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Journal Epidemiology and Community Health

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Journal of Epidemiology & Community Health

The impulse to paint comes neither from observation nor from the soul (which is probably blind) but from an encounter: the encounter between painter and model: even if the model is a mountain or a shelf of empty medicine bottles

John Berger, The Shape of a Pocket

How do we transmit epidemiological information? How do we transmit the information to guide public health and community health? Do we have stories to be told? How do we tell the stories about health and disease situation in our population? Do we know how to tell stories about ‘numbers’? Are we using the same graphic designs as those used 30 years ago? Do we consider presentation of the data as important as collecting the information and analysing it? Is that collected information useful to improve the health of our population?

Bridging gaps between epidemiology and community health promotion

Epidemiological information...


Background

Studies, particularly from low-income and middle-income countries, suggest that exposure to smoke from household air pollution (HAP) may be a risk factor for tuberculosis. The primary aim of this study was to quantify the risk of tuberculosis from HAP and explore bias and identify possible causes for heterogeneity in reported effect sizes.

Methods

A systematic review was conducted from original studies. Meta-analysis was performed using a random effects model, with results presented as a pooled effect estimate (EE) with 95% CI. Heterogeneity between studies was assessed.

Results

Twelve studies that considered active tuberculosis and reported adjusted effect sizes were included in the meta-analyses. The overall pooled EE (OR, 95% CI) showed a significant adverse effect (1.43, 1.07 to 1.91) and with significant heterogeneity between studies (I2=70.8%, p<0.001). When considering studies of cases diagnosed microbiologically, the pooled EE approached significance (1.26, 0.95 to 1.68). The pooled EE (OR, 95% CI) was significantly higher among those exposed only to biomass smoke (1.49, 1.08 to 2.05) when compared with the use of kerosene only (0.70, 0.13 to 3.87). Similarly, the pooled EE among women (1.61, 0.73 to 3.57) was greater than when both genders were combined (1.39, 1.01 to 1.92). There was no publication bias (Egger plot, p=0.136). Significant heterogeneity was observed in the diagnostic criteria for tuberculosis (coefficient=0.38, p=0.042).

Conclusions

Biomass smoke is a significant risk factor for active tuberculosis. Most of the studies were small with limited information on measures of HAP.


Background

The seasonal trend of out-of-hospital coronary death (OHCD) and sudden cardiac death has been observed, but whether extreme temperature serves as a risk factor is rarely investigated. We therefore aimed to evaluate the impact of extreme temperatures on OHCDs in China. We obtained death records of 126 925 OHCDs from six large Chinese cities (Harbin, Beijing, Tianjin, Nanjing, Shanghai and Guangzhou) during the period 2009–2011.

Methods

The short-term associations between extreme temperature and OHCDs were analysed with time-series methods in each city, using generalised additive Poisson regression models. We specified distributed lag non-linear models in studying the delayed effects of extreme temperature. We then applied Bayesian hierarchical models to combine the city-specific effect estimates.

Results

The associations between extreme temperature and OHCDs were almost U-shaped or J-shaped. The pooled relative risks (RRs) of extreme cold temperatures over the lags 0–14 days comparing the 1st and 25th centile temperatures were 1.49 (95% posterior interval (PI) 1.26–1.76); the pooled RRs of extreme hot temperatures comparing the 99th and 75th centile temperatures were 1.53 (95% PI 1.27–1.84) for OHCDs. The RRs of extreme temperature on OHCD were higher if the patients with coronary heart disease were old, male and less educated.

Conclusions

This multicity epidemiological study suggested that both extreme cold and hot temperatures posed significant risks on OHCDs, and might have important public health implications for the prevention of OHCD or sudden cardiac death.


Background

Switzerland had the highest life expectancy at 82.8 years among the Organisation for Economic Co-operation and Development (OECD) countries in 2011. Geographical variation of life expectancy and its relation to the socioeconomic position of neighbourhoods are, however, not well understood.

Methods

We analysed the Swiss National Cohort, which linked the 2000 census with mortality records 2000–2008 to estimate life expectancy across neighbourhoods. A neighbourhood index of socioeconomic position (SEP) based on the median rent, education and occupation of household heads and crowding was calculated for 1.3 million overlapping neighbourhoods of 50 households. We used skew-normal regression models, including the index and additionally marital status, education, nationality, religion and occupation to calculate crude and adjusted estimates of life expectancy at age 30 years.

