Showing papers in "Journal of Epidemiology and Community Health in 1990"

Magnitude and causes of socioeconomic differentials in mortality: further evidence from the Whitehall Study.

Abstract: STUDY OBJECTIVE--The aim was to explore the magnitude and causes of the differences in mortality rates according to socioeconomic position in a cohort of civil servants. DESIGN--This was a prospective observational study of civil servants followed up for 10 years after baseline data collection. SETTING--Civil service offices in London. PARTICIPANTS--11,678 male civil servants were studied, aged 40-64 at baseline screening between 1967 and 1969. Two indices of socioeconomic position were available on these participants--employment grade (categorised into four levels), and ownership of a car. MEASUREMENTS AND MAIN RESULTS--Main outcome measures were all cause and cause specific mortality, with cause of death taken from death certificates coded according to the eighth revision of the ICD. Employment grade and car ownership were independently related to total mortality and to mortality from the major cause groups. Combining the indices further improved definition of mortality risk and the age adjusted relative rate between the highest grade car owners and the lowest grade non-owners of 4.3 is considerably larger than the social class differentials seen in the British population. Factors potentially involved in the production of these mortality differentials were examined. Smoking, plasma cholesterol concentration, blood pressure, and glucose intolerance did not appear to account for them. The pattern of differentials was the same in the group who reported no ill health at baseline as it was in the whole sample, which suggests that health selection associated with frank illness was not a major determinant. The contribution of height, a marker for environmental factors acting in early life, was also investigated. Whereas adjustment for employment grade and car ownership attenuated the association between short stature and mortality, height differences within employment grade and car ownership groups explained little of the differential mortality. CONCLUSION--The use of social class as an index of socioeconomic position leads to underestimation of the association between social factors and mortality, which may be reflected in public health initiatives and priorities. Known risk factors could not be shown to account for the differentials in mortality, although the degree to which this can be explored with single measurements is limited.

Incidence of fractures in a geographically defined population.

Abstract: STUDY OBJECTIVE--The aim was to describe the population based age and sex specific incidence of fractures at different sites in a large English health district. DESIGN--Recording of fractures was accomplished by a specially constructed outpatient index and by record linkage to hospital inpatient information, for the three years surrounding the 1981 census. SETTING--The fracture index was held by the Department of Community Health in Leicester using data from the fracture clinic at the central large district general hospital, supplemented by hospital inpatient data from Trent Region and the two adjoining regions. PARTICIPANTS--The denominator population was the Leicestershire Health Authority resident population. In the three years, 12,711 fractures amongst males and 10,565 amongst females were recorded. MEASUREMENTS AND MAIN RESULTS--The overall estimated annual incidence of fractures was 100 per 10,000 population for males and 81 per 10,000 population for females. Below the age of 55 years all fractures showed a higher incidence amongst males but amongst the over 55s, there was a consistent fall in the male:female incidence ratio with some sites showing a striking female preponderance. The results also show an apparent age specific temporal increase in incidence at certain fracture sites compared with earlier British data, but fracture incidence figures still suggest lower rates in this country than in North America and some Scandinavian countries. CONCLUSIONS--These findings provide population based incidence data on a major public health problem and are consistent with the major determinants of osteoporosis and increase in falls in postmenopausal women. The temporal and geographical variation in fracture incidence remain to be explained.

Cardiovascular diseases in Chinese, Malays, and Indians in Singapore. II. Differences in risk factor levels.

Abstract: STUDY OBJECTIVE--The aim of the study was to examine cardiovascular risk factors to see how these might explain differences in cardiovascular disease mortality among Chinese, Malays, and Indians in the Republic of Singapore. DESIGN--The study was a population based cross sectional survey. Stratified systematic sampling of census districts, reticulated units, and houses was used. The proportions of Malay and Indian households were increased to improve statistical efficiency, since about 75% of the population is Chinese. SETTING--Subjects were recruited from all parts of the Republic of Singapore. SUBJECTS--2143 subjects aged 18 to 69 years were recruited (representing 60.3% of persons approached). There were no differences in response rate between the sexes and ethnic groups. MEASUREMENTS AND MAIN RESULTS--Data on cardiovascular risk factors were collected by questionnaire. Measurements were made of blood pressure, serum cholesterol, low and high density lipoprotein cholesterol, fasting triglycerides and plasma glucose. In males the age adjusted cigarette smoking rate was higher in Malays (53.3%) than in Chinese (37.4%) or Indians (44.5%). In both sexes, Malays had higher age adjusted mean systolic blood pressure: males 124.6 mm Hg v 121.2 mm Hg (Chinese) and 121.2 mm Hg (Indians); females 122.8 mm Hg v 117.3 mm Hg (Chinese) and 118.4 mm Hg (Indians). Serum cholesterol, low density lipoprotein cholesterol and triglyceride showed no ethnic differences. Mean high density lipoprotein cholesterol in males (age adjusted) was lower in Indians (0.69 mmol/litre) than in Chinese (0.87 mmol/litre) and Malays (0.82 mmol/litre); in females the mean value of 0.95 mmol/litre in Indians was lower than in Chinese (1.05 mmol/litre) and Malays (1.03 mmol/litre). Rank prevalence of diabetes for males was Indians (highest), Malays and then Chinese; for females it was Malays, Indians, Chinese. CONCLUSIONS--The higher mortality from ischaemic heart disease found in Indians in Singapore cannot be explained by the major risk factors of cigarette smoking, blood pressure and serum cholesterol; lower high density lipoprotein cholesterol and higher rates of diabetes may be part of the explanation. The higher systolic blood pressures in Malays may explain their higher hypertensive disease mortality.

