 decrease in PM2.5 concentrations would have led to approximately 260 (estimated range=70–460) fewer ambulance dispatches in Fukuoka for 2012.

    Conclusions

    Providing further evidence on the short-term health effects of PM2.5 exposure, we found that exposure was associated with an increased number of emergency ambulance dispatches. The effect was, however, relatively small.


    In two 1959 papers, one coauthored, Jerome Cornfield asserts that ‘relative’ measures are more useful for causal inference while ‘absolute’ measures are more useful for public health purposes. In one of these papers (the single-authored one), he asks how epidemiology should respond to the fact that its domain is not a highly ‘articulated’ one—it is not susceptible to being subsumed under general laws. What is the connection between these issues? There has recently been some backlash against ‘risk relativism’, and Charles Poole has recently dismantled the mathematical argument for the first claim. However the problem with ‘Cornfield's Principle’ seems to go much deeper. The whole attempt to partition measures into absolute and relative is fundamentally mistaken. Why, then, has it seemed so appealing? Perhaps one reason is the influence that early education in the physical sciences continues to exert on the way epidemiologists think, and their response to the low articulation of their domain of study.


    Hata J, Kishimoto, H Ninomiya T, et al. Midlife and late-life handgrip strength and risk of causespecific death in a general Japanese population: the Hisayama Study. J Epidemiol Community Health 2014;68:663–8. The description in the statistical analysis section has been corrected to ‘T1: 3.5 to 23.5, T2: 24.0 to 27.5, and T3: 28.0 to 42.0 kg for middle aged women’.


    Although it might be assumed that most public health programmes involving social or behavioural rather than clinical interventions are unlikely to be iatrogenic, it is well established that they can sometimes cause serious harms. However, the assessment of adverse effects remains a neglected topic in evaluations of public health interventions. In this paper, we first argue for the importance of evaluations of public health interventions not only aiming to examine potential harms but also the mechanisms that might underlie these harms so that they might be avoided in the future. Second, we examine empirically whether protocols for the evaluation of public health interventions do examine harmful outcomes and underlying mechanisms and, if so, how. Third, we suggest a new process by which evaluators might develop ‘dark logic models’ to guide the evaluation of potential harms and underlying mechanisms, which includes: theorisation of agency-structure interactions; building comparative understanding across similar interventions via reciprocal and refutational translation; and consultation with local actors to identify how mechanisms might be derailed, leading to harmful consequences. We refer to the evaluation of a youth work intervention which unexpectedly appeared to increase the rate of teenage pregnancy it was aiming to reduce, and apply our proposed process retrospectively to see how this might have strengthened the evaluation. We conclude that the theorisation of dark logic models is critical to prevent replication of harms. It is not intended to replace but rather to inform empirical evaluation.