Results

Based on over 4.5 million individuals and over 400 000 deaths, estimates of life expectancy at age 30 in neighbourhoods ranged from 46.9 to 54.2 years in men and from 53.5 to 57.2 years in women. The correlation between life expectancy and neighbourhood SEP was strong (r=0.95 in men and r=0.94 women, both p values <0.0001). In a comparison of the lowest with the highest percentile of neighbourhood SEP, the crude difference in life expectancy from skew-normal regression was 4.5 years in men and 2.5 years in women. The corresponding adjusted differences were 2.8 and 1.9 years, respectively (all p values <0.0001).

Conclusions

Although life expectancy is high in Switzerland, there is substantial geographical variation and life expectancy is strongly associated with the social standing of neighbourhoods.


Background

The objective of this study was to examine the relative contribution of factors explaining ethnic health inequalities (EHI) in poor self-reported health (pSRH) and limiting long-standing illness (LLI) between Health Survey for England (HSE) participants.

Method

Using HSE 2003–2006 data, the odds of reporting pSRH or of LLI in 8573 Bangladeshi, Black African, Black Caribbean, Chinese, Indian, Irish and Pakistani participants was compared with 28 470 White British participants. The effects of demographics, socioeconomic position (SEP), psychosocial variables, community characteristics and health behaviours were assessed using separate regression models.

Results

Compared with White British men, age-adjusted odds (OR, 95% CI) of pSRH were higher among Bangladeshi (2.05, 1.34 to 3.14), Pakistani (1.77, 1.34 to 2.33) and Black Caribbean (1.60, 1.18 to 2.18) men, but these became non-significant following adjustment for SEP and health behaviours. Unlike Black Caribbean men, Black African men exhibited a lower risk of age-adjusted pSRH (0.66, 0.43 to 1.00 (p=0.048)) and LLI (0.45, 0.28 to 0.72), which were significant in every model. Likewise, Chinese men had a lower risk of age-adjusted pSRH (0.51, 0.26 to 1.00 (p=0.048)) and LLI (0.22, 0.10 to 0.48). Except in Black Caribbean women, adjustment for SEP rendered raised age-adjusted associations for pSRH among Pakistani (2.51, 1.99 to 3.17), Bangladeshi (1.85, 1.08 to 3.16), Black Caribbean (1.78, 1.44 to 2.21) and Indian women (1.37, 1.13 to 1.66) insignificant. Adjustment for health behaviours had the largest effect for South Asian women. By contrast, Irish women reported better age-adjusted SRH (0.70, 1.51 to 0.96).

Conclusions

SEP and health behaviours were major contributors explaining EHI. Policies to improve health equity need to monitor these pathways and be informed by them.


Background

In the past two decades, health inequality has persisted or increased in states with comprehensive welfare.

Methods

We conducted a national registry-based repeated cohort study with a 3-year follow-up between 1990 and 2007 in Sweden. Information on all-cause mortality in all working-age Swedish men and women aged between 30 and 64 years was collected. Data were subjected to temporal trend analysis using joinpoint regression to statistically confirm the trajectories observed.

Results

Among men, age-standardised mortality rate decreased by 38.3% from 234.9 to 145 (per 100 000 population) over the whole period in the highest income quintile, whereas the reduction was only 18.3% (from 774.5 to 632.5) in the lowest quintile. Among women, mortality decreased by 40% (from 187.4 to 112.5) in the highest income group, but increased by 12.1% (from 280.2 to 314.2) in the poorest income group. Joinpoint regression identified that the differences in age-standardised mortality between the highest and the lowest income quintiles decreased among men by 18.85 annually between 1990 and 1994 (p trend=0.02), whereas it increased later, with a 2.88 point increase per year (p trend <0.0001). Among women, it continuously increased by 9.26/year (p trend <0.0001). In relative terms, age-adjusted mortality rate ratios showed a continuous increase in both genders.

Conclusions

Income-based inequalities among working-age male and female Swedes have increased since the late 1990s, whereas in absolute terms the increase was less remarkable among men. Structural and behavioural factors explaining this trend, such as the economic recession in the early 1990s, should be studied further.


Background

The evidence on mortality patterns by education in Spain comes from regional areas. This study aimed to estimate these patterns in the whole Spanish population.