Bias in case-control studies. A review.

Abstract: consistent terminology has not evolved. Different authors have used different terms when referring to essentially the same type of bias. For example, Kleinbaum et al1 and Rothman2 classify biases into selection bias, information bias and confounding. Sackett offered a more detailed classification, with five major types of sampling bias (eg, admission rate bias, membership bias) and four types of measurement bias (eg, diagnostic suspicion bias, recall bias).3 Feinstein distinguishes, inter alia, among susceptibility bias, performance bias, transfer bias and detection bias.4 Last's Dictionary of epidemiology5 gives definitions of 26 biases but fails to mention many of the terms proposed by other authors. It is not our objective to provide a comprehensive list of biases, or to propose a new, improved taxonomy. Our purpose is to review the most common threats to validity in the design of case-control studies?commonly regarded as being particularly susceptible to bias?and to discuss some useful strategies in dealing with these problems. Certain issues will not be addressed, notably methods of controlling confounding, and the statistical analysis of case control studies.

"Avoidable" mortality and health services: a review of aggregate data studies.

Abstract: STUDY OBJECTIVE--The aim of the study was to review published work reporting mortality from conditions amenable to medical intervention and compare the methods used and the results obtained. SOURCE MATERIAL--Two types of analysis were examined: (1) analyses of time trends, relating decline in mortality from amenable conditions to improvements in medical care (3 papers); (2) analyses of geographical variation, either between or within countries, in which mortality was related to the availability of health care resources and to other factors (8 papers). RESULTS--Time-trend studies have in general shown that mortality from amenable causes has declined faster over the past decades than most other causes of death. Studies of geographical variation have shown that mortality from amenable causes is consistently associated with socioeconomic factors, and that the association with the provision of health care resources is rather weak and inconsistent. CONCLUSIONS--(1) The low levels of mortality from amenable causes which presently prevail in industrialised countries are likely to reflect, at least in part, the increased effectiveness of health services; (2) geographical variation in mortality from amenable causes has not yet been shown to reflect differences in effectiveness of health services; and (3) if geographical variation in avoidable mortality does reflect such differences, they must arise from circumstances other than the level of supply, for example from more specific aspects of health care delivery, and are probably closely related to socioeconomic circumstances. In depth studies at the individual level are now more likely to produce information about factors limiting the effectiveness of health services than further studies of aggregate data.

A case-control study of lung cancer with special reference to the effect of air pollution in Poland.

Abstract: STUDY OBJECTIVE--The aim of the study was to assess the affect of inhaled pollutants on lung cancer risk. DESIGN--The study was a retrospective case-control survey of lung cancer deaths over a six year period (1980-1985). Information on occupation, smoking habits, and residency was collected from next of kin. Classification of exposure to community air pollution was based on measured levels of total suspended particular matter and sulphur dioxide. SETTING--Cases and controls had been resident in the city of Cracow, Poland. PARTICIPANTS--Cases were male (n = 901, questionnaire response rate 70.7%) and female (n = 198, response rate 65.1%) lung cancer deaths; controls were deaths from other causes, excluding other respiratory diseases, and frequency matched by age and sex (males n = 875, response rate 73.5%; females n = 198, response rate 64.0%). MAIN RESULTS--Lung cancer risk was found to depend strongly on total cigarette consumption, on age at starting to smoke, and on time since stopping smoking. Relative risk estimates for occupational exposure in iron and steel foundries or in other industries were significantly increased in males. Relative risk in men for highest air pollution level was 1.48 (95% confidence interval 1.08-2.01), while in women the increase was not significant. The joint action of the risk facts of smoking, occupational exposure, and air pollution was found to fit almost perfectly into a multiplicative model. CONCLUSIONS--Under conditions found in Cracow, air pollution may increase lung cancer risk, acting multiplicatively with known risk factors such as smoking and industrial exposure.

Cardiovascular diseases in Chinese, Malays, and Indians in Singapore. I. Differences in mortality.

