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Journal Epidemiology and Community Health

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Journal of Epidemiology & Community Health

Accurate prediction allows us to plan. This prediction capability has been made possible through the understanding of epidemiological principles of causation, while relying on statistical tools, or models, using an unbiased sample from a representative population in order to make an accurate claim. In the research work of Grau et al, an attempt had been undertaken to validate a prediction tool to estimate the disease burden, or risk, of coronary heart disease (CHD) should certain and known modifiable risk factors be altered given a public health initiative aimed at disease reduction.

The risk factors identified include those that are non-modifiable (age, gender) and those that may be modified (smoking, hypertension, diabetes, blood pressure). These had been originally defined in the Framingham Heart Study with 10-year risk of CHD contingent on the role of each of these factors. Risk of disease had been determined via a multivariate regression analysis to...


This article argues that in public health research, standard approaches to knowledge translation are based on (1) an invalid model of the relationship between research knowledge and policy and (2) an oversimplified concept of ‘knowledge’. Standard approaches tend to focus primarily on communicating research knowledge to policy makers in order to increase the impact of research on policy making.1 2 However, the process of policy making is complex and political (in the broad sense); it is not a neutral or technical exercise that simply requires greater use of scientific evidence to improve decision making. Neither is research knowledge neutral or wholly technical; it is produced in social contexts and also operates in societies in uneven ways. There is significant socio-political literature which has analysed the relationship between knowledge and policy, including how they are embedded in social and political contexts, but this is rarely drawn...


Background

The use of validated multivariate cardiovascular predictive models in a population setting is of interest for public health policy makers. We aimed to validate the estimations of the CASSANDRA model (coronary heart disease (CHD) incidence and CHD risk distribution), considering the population changes in age, sex and CHD risk factors prevalence in a 10-year period.

Methods

We compared the projected CHD incidence estimated with CASSANDRA with that observed in the Girona Heart Registry (REGICOR) for 1995–2004 and 2000–2009 in the population of Girona (Spain) aged 35–74 years. We used official age and sex distributions for this population. Baseline cardiovascular risk factors prevalence and the distribution of cardiovascular risk were obtained from three cross-sectional studies performed in 1995, 2000 and 2005. To validate the future distribution of cardiovascular risk, we tested the yearly CHD risk variance over the study period.

Results

No significant differences between the estimated and observed annual CHD incidence per 100 000 men were found in 1995–2004 (CASSANDRA=457.8 and REGICOR=420.3, incidence rate ratio (IRR) (95% CI)=0.92 (0.89 to 0.96)) and in 2000–2009 (441.4 and 409.6, respectively, IRR=0.93 (0.90 to 0.96)). However, overpredictions of 18% and 22%, respectively, were observed in women (198.8 and 160.4, IRR=0.82 (0.77 to 0.86), and 197.1 and 152.8, IRR=0.78 (0.74 to 0.83), respectively). No significant differences were found in the CHD risk variance in the three different cross-sectional studies.

Conclusions

The CASSANDRA model produces valid estimates, particularly in men, of the future burden of disease and in the distribution of cardiovascular risk in individuals aged 35–74 years.


Background

The main strategy for alleviating heart disease has been to target individuals and encourage them to change their health behaviours. Although important, emphasis on individuals has diverted focus and responsibility away from neighbourhood characteristics, which also strongly influence people's behaviours. Although a growing body of research has repeatedly demonstrated strong associations between neighbourhood characteristics and cardiovascular health, it has typically focused on negative neighbourhood characteristics. Only a few studies have examined the potential health enhancing effects of positive neighbourhood characteristics, such as perceived neighbourhood social cohesion.

Methods

Using multiple logistic regression models, we tested whether higher perceived neighbourhood social cohesion was associated with lower incidence of myocardial infarction. Prospective data from the Health and Retirement Study—a nationally representative panel study of American adults over the age of 50—were used to analyse 5276 participants with no history of heart disease. Respondents were tracked for 4 years and analyses adjusted for relevant sociodemographic, behavioural, biological and psychosocial factors.

Results

In a model that adjusted for age, gender, race, marital status, education and total wealth, each SD increase in perceived neighbourhood social cohesion was associated with a 22% reduced odds of myocardial infarction (OR=0.78, 95% CI 0.63 to 0.94. The association between perceived neighbourhood social cohesion and myocardial infarction remained even after adjusting for behavioural, biological and psychosocial covariates.

Conclusions

Higher perceived neighbourhood social cohesion may have a protective effect against myocardial infarction.


Background

Few studies have examined the association between the food environment and adiposity in early childhood, a critical time for obesity prevention. The objective of this study was to examine the longitudinal association between neighbourhood food environment and adiposity among low-income preschool-aged children in a major metropolitan region in the USA.