Methods

All citizens aged 25 years and over and residing in Spain in 2001 were followed during 7 years to determine their vital status, resulting in a total of 196 470 401 person-years and 2 379 558 deaths. We estimated the age-adjusted total and cause-specific mortality by educational level—primary, lower secondary, upper secondary and university education—and then calculated the relative and absolute measures of inequality in mortality and contribution of the leading causes of death to absolute inequalities.

Results

Except for some cancer sites, the mortality rate for the leading causes of death shows an inverse gradient with educational level. The leading causes of death with the highest relative index of inequality ratios were HIV disease (9.81 in women and 11.61 in men), diabetes in women (4.02) and suicide in men (3.52). The leading causes of death that contribute most to the absolute inequality in mortality are cardiovascular diseases (48.8%), respiratory diseases (9.3%) and diabetes mellitus (8.8%) in women, and cardiovascular diseases (20.8%), respiratory diseases (19.8%) and cancer (19.6%) in men.

Conclusions

Although the causes of death with the strongest gradient in mortality rate are HIV disease in both sexes, diabetes mellitus in women and suicide in men, most of the absolute education-related inequalities in total mortality are due to cardiovascular diseases, respiratory diseases and diabetes mellitus in women and to cardiovascular diseases, respiratory diseases and cancer in men.


Background

Fetal and postnatal growth have been associated with adult blood pressure (BP), but findings about the relative importance of growth at different stages of life on BP are inconsistent.

Methods

The study population comprised 5198 participants from the Northern Finland Birth Cohort 1966 with data on birth weight, height and weight measurements until adolescence, systolic and diastolic BP at 31 years and several covariates. Structural equation modelling was used in the analysis.

Results

Negative direct effects of birth weight on adult systolic BP were observed (standardised regression coefficients: –0.08 (–0.14 to –0.03) in males and –0.04 (–0.09 to 0.01) in females, equalling –1.99 (–3.32 to –0.65) and –1.01 (–2.33 to 0.32) mm Hg/kg, respectively). Immediate postnatal growth was associated with adult BP only indirectly via growth later in life. In contrast, growth from adiposity rebound onwards had large direct, indirect and total effects on adult BP. Current body mass index was the strongest growth-related predictor of adult BP (0.36 (0.30 to 0.41) in males and 0.31 (0.24, 0.37) in females, equalling 1.29 (1.09 to 1.48) and 0.81 (0.63 to 0.99) mm Hg/(kg/m2), respectively).

Conclusions

Our path analytical approach provides evidence for the importance of both fetal growth and postnatal growth, especially from adiposity rebound onwards, in determining adult BP, together with genetic predisposition and behavioural factors.


Background

Although working smoke alarms halve deaths in residential fires, many households do not keep alarms operational. We tested whether theory-based education increases alarm operability.

Methods

Randomised multiarm trial, with a single arm randomly selected for use each day, in low-income neighbourhoods in Maryland, USA. Intervention arms: (1) Full Education combining a health belief module with a social-cognitive theory module that provided hands-on practice installing alarm batteries and using the alarm's hush button; (2) Hands-on Practice social-cognitive module supplemented by typical fire department education; (3) Current Norm receiving typical fire department education only. Four hundred and thirty-six homes recruited through churches or by knocking on doors in 2005–2008. Follow-up visits checked alarm operability in 370 homes (85%) 1–3.5 years after installation. Main outcome measures: number of homes with working alarms defined as alarms with working batteries or hard-wired and number of working alarms per home. Regressions controlled for alarm status preintervention; demographics and beliefs about fire risks and alarm effectiveness.

Results

Homes in the Full Education and Practice arms were more likely to have a functioning smoke alarm at follow-up (OR=2.77, 95% CI 1.09 to 7.03) and had an average of 0.32 more working alarms per home (95% CI 0.09 to 0.56). Working alarms per home rose 16%. Full Education and Practice had similar effectiveness (p=0.97 on both outcome measures).

Conclusions

Without exceeding typical fire department installation time, installers can achieve greater smoke alarm operability. Hands-on practice is key. Two years after installation, for every three homes that received hands-on practice, one had an additional working alarm.

Trial registration number

http://www.clinicaltrials.gov number NCT00139126.


Background

Childhood malnutrition is a major consequence of poverty worldwide. Microcredit programmes—which offer small loans, financial literacy and social support to low-income individuals—are increasingly promoted as a way to improve the health of clients and their families. This study evaluates the hypothesis that longer participation in a microcredit programme is associated with improvements in the health of children of microcredit clients.