Abstract: STUDY OBJECTIVE--The aim of the study was to analyse differences in mortality from the main cardiovascular diseases (ischaemic heart disease, hypertensive disease, and cerebrovascular disease) among Chinese, Malays, and Indians in Singapore. DESIGN--The study was a survey using national death registration data in Singapore for the five years 1980 to 1984. The underlying cause of death, coded according to the ninth revision of the International Classification of Diseases, was taken for the analyses. SETTING--The study was confined to the independent island state of Singapore, population 2.53 million (Chinese 76.5%, Malays 14.8%, Indians 6.4%, Others 2.3%). Death registration is thought to be complete. SUBJECTS--All registered deaths in the age range 30-69 years during the study period were analysed by ethnic group. MEASUREMENT AND MAIN RESULTS--Indians had higher mortality from ischaemic heart disease than the other ethnic groups in both sexes, with age-standardised relative risks of Indian v Chinese (males 3.8, females 3.4), Indian v Malay (males 1.9, females 1.6), and Malay v Chinese (males 2.0, females 2.2). The excess mortality in Indians declined with age. For hypertensive disease Malays had the highest mortality, with age-standardised relative risks of Malay v Chinese (males 3.4, females 4.4), Malay v Indian (males 2.0, females 2.5), and Indian v Chinese (males 1.6, females 1.6). For cerebrovascular disease there was little ethnic difference except for lower rates in Chinese females, with age-standardised relative risks of Malay v Chinese (males 1.1, females 1.9), Malay v Indian (males 1.0, females 1.1), and Indian v Chinese (males 1.1, females 1.7). CONCLUSIONS--There are significant differences in mortality from the three main cardiovascular diseases in the different ethnic groups in Singapore.

Risk factors for cancer of the buccal and labial mucosa in Kerala, southern India.

Abstract: STUDY OBJECTIVE--The aim was to investigate risk factors for cancer of the buccal and labial mucosa in Kerala, southern India. DESIGN--The investigation was a case-control study. SETTING--Regional Cancer Centre, Trivandrum, Kerala, and local teaching hospitals. PARTICIPANTS--Cases were all those registered with oral cancers at the Regional Cancer Centre during 1983 and 1984 (n = 414). Controls (n = 895) were selected from admissions to the cancer centre who were found to have non-malignant conditions, or from patients attending outpatients in teaching hospitals of Trivandrum medical college with non-malignant conditions. MEASUREMENTS AND MAIN RESULTS--The risk in males of the following habits was investigated: pan (betel)-tobacco chewing, bidi and cigarette smoking, drinking alcohol, and taking snuff. Only pan-tobacco chewing was investigated in females as very few indulged in other habits. Among males predisposing effects were found for pan-tobacco chewing (p less than 0.001), bidi smoking (p less than 0.001), drinking alcohol (p less than 0.001), and taking snuff (p less than 0.01). As in males, pan-tobacco chewing also had a predisposing effect in females (p less than 0.001). Duration of use was a better predictor of risk than either daily frequency of use or total lifetime exposure, both for pan-tobacco chewing (especially if the habit started before age 21 years) and bidi smoking. However, there were also very high risks associated with the current occasional use of both factors. Pan-tobacco chewing was the most important risk factor, with relative risk of 13.24 with 31-40 years' use, and 37.75 with greater than 40 years' use among males. Corresponding relative risks in females were 21.30 and 54.93. No effect of cigarette smoking was observed (relative risk 0.64, p greater than 0.1). CONCLUSIONS--A substantial majority of cases of buccal and labial cancers are attributable to chewing pan-tobacco. This has obvious implications for instituting preventive measures.

Postal survey on airborne occupational exposure and respiratory disorders in Norway: causes and consequences of non-response.

Abstract: STUDY OBJECTIVE--The aim was to examine causes for non-response in a community survey, and how non-response influences prevalence estimates of some exposure and disease variables, and associations between the variables. DESIGN--This was a cross sectional questionnaire study with two reminder letters. The questionnaire asked for information on smoking habits, occupational airborne exposure and respiratory disorders. SETTING--A random sample of 4992 subjects from the general population aged 15-70 years of Hordaland County, Norway. MAIN RESULTS--The overall response rate was 90%, with a 63% response to the initial letter. The response rates to the first and second reminder letters were 56% and 36% respectively. In 20% of the non-respondents an uncompleted questionnaire was returned with cause for non-response; in two thirds of these the cause for non-response was that the subject was not resident at the mailing address. A home visit to a random sample of 50 urban non-respondents provided further information on 29 subjects. A wrong address at the Central Population Registry and the subject9s feeling of lack of personal benefit from a postal survey were the major reasons for non-response. Smokers were late respondents and subjects with respiratory disorders tended to be early respondents. CONCLUSION--The main reasons for non-response were a wrong mailing address and a feeling of lack of personal benefit from responding. Using only the initial letter would have changed the estimated prevalence of smokers from 39% to 35%. Otherwise, the estimated prevalence of the exposure and disease variables as well as the associations between them were only slightly changed after including the respondents to the first and second reminder letters.