Methods

The study sample was 32 172 low-income preschool-aged children in Los Angeles County who had repeated weight and height measurements collected between ages 2 and 5 years through a federal nutrition assistance programme. We conducted multilevel longitudinal analyses to examine how spatial densities of healthy and unhealthy retail food outlets in the children's neighbourhoods were related to adiposity, as measured by weight-for-height z-score (WHZ), while controlling for neighbourhood-level income and education, family income, maternal education, and child's gender and race/ethnicity.

Results

Density of healthy food outlets was associated with mean WHZ at age 3 in a non-linear fashion, with mean WHZ being lowest for those exposed to approximately 0.7 healthy food outlets per square mile and higher for lesser and greater densities. Density of unhealthy food outlets was not associated with child WHZ.

Conclusions

We found a non-linear relationship between WHZ and density of healthy food outlets. Research aiming to understand the sociobehavioural mechanisms by which the retail food environment influences early childhood obesity development is complex and must consider contextual settings.


Background

Clustered obese parents and children are prevalent, but there is little knowledge about whether and how child–parent resemblance varies by sociodemographic groups.

Methods

This paper used nationally representative data from the National Health and Nutrition Examination Survey III (NHANES: 1988–1994). We matched 4958 parents with 6765 children aged 2–16 years old for whom we had complete data on body mass index (BMI), overweight and obesity status. Correlation coefficients and statistics between parents’ and children's BMI and body weight status were calculated for different sociodemographic groups. Multivariate linear and logistic regression models were fit to study the child–parent resemblance and socioeconomic and demographic differences in the resemblance.

Results

The child–parent correlation coefficients for BMI were greater in Caucasians than in minorities and greater in groups with higher socioeconomic status. The mother–child resemblance in BMI was negatively associated with child age (p<0.001). The mother–daughter resemblance in overweight was significantly lower in non-Hispanic blacks (OR=0.53, 95% CI (0.36 to 0.78)) and Mexican Americans (OR=0.58, 95% CI (0.36 to 0.93)) than in Caucasians. The father–child resemblance in overweight was significantly lower in high school graduates compared with those with less-than-high-school-graduate fathers (OR=0.53, 95% CI (0.37 to 0.77) for father–son dyads and OR=0.69, 95% CI (0.50 to 0.96) for father–daughter dyads). Similar results were found for parent–child resemblance in obesity.

Conclusions

Child–parent resemblance in body weight status exists across sociodemographic groups in the USA, but it varies by demographics and socioeconomic status.


Background

A healthy diet is important to promote health and well-being while preventing chronic disease. However, the monetary cost of consuming such a diet can be a perceived barrier. This study will investigate the cost of consuming a range of dietary patterns.

Methods

A cross-sectional analysis, where cost of diet was assigned to dietary intakes recorded using a Food Frequency Questionnaire. A mean daily diet cost was calculated for seven data-driven dietary patterns. These dietary patterns were given a healthiness score according to how well they comply with the UK Department of Health's Eatwell Plate guidelines. This study involved ~35 000 women recruited in the 1990s into the UK Women's Cohort Study.

Results

A significant positive association was observed between diet cost and healthiness of the diet (p for trend >0.001). The healthiest dietary pattern was double the price of the least healthy, £6.63/day and £3.29/day, respectively. Dietary diversity, described by the patterns, was also shown to be associated with increased cost. Those with higher education and a professional or managerial occupation were more likely to consume a healthier diet.

Conclusions

A healthy diet is more expensive to the consumer than a less healthy one. In order to promote health through diet and reduce potential inequalities in health, it seems sensible that healthier food choices should be made more accessible to all.


Background and aims

Studies on the role of labour market position and change in alcohol use during midlife are scarce and their results are inconclusive mainly due to their failure to define comprehensive and distinct labour market groups and the short periods of time studied. In this study we used different activity categories for men and women to examine alcohol use trajectories in midlife covering a period of 17 years.

Methods

Using data from four sweeps of the National Child Development Study covering ages 33–50 (N=9960), we used multilevel growth models to study the association between labour market categories and longitudinal changes in weekly units of alcohol consumed.

Results

In the reference group of full-time employed men alcohol trajectory decreased over the follow-up period (β=–0.14; 95% CI –0.18 to –0.11) while in the reference group of employed women it increased (β=0.06; 95% CI 0.04 to 0.08). Men and women who were ‘mainly sick’ had significantly steeper declines in their alcohol consumption trajectory. Women who became employed after being homemakers had the steepest increase in alcohol use (β=0.05; 95% CI 0.01 to 0.09).

Conclusions

Being employed is a strong determinant of alcohol use for men and women in midlife, making the workplace a good target for health promotion programmes and policies aimed at reducing alcohol use. Caution is needed when interpreting the health effects of alcohol consumption as low alcohol users may have previously been heavy drinkers.