Methods

Cross-sectional data were collected in February 2007 from 511 clients of a microcredit organisation in Peru and 596 of their children under 5 years of age. The primary predictor variable was length of participation in the microcredit programme. Outcome variables included height, weight, anaemia, household food security and parent-reported indicators of child health. Multivariate linear and logistic regressions assessed the association between the number of loan cycles and child health outcomes. Pathways through which microcredit may have influenced health outcomes were also explored via mediation analyses.

Results

Longer participation in microcredit was associated with greater household food security and reduced likelihood of childhood anaemia. No significant associations were observed between microcredit participation and incidence of childhood illnesses or anthropometric indicators. Increased consumption of red meat may mediate the association between the number of loan cycles and food security, but not the association with anaemia.

Conclusions

The effects of microcredit on the health of clients’ children are understudied. Exploratory findings from this analysis suggest that microcredit may positively influence child health, and that diet may play a causal role.


Background

A key aim of the Hepatitis C Action Plan for Scotland was to reduce the undiagnosed population through awareness-raising activities, for general practitioners and those at risk, and the introduction of dried blood spot (DBS) sampling in community drug services to overcome barriers to testing. This study evaluates the impact of these activities on testing and diagnosis.

Methods

Data on hepatitis C virus (HCV) testing undertaken between January 1999 and December 2011 in Scotland's four largest health boards were analysed. Segmented regression analysis was used to examine changes in testing following the (1) launch of the Action Plan and (2) introduction of DBS testing.

Results

Between the pre-Action Plan and Action Plan periods, increases were observed in the average number of HCV tests (19 058–29 045), positive tests (1993–2405) and new diagnoses (1221–1367). Since July 2009, 26% of new diagnoses were made in drug services. The trend in the number of positive tests was raised during the Action Plan, compared to pre-Action Plan, particularly in drug services (rate ratio (RR)=1.4, p<0.001) and prisons (RR=1.2, p<0.001); no change was observed in general practice. Following introduction of DBS testing, there was a 3-fold increase in testing (RR=3.5, p<0.001) and 12-fold increase in positives (RR=12.1, p<0.001) in drug services.

Conclusions

The introduction of DBS sampling in community drug services has made an appreciable contribution to efforts to diagnose the HCV-infected population in Scotland. These findings are important to other countries, with injecting-related HCV epidemics, needing to scale-up testing/case-finding initiatives.


Background

The impact of early initiation of diabetes care soon after the identification of hyperglycaemia rather than leaving diabetes untreated on changes in glycaemic control has not been fully clarified. We aimed to quantify the effect of initiating and continuing diabetes care compared with not starting management of diabetes on short-term changes in glycaemic control among the Japanese with newly screening-detected diabetes.

Methods

We retrospectively reviewed data from a nationwide claims database to assess histories of physician-diagnosed diabetes or hyperglycaemia, as well as the use of antidiabetic agents, blood testing for hyperglycaemia or dietary advice among individuals without a history of diabetes care. Changes in glycated haemoglobin (HbA1c) concentrations were evaluated using baseline data and data from a health examination during the following year.

Results

Among 1393 individuals with newly screening-detected diabetes, 62% (n=864) did not initiate diabetes management during the follow-up period; 49.2% (n=425) of the untreated group had poor glycaemic control (HbA1c ≥7%) at the baseline examination. Only 38% (n=529) began diabetes management in medical settings. Individuals who remained untreated had a 1.87 (95% CI 1.38 to 2.52) or 1.63 (1.10 to 2.41) times higher risk of absolute increases in HbA1c ≥0.5% or ≥1%, respectively, compared with the treated patients, a difference that was significant. Making more frequent clinic visits especially after the first visit was dose-dependently associated with improved HbA1c levels compared with no diabetes management.

Conclusions

In comparison with a lack of management of diabetes, immediately initiating and continuing diabetes care after identification of hyperglycaemia in a screening setting would contribute to clinically meaningful, improved glycaemic control in the Japanese.


Background

Job insecurity has been identified as a risk factor for adverse health outcomes. Perceptions of job insecurity steeply increased during Europe's recent economic downturn, which commenced in 2008. The current study assessed whether job insecurity was associated with incident asthma in Germany during this period.