Health Promotion: Models and Values

Abstract: our experiences of an anonymous postal questionnaire survey which extends their observations. A postal survey was recently undertaken in three further and higher educational establishments in the Tyne Tees area, to ascertain students' AIDS related knowledge, attitudes and behaviour, and opinions on an HIV information pack supported by the Health Education Authority. The survey was administered anonymously for three reasons: first, to gain

Evaluation in health education. A review of progress, possibilities, and problems.

Abstract: Accepted for publication November 1989 The quality of evaluation in health education has been an important obstacle to better interventions, and wider acknowledgement of the importance of health education in improving public health. In the past, the urgency of immediate health problems, the practical orientation of health educators, and the complex nature of evaluation in health education have usually meant that interventions were established on the basis of limited research, and with little or no consideration given to the need to evaluate. Progress in evaluation has been painfully slow. In the past two decades greater attention has been given to the need to evaluate, particularly in the United States, and there has been a corresponding development in the quality and range of examples of well evaluated health education projects and programmes. This paper has been developed on a review of the growing literature on the subject of evaluation in health education, and illustrates key issues with examples from a range of evaluated programmes. A framework for evaluating health education programmes is proposed and suggestions are made for improved health education research.

Variations in lengths of stay and rates of day case surgery: implications for the efficiency of surgical management.

Abstract: Variability in lengths of acute hospital stay and rates of day case surgery is shown to be a continuing pattern which occurs both between and within countries. A model of the determinants of health service activity is presented and the contribution of different factors to the observed variations is assessed. Differences in methods of funding health services are identified as a major determinant of the between country variations, while the within country variations largely reflect the influence of local differences in facilities and services and the organisation of care at a hospital level, as well as the independent effects of differences in clinical practice style. The main rationale for advocating a reduction in length of stay and increased use of day surgery is to increase efficiency by reducing costs per case while maintaining the quality of care. These criteria of costs, clinical outcomes and patient acceptability are examined in relation to day case surgery for an intermediate surgical procedure (inguinal hernia repair) and short stay surgery for cholecystectomy. The precise cost savings are shown to depend on the methods of costing, assumptions made and facilities employed, while factors influencing the outcomes achieved include the criteria of patient selection, the surgical techniques employed, and the adequacy of preoperative communication. Barriers to the more widespread adoption of short stay and day case surgery include practical and organisational constraints on clinical practice at a hospital level, lack of awareness among clinicians as to how far their practices differ from current norms, and clinical barriers raised by surgeons who do not see short stay policies as advantageous. Mechanisms to promote changes in clinical practice styles include independent professional audit, peer review, and involvement of clinicians in budgeting and resource allocation. Assessing quality requires that attention is given to patient acceptability and satisfaction as well as to the monitoring of clinical outcomes.

Acute respiratory illness in Adelaide children: breast feeding modifies the effect of passive smoking.

Abstract: STUDY OBJECTIVE--The aim was to investigate the relation between passive smoking and childhood acute respiratory illness. DESIGN--The study involved an initial postal survey on a random sample of children followed by a case-control study based on the survey. A respiratory illness score was calculated from maternal reports of episodes of illness in the previous 12 months. SETTING--The study was a population survey based on Adelaide metropolitan area in South Australia. PARTICIPANTS--The reference population (n = 13,996) was all live born children registered in South Australia in 1983 whose parents lived in Adelaide metropolitan area. Of these, 4985 families were contacted by post and from 2125 respondents, 1218 (58%) gave consent for home interview. "Cases" were children with respiratory illness scores in the top 20%, controlling for age and time of year (n = 258); "controls" were taken in the bottom 20% (n = 231). MEASUREMENTS AND MAIN RESULTS--Maternal smoking in the first year of life was associated with a doubling in relative odds of respiratory proneness in the child (odds ratio = 2.06, 95% CI 1.25-3.39) after adjustment for confounding by parental history of respiratory illness, other smokers in the home, use of group child care, parent's occupation, and levels of maternal stress and social support. There was no evidence that this association was attributable to differences in the way smoking and non-smoking parents perceived or managed childhood acute respiratory illness. Maternal smoking in the first year, without smoking in pregnancy, was also associated with increased risk of respiratory proneness (odds ratio 1.75, 95% CI 1.03-3.0), showing an effect of passive smoking independent of any in utero effect. There was a strong negative effect modification by breast feeding: relative odds of respiratory proneness with maternal smoking were seven times higher among children who were never breast fed than among those who were breast fed. CONCLUSIONS--The results suggest a relatively small but real effect of passive smoking on childhood acute respiratory illness. Effect modification by breast feeding may be due to a combination of behavioural and biological mechanisms.