Background

Immigrants may be at a higher risk of adverse drug reactions, in that poor language proficiency reduces individuals understanding of drug label instructions. Additionally, there are reports of severe or fatal toxicity due to CYP2D6 ultrarapid hepatic metabolism of codeine to morphine among some ethnic groups, especially those from Eastern Africa.

Methods

Between 2002 and 2012 we conducted a population-based cohort study among residents of Ontario, Canada. We used administrative health databases that linked immigrants and Canadian-born individuals to both prescription medication use and emergency department visits and hospital admissions. The primary composite outcome was the risk of drug overdose or all-cause mortality within 30 days of codeine prescription, comparing patients from various world regions to Canadian-born individuals. A secondary analysis stratified by codeine dose and ability to speak English and/or French.

Results

There were 553 504 individuals exclusively prescribed codeine. Relative to an incidence rate of 57.1/100 000 person-days among Canadian-born codeine recipients, those who migrated from various world regions were at a lower risk of drug overdose or death. For example, Eastern Africans had an adjusted HR of 0.60 (95% CI 0.31 to 1.17) on controlling for potential confounders such as age, sex, income and physician visits. Patients unable to speak English or French who were prescribed codeine were at a lower risk of the composite outcome relative to those proficient in either language (adjusted HR 0.63, 95% CI 0.54 to 0.74).

Interpretation

Overdose and death following the institution of codeine therapy are not more commonly observed among immigrants from world regions with a high prevalence of ultrarapid CYP2D6 status relative to those born in Canada. Lower proficiency in English or French also did not appear to heighten the risk.


Background

Unemployment and economic inactivity are associated with worse mental health in the general population, but there is limited understanding of whether these relationships are different for those persons with mental or physical disabilities. The aim of this study was to assess whether there were differences in mental health by labour force status among persons with and without disabilities.

Method

Over eight annual waves of the Household, Income and Labour Dynamics in Australia (HILDA) survey, a total of 2379 people with disabilities and 11 417 people without disabilities were identified. Mental health using the Mental Component Summary (MCS) from the Short Form 36 was modelled as a function of labour force status using fixed-effects regression models to control for time invariant confounding. Differences between those with and without disabilities were assessed by including an interaction term in regression models.

Results

After finding evidence of effect modification, regression models were stratified by disability status. After adjustment, unemployment and economic inactivity were associated with a –1.85 (95% CI –2.96 to –0.73, p=0.001) and –2.66 (95% CI –3.46 to –1.86, p<0.001) reduction in scores of the MCS among those with a disability. For those without a disability, there were smaller declines associated with unemployment (–0.57, 95% CI –1.02 to –0.12, p=0.013) and economic inactivity (–0.34, 95% CI –0.64 to 0.05, p=0.022).

Conclusions

These results suggest a greater reduction in mental health for those persons with disabilities who were unemployed or economically inactive than those who were employed. This highlights the value of employment for people with disabilities.


Background

The late-2000s financial crisis had a severe impact on the national economies on a global scale. In Europe, the Baltic countries were among those most affected with more than a 20% decrease in per capita gross domestic product in 2008–2009. In this study, we explored the effects of economic recession on self-rated health in Estonia and Lithuania using Finland, a neighbouring Nordic welfare state, as a point of reference.

Methods

Nationally representative cross-sectional data for Estonia (n=10 966), Lithuania (n=7249) and Finland (n=11 602) for 2004–2010 were analysed for changes in age-standardised prevalence rates of less-than-good self-rated health and changes in health inequalities using logistic regression analysis.

Results

The prevalence of less-than-good self-rated health increased slightly (albeit not statistically significantly) in all countries during 2008–2010. This was in sharp contrast to the statistically significant decline in the prevalence of less-than-good health in 2004–2008 in Estonia and Lithuania. Health disparities were larger in Estonia and Lithuania when compared to Finland, but decreased in 2008–2010 (in men only). In Finland, both the prevalence of less-than-good health and health disparities remained fairly stable throughout the period.

Conclusions

Despite the rapid economic downturn, the short-term health effects in Estonia and Lithuania did not differ from those in Finland, although the recession years marked the end of the previous positive trend in self-rated health. The reduction in health disparities during the recession indicates that different socioeconomic groups were affected disproportionately; however, the reasons for this require further research.


Background

It was supposed that associations of wealth and health might be higher after retirement than in the economically active periods of life, but no comparisons were available. Most studies on wealth were based on net worth, a measure combining several elements of wealth into an index. We examined associations between different elements of wealth and health by comparing retired women and men with economically active ones.

Method

Data were drawn from the German Socio-Economic Panel, a nationwide longitudinal survey project. Two waves (2002 and 2007) included indicators of wealth in addition to household income and education. Wealth was not depicted by an index. Instead, debts, property of life insurances, home ownership and assets were considered separately with their associations with self-rated health. Two data sets were used to examine whether the results were occasional, or whether they can be replicated.