Methods

We used prospective data from the German Socio-Economic Panel for the period 2009–2011 (follow-up rate=77.5%, n=7031). Job insecurity was defined by respondents’ ratings of the probability of losing their job within the next 2 years and asthma as self-reports of physician-diagnosed asthma. Associations between job insecurity in 2009 (continuous z-scores or categorised variables) and incident asthma by 2011 were assessed using multivariable Poisson regression.

Results

The risk of asthma increased significantly by 24% with every one SD increase of the job insecurity variable. In dichotomised analyses, a probability of job loss of ≥50% (vs <50%) was associated with a 61% excess risk of asthma. A trichotomous categorisation of job insecurity confirmed this finding.

Conclusions

This study has shown, for the first time, that perceived job insecurity may increase the risk of new onset asthma. Further prospective studies may examine the generalisability of our findings and determine the underlying mechanisms.


Background

Evidence that passive smoking is a risk factor for cardiovascular disease and selected cancers is largely derived from studies in which this exposure is self-reported. Objective assessment using biochemical techniques may yield a more accurate estimate of risk, although each approach has its strengths and weaknesses. We examined the association of salivary cotinine, a widely utilised biomarker for passive smoking, and self-reported passive smoking in the home, with mortality from all causes, cardiovascular disease and all cancers combined.

Methods

In 1992, investigators on the UK Health and Lifestyle Survey collected data on salivary cotinine, self-reported smoking (direct and passive) and a range of covariates in 3731 men and women aged 25 years and over. Mortality was ascertained using linkage to national death records.

Results

Analyses were based on 2523 individuals (1433 [57%] women) who classified themselves as non-smokers (never and former). Seventeen years of follow-up gave rise to 588 deaths (253 from cardiovascular disease and 146 from cancer). In men, adjusted hazard ratios (HR) for the association between cotinine levels (1.3–15.0 [high] vs ≤0.3 [low] ng/mL) and the various mortality outcomes were weak for total mortality (HR; 95% CI: 1.22; 0.91 to 1.64) and cardiovascular disease (1.25; 0.78 to 1.99) and absent for all cancers combined (1.10; 0.61 to 2.00). Corresponding associations were generally stronger when self-reported passive smoking (some vs none) was the exposure of interest: 1.53 (1.12 to 2.08), 1.88 (1.20 to 2.96) and 1.58 (0.85 to 2.93). The pattern of association for women in both sets of analyses was less consistent.

Conclusions

In men in the present study, compared with our biochemical marker of passive smoking, cotinine, mortality was generally more consistently associated with self-reported passive smoking.


Rise in unemployment following the 2008 economic crisis has been associated with a significant increase in the suicide rates in European and American countries.1 From the fourth trimester of 2008 to the fourth trimester of 2012, Greece witnessed a snowballing 22% recession in gross domestic product at constant prices, accompanied by a soaring unemployment rate that shot up from 8% to 26%. There has been much discussion regarding the effects of the economic crisis on suicides in Greece with early conclusions being put forward quoting temporary leveling-off,2 increase3 or decline4 in suicide rates during the current economic recession. Here, we present recent trends in suicide rates in Greece based on the official data obtained from the Hellenic Statistical Authority.

During the first 2 years of the economic crisis, from 2008 to 2010, suicide mortality remained unaffected, with the age-standardised suicide rate increasing...


Background

To generate unbiased estimates for data collected using respondent-driven sampling (RDS), a number of assumptions need to be met: individuals recruit randomly from their social network and people can accurately report their eligible network size. However, research has shown that these assumptions are often violated.

Methods

This study used baseline data from Crew 450, a longitudinal study of young men who have sex with men in Chicago who were recruited via a modified form of RDS and its network substudy, in which a subset of 175 participants reported details on the composition and characteristics of their social network at either 1 or 2 years postbaseline.

Results

Nearly two-thirds of participants reported giving coupons to at least one alter (64%), and 56.3% believed their alter(s) used the coupons. Frequency of communication, closeness and type of relationship played a major role in determining coupon distribution. Participants whose alters used coupons were significantly less likely to describe the strength of their relationship as ‘not at all close’ (OR=0.08; 95% CI 0.02 to 0.36) compared with ‘very close’ and to communicate weekly (OR=0.20; 95% CI 0.08 to 0.49) or 1–6 times in the past 6 months (OR=0.18; 95% CI 0.06 to 0.59).

Conclusions

Contrary to RDS assumptions, we found that relationship characteristics played a significant role when individuals decided to whom they would give coupons.