Effects of ultrasound, shortwaves, and physical exertion on pregnancy outcome in physiotherapists.

Abstract: STUDY OBJECTIVE--The aim of the study was to investigate whether occupational exposure among physiotherapists is associated with spontaneous abortion or congenital malformation in the offspring. DESIGN--The study was a retrospective nested case-control study, where the pregnancy outcome data were based on the medical registers. SETTING--All registered physiotherapists in Finland who had become pregnant during the study period were included in the study. SUBJECTS--Cases were defined as women who had been treated for spontaneous abortion during 1973-1983 or had delivered a malformed child during 1973-1982. One pregnancy per woman was randomly selected for the study. Three age matched (+/- 18 months) controls were selected for each abortion case and five for each malformation case. The final study population was 204 cases and 483 controls in the spontaneous abortion study, and 46 cases and 187 controls in the congenital malformation study. MEASUREMENTS AND MAIN RESULTS--Exposure information was collected by mailed questionnaires from 1329 women. The response rate was 92% in the spontaneous abortion study, and 89% in the congenital malformation study. Heavy lifting (including patient transfers) was associated significantly with spontaneous abortion. Exposure to ultrasound and shortwaves showed about threefold odds ratios for spontaneous abortions occurring after the 10th week of gestation but in analysis where potential confounding variables were controlled, neither reached statistical significance. Deep heat therapies together, and shortwaves alone, were associated significantly with congenital malformations, but the increase was found in the lower exposure category only. From the potential confounding variables, previous abortion (spontaneous or induced) was associated significantly with spontaneous abortion, and febrile disease in early pregnancy was associated with congenital malformation. CONCLUSION--Physical exertion during early pregnancy seems to be a risk factor for spontaneous abortion. The findings raise suspicion of the potential harmful effect of shortwaves and ultrasound on the pregnancy, but no firm conclusion can be drawn on the bases of these results alone.

Reliability of routine hospital data on poisoning as measures of deliberate self poisoning in adolescents.

Abstract: STUDY OBJECTIVE--The aim was to assess the extent to which routinely collected data on poisoning in adolescents reflected deliberate self poisoning and, in doing, so to assess the accuracy of the diagnostic information on poisoning in the routine hospital abstracts which form the joint data base of Hospital Activity Analysis and the Oxford Record Linkage Study (ORLS). DESIGN--A comparison was made (a) of all eligible ORLS records during the study period with an independent source of records; and (b) of a random sample of records from an independent source with ORLS. SETTING--Records of patients admitted to the John Radcliffe Hospital in Oxford were used. SUBJECTS--These were (a) patients aged 10-20 years between 1980 and 1985 with a diagnosis of poisoning by drugs and medicaments in ORLS; (b) a random sample of 500 patients selected from the self harm monitoring files at the hospital (12 patients were not eligible for inclusion in ORLS and were therefore excluded from the rest of the study). MEASUREMENTS AND MAIN RESULTS--The recorded diagnosis was compared on the records selected from the two files. Of the 1123 events of poisoning identified in ORLS, 1081 (96.3%) were correctly coded as poisoning and 1065 (95%) of these were deliberate self poisoning. Of the 488 cases from the monitoring files, 467 (95.7%) of all cases had a correct diagnosis of injury or poisoning on the ORLS file. Of the 453 poisoning cases 436 (96.2%) were correctly recorded in ORLS. CONCLUSIONS--Deliberate self poisoning in adolescents can be identified through routinely collected hospital statistics. A very high percentage of the diagnostic information on poisoning in ORLS files is correctly recorded.

Race, consanguinity and social features in Birmingham babies: a basis for prospective study.

Abstract: STUDY OBJECTIVE--The aim of the study was to investigate the influence of consanguinity on children's health. DESIGN--The study is a prospective survey from birth to five years of a cohort of babies born in a multiracial community. This report details the initial findings on consanguinity. SETTING--Participating families live predominantly in three health districts of Birmingham, and were recruited in three local maternity hospitals. PARTICIPANTS--Babies of 2432 European mothers, 509 Afro-Caribbean mothers, 625 Indian mothers, 956 Pakistani mothers, and 216 Bangladeshi mothers have been enrolled in the study. Eighty mothers refused to participate. MEASUREMENTS AND RESULTS--Sociodemographic information was obtained using a structured questionnaire administered at interview. Interview data were supplemented with obstetric information from the medical records. The highest prevalence of parental consanguinity was in Pakistani Muslims (69%), whereas in Muslims from other countries it was 23%, and it was less than 1% in non-Muslims. In the majority of consanguineous Muslim pedigrees the degree of inbreeding was greater than that for first cousin parents. CONCLUSIONS--This prospective study will allow an assessment to be made about any ill health in childhood arising from parental consanguinity, about whether screening programmes are indicated for particular autosomal recessive diseases, and about whether premarital health education might be beneficial. The study has also documented parental ages in different races and this, together with the levels of parental consanguinity in all races, will be useful in genetic methods for assessing the frequency of recessive genes, the possibility of genetic heterogeneity, and whether or not parental age effect exists for new mutations of specific genetic disorders.