Results

Associations of income and education emerged in respondents in their active periods of life. In most cases indicators of wealth were associated with subjective health. In retired respondents home ownership was the only indicator yielding consistent associations with health, but their sizes turned out as rather moderate.

Conclusions

Contrary to expectation, the associations of wealth and health were inconsistent in the retired study population. These results were obtained in a country with national pension schemes, and it has to be examined whether the findings can be generalised to other countries. The inconsistent findings of indicators of wealth are calling the utility of net worth into question.


Background

Population-based data are paramount to investigate the long-term course of diabetes, for planning in healthcare and to evaluate the cost-effectiveness of primary prevention. We analysed regional differences in the incidence of self-reported type 2 diabetes mellitus in Germany.

Methods

Data of participants (baseline age 45–74 years) from five regional population-based studies conducted between 1997 and 2010 were included (mean follow-up 2.2–7.1 years). The incidence of self-reported type 2 diabetes mellitus at follow-up was compared. The incidence rates per 1000 person-years (95% CI) and the cumulative incidence (95% CI) from regional studies were directly standardised to the German population (31 December 2007) and weighted by inverse probability weights for losses to follow-up.

Results

Of 8787 participants, 521 (5.9%) developed type 2 diabetes mellitus corresponding to an incidence rate of 11.8/1000 person-years (95% CI 10.8 to 12.9). The regional incidence was highest in the East and lowest in the South of Germany with 16.9 (95% CI 13.3 to 21.8) vs 9.3 (95% CI 7.4 to 11.1)/1000 person-years, respectively. The incidence increased with age and was higher in men than in women.

Conclusions

The incidence of self-reported type 2 diabetes mellitus shows regional differences within Germany. Prevention measures need to consider sex-specific differences and probably can be more efficiently introduced toward those regions in need.


Epidemiological studies evaluate multiple exposures, but the extent of multiplicity often remains non-transparent when results are reported. There is extensive debate in the literature on whether multiplicity should be adjusted for in the design, analysis, and reporting of most epidemiological studies, and, if so, how this should be done. The challenges become more acute in an era where the number of exposures that can be studied (the exposome) can be very large. Here, we argue that it can be very insightful to visualize and describe the extent of multiplicity by reporting the number of effective exposures for each category of exposures being assessed, and to describe the distribution of correlation between exposures and/or between exposures and outcomes in epidemiological datasets. The results of new proposed associations can be placed in the context of this background information. An association can be assigned to a percentile of magnitude of effect based on the distribution of effects seen in the field. We offer an example of how such information can be routinely presented in an epidemiological study/dataset using data on 530 exposure and demographic variables classified in 32 categories in the National Health and Nutrition Examination Survey (NHANES). Effects that survive multiplicity considerations and that are large may be prioritized for further scrutiny.


Background

Community-based rehabilitation (CBR) programmes have been described as highly effective means of promoting the rights and opportunities of persons with disabilities (PwD). Although CBR is often the main way in which PwD in low-income and middle-income countries access rehabilitation services, there is little literature providing rigorous evaluation of their impact on people's well-being.

Methods

Data were collected in the Mandya and Ramanagar districts (Karnataka state, India), between December 2009 and May 2010. In total 2540 PwD were interviewed using stratified random sampling: 1919 CBR beneficiaries (who joined the programme between 1997 and 2009) and 621 persons who were living in villages not covered by the programme. We controlled for the systematic differences between people joining and not joining the programme using the propensity score matching method controlling for covariates at individual and village level. We evaluated the impact of the programme on the subgroups of PwD who are disadvantaged on the dimensions of interest: access to pensions, use of aid appliances, access to paid jobs and improvement in personal-practical autonomy after 4 and 7 years of joining the CBR.

Results

We observed a positive and significant impact of the programme on access to services, rights and opportunities of PwD. The results indicate that compared with the control group access to pensions and allowances, aid appliances, access to paid jobs and personal-practical autonomy increased by 29.7%, 9.4%, 12.3% and 36.2%, respectively, after 7 years.

Conclusions

The CBR programme analysed has a positive impact on access to services and the well-being of PwD who are particularly deprived on outcomes of interest.


Hansen SF, Gee D. Adequate and Anticipatory research on the potential hazards of emerging technologies: a case of myopia and inertia? J Epidemiol Community Health 2014;68:890-5. The affiliation of the second author, Dr David Gee, has changed to Science, Policy and Emerging Issues, European Environment Agency, Copenhagen (retired).


Cooper R, Benzeval, M Deary IJ, et al. Grip strength across the life course: normative data from twelve British studies. J Epidemiol Community Health 2014;68:A4. The order of the authors is incorrect. The first two authors should be RM Dodds and HE Syddall.