Use of survey data and small area statistics to assess the link between individual morbidity and neighbourhood deprivation.

Abstract: STUDY OBJECTIVE--The aim of the study was to examine the relationship between sociogeographic factors and health, using a particular social indicator of neighbourhood deprivation. DESIGN--The study analysed the relationship between health problems (reported by randomly selected respondents to a household survey) and an area social indicator for the neighbourhoods where the respondents lived (based on census data). The area social indicator tested was the underprivileged areas indicator developed by the St Mary's Hospital Department of General Practice, London. Generalised linear interactive modelling with a logistic model was used to test the strength of the relationship between social indicators and morbidity, and to calculate the probability of reporting illness or consultations for survey respondents living in different types of area. SETTING--The study population was derived from three London health districts and their corresponding census enumeration districts. PARTICIPANTS--Responses were obtained from 738 households drawn from the local taxation evaluation list (66% of those sampled), and 1384 persons over 16 participated in the survey (94% of eligible adults in households surveyed). Of these, 1221 provided complete data on health problems. The survey population was considered representative of the general population in the areas studied since its characteristics were similar to those reported for the population as a whole in the 1981 census. RESULTS--Within different age and sex groups, those living in very deprived areas, with high underprivileged area scores, were more likely to consult their doctor and to report various indicators of poor health than those living in privileged areas, with low underprivileged area scores. CONCLUSIONS--The underprivileged areas index may provide a useful surrogate indicator to estimate morbidity and use of general practitioner services in small areas. It is likely to be most effective in areas where sociodemographic profiles of the local population are highly contrasting.

Air pollution and cause specific mortality in Athens.

Abstract: STUDY OBJECTIVE--The aim was to investigate the reported association between air pollution and cause specific mortality in the city of Athens. DESIGN--Cause specific mortality was contrasted between 199 d with high values of air pollution and 2*199 comparison days with low pollution, matched in a 1:2 ratio on the basis of various confounding factors. Statistical analysis was done, taking matching into account, using analysis of variance for randomised blocks. SETTING--The study was confined to the city of Athens, using data obtained between 1975 and 1982. PARTICIPANTS--Cause of death was assessed in all 25 138 persons dying in the 3*199 d studied. MEASUREMENTS AND MAIN RESULTS--Causes of death were evaluated blindly by two medically qualified investigators on the basis of information in the death certificates. Mortality was generally higher during the high pollution days but the difference was more pronounced and more significant for respiratory conditions, even though the number of deaths in this category was smaller than the corresponding numbers in the other two categories examined (cardiac and "other" deaths). CONCLUSION--The results show that the short term association between air pollution and overall mortality in Athens is likely to be causal, since it is particularly evident with respect to respiratory conditions, for which a biological air pollution link is more plausible.

Is there a fetal effect with low to moderate alcohol use before or during pregnancy

Abstract: STUDY OBJECTIVE--The aim was to investigate the effect of low or moderate alcohol consumption upon fetal outcome. DESIGN--This was a prospective randomised cohort study with mother and infant follow-up sample stratified on level of maternal alcohol intake. SETTING--A large maternity hospital in Western Australia. PARTICIPANTS--2002 randomly selected pregnant women were recruited over a 3 year period for questionnaire survey (19 mothers refused participation). From 665 women in a stratified subsample selected on the basis of prepregnancy alcohol consumption, 605 newborns were available for study. INVESTIGATION AND MAIN RESULTS--All 2002 women completed a comprehensive questionnaire on demographic, lifestyle (including diet), health, and obstetric factors. Of the 665 mothers who were followed through pregnancy, 605 liveborns were available at birth for measurement and detailed clinical evaluation. Low to moderate prepregnancy maternal alcohol intake was not associated with any untoward effect upon weight, length, head circumference at birth, or clinical well-being as indicated by Apgar score, respiratory distress syndrome, and overall clinical state. Other factors, particularly nicotine, were of much greater importance. CONCLUSIONS--This study fails to show any significant relationship between low to moderate prepregnancy maternal alcohol intake and newborn clinical status. The outcome suggests that cautionary advice to pregnant women warning that any alcohol taken during pregnancy is potentially harmful to the fetus is inaccurate and therefore probably counterproductive.

Head injuries in accident and emergency departments. How different are children from adults

Abstract: STUDY OBJECTIVE--The aim of the study was to examine the differences between child and adult patients attending accident and emergency departments after recent head injuries. DESIGN AND SETTING--A retrospective survey based on existing case records from 23 Scottish accident and emergency departments for 1985 was compared with prospective data from one hospital over 9 months in 1984. PATIENTS--3838 children under 15 and 4775 adults attended hospital with head injuries during the period analysed. MAIN RESULTS--Only 9% of children and 20% of adults had evidence of brain damage (altered consciousness on arrival, or history of altered consciousness with amnesia on arrival). Scalp lacerations were recorded in approximately 40% of both children and adults, more commonly in those without brain damage. Fewer children than adults had a skull x ray; in both age groups x rays were more often done if there was evidence of brain damage, headache, or vomiting, and less often when there was a scalp laceration. Only 11% of children were admitted compared with 20% of adults. Admission rates per 100,000 population per year were 4011 for children and 1473 for adults (1967 overall); admission rates for brain damage were 290 for children and 341 for adults (331 overall). CONCLUSIONS--These are the first population based estimates of frequency of head injuries presenting at accident and emergency departments, analysed by age, gender and cause of injury. They should be of value when planning services for the head injured.

Pattern of childbearing and mortality in married women--a national prospective study from Norway.

Abstract: STUDY OBJECTIVE--The aim of the study was to investigate the effect of different pattern of childbearing on total mortality. DESIGN--A cohort study with all currently married women aged 25 years or more at the Norwegian census in 1970 with follow up to the end of 1985. Information on childbearing was obtained by questionnaires collected by enumerators. Follow up on death was found by a linkage based on the unique Norwegian identification number, between census information and the death register in the Central Bureau of Statistics. SETTING--The study was a national population survey. PARTICIPANTS--A total of 822,593 women with 11.5 million years of follow up and 112,023 deaths. MAIN RESULTS--Nulliparous women had higher mortality than parous women in all age groups. Parity showed a weak association with increasing mortality among high parous women. Lowest mortality was found for parous women with 2-4 children and a late first and last birth, adjusted for socioeconomic group by level of women's education. CONCLUSION--The findings indicate that postponed childbearing may benefit the health of women.

Risk of death from cardiovascular disease and chronic bronchitis determined by place of birth in England and Wales.

Abstract: STUDY OBJECTIVE--The aim of the study was to examine the relation between place of birth within England and Wales and cause of death. DESIGN--The study was a population survey using data provided by the Office of Population Censuses and Surveys which, for a trial period between 1969 and 1972, coded place of birth on death certificates. SETTING--The survey involved almost 2 million people who died in England and Wales between April 1969 and December 1972. MAIN RESULTS--Persons born in northern counties and industrial towns, and in Wales, had increased risk of ischaemic heart disease and stroke, which persisted whether or not they had moved to other parts of the country. A low risk of cardiovascular disease among people born in and around London went with them when they moved. People born in cities and large towns had an increased and persisting risk of chronic bronchitis. CONCLUSIONS--These findings are evidence that past geographical differences in fetal and infant growth, and in exposure to respiratory infection in early childhood, partly determine today's differences in adult death rates.

Alcohol use in pregnancy, craniofacial features, and fetal growth.

Abstract: STUDY OBJECTIVE--The aim was to study the relationship between the level of alcohol consumption in pregnancy and craniofacial characteristics of the neonate. DESIGN--This was a prospective survey of a sample of pregnant women, stratified on prepregnancy level of alcohol consumption. SETTING--The study was carried out at the public antenatal clinic of Roubaix maternity hospital. PARTICIPANTS--During an eight month period, 684 women (89% of those eligible) were interviewed in a standardised way at their first antenatal clinic visit. Of these, all who were suspected of being alcoholic or heavy drinkers (at least 21 drinks per week) were selected for follow up, as was a subsample of light (0-6 drinks per week) and moderate (7-20 drinks per week) drinkers. Of 347 women selected in this way, 202 had their infants assessed by a standardised morphological examination. MEASUREMENTS AND AND MAIN RESULTS--Suggestive craniofacial characteristics of the infants, present either in isolation or in association with growth retardation ("fetal alcohol effects"), were compared in relation to maternal alcohol consumption (alcoholic 12%; heavy drinking 24%; moderate drinking 28%; light drinking 36%). No differences were found between light and moderate drinkers. Infants born to alcoholics had a greater number of craniofacial characteristics and the proportion with features compatible with fetal alcohol effects was higher. There was a similar trend for infants of heavy drinkers. Infants of heavy drinkers who had decreased their alcohol consumption during pregnancy had fewer craniofacial features. Infants of heavy smokers were also found to have increased numbers of craniofacial characteristics. CONCLUSIONS--Craniofacial morphology could be a sensitive indicator of alcohol exposure in utero. Altered morphology is usually considered specific for alcohol exposure, but the relation observed with smoking needs further exploration.

Incidence of cancer in Bradford Asians.

Abstract: STUDY OBJECTIVE--The aim of the study was to investigate the incidence of cancer in Asians living in Bradford. DESIGN--Cancer registrations were obtained from the Yorkshire Regional Cancer Registry for the six year period 1979-1984. Registrations relating to persons of Asian background were extracted using forenames and surnames. Data were analysed by disease category and age and sex specific incidence rates were calculated. These were compared with expected incidence rates for the non-Asian population and with rates for the Indian subcontinent derived from the Bombay Cancer Registry. SETTING--Data collection was confined to the Bradford Metropolitan District, population 449,897 (1981). SUBJECTS--The Asians studied originated from Pakistan (65%), India (28%), Bangladesh (4%), and East Africa (3%). The total Asian population of the Bradford Metropolitan District was approximately 45,000. MAIN RESULTS--Over the study period there were 178 Asian cancer registrations. The overall standardised registration ratio was 53.7 for males (100 cases, 95% confidence interval 43-64), and 43.5 for females (78 cases, 95% CI 34-53). The standardised registration ratios for cancer of the hypopharynx in males and gall bladder in females were significantly raised. There was a particularly low incidence of cancer of the stomach, large bowel, lung, skin, and bladder in males, and of skin, breast, cervix (in situ), and ovary in females. The analyses suggested that lung and breast cancer incidence may be increasing towards the non-Asian level. In situ cancer of cervix in Asians shows no evidence of the high rates found in younger non-Asian age groups. CONCLUSIONS--Lower incidence of many cancers in Asians may be due to lower exposure to major risk factors. Demographic change resulting in increased exposure to these risk factors can be expected to result in an increase in cancer incidence in Asians.

Models for forecasting hospital bed requirements in the acute sector.

Abstract: STUDY OBJECTIVE--The aim was to evaluate the current approach to forecasting hospital bed requirements. DESIGN--The study was a time series and regression analysis. The time series for mean duration of stay for general surgery in the age group 15-44 years (1969-1982) was used in the evaluation of different methods of forecasting future values of mean duration of stay and its subsequent use in the formation of hospital bed requirements. RESULTS--It has been suggested that the simple trend fitting approach suffers from model specification error and imposes unjustified restrictions on the data. Time series approach (Box-Jenkins method) was shown to be a more appropriate way of modelling the data. CONCLUSION--The simple trend fitting approach is inferior to the time series approach in modelling hospital bed requirements.

Geographical variation in cancer patient survival in Finland: chance, confounding, or effect of treatment?

Abstract: STUDY OBJECTIVE--The aim was to determine whether survival of cancer patients in Finland varies with their place of residence, and if so, what proportion of the variation might be due to health services rather than to confounding variables. DESIGN--Patients with breast and prostatic cancer diagnosed in Finland between 1970 and 1981 were classified by place of residence (from 21 hospital districts), and area specific 5 year relative survival rates were estimated. SETTING--This was a population based survey of the whole of Finland. PATIENTS--16,754 cases of breast cancer and 9483 cases of prostatic cancer were identified. Of these, 0.5% of breast cancers and 4.1% of prostatic cancers were excluded because diagnosis was based only on necropsy findings or because the only information available was from the death certificate. MEASUREMENTS AND MAIN RESULTS--There was a large variation in rates, ranging from 59% to 76% for breast cancer, and from 30% to 65% for prostatic cancer. However, after accounting for age of patient and extent of disease, the standardised differences for prostatic cancer closely followed random distribution, indicating equal results of treatment in different areas. For breast cancer there was more variation than expected by chance and patients resident in any of the university central hospital districts with modern radiotherapy equipment survived better than other patients. CONCLUSIONS--There is little indication that large variations in crude mortality rates from these two cancers in different parts of Finland are due to inequalities of medical care, though a small effect on breast cancer survival which might be care related was shown.

Childhood morbidity and adulthood ill health.

Abstract: STUDY OBJECTIVE--The aim of the study was to investigate the relationship between the state of health in childhood and ill health in early adult life. DESIGN--The study used data collected as part of the National Child Development Study and related health at 7 years of age to that at 23. A wide range of information on child health in the cohort was available, which was used to construct a broader measure of health status than selected diagnostic categories. SETTING--The survey population was nationwide. PARTICIPANTS--The study population included all children born in the week 3-9 March 1958. They were followed up at 7, 11, 16, and 23 years. Of the target population of 17,733 births, 12,537 (76%) were retraced and interviewed at 23. MEASUREMENTS AND MAIN RESULTS--Children at age 7 were allocated to 13 morbidity groups; 20% of children had reported no ill-health apart from the common infectious diseases, but 10% were included in four or more of the morbidity groups. Children with no reported morbidity retained their health advantage into early adulthood: ratios of observed to expected ill health for four of the five indices examined at age 23 were all significantly below one (self rated health 0.81, asthma and/or wheezy bronchitis 0.63, allergies 0.79, emotional health 0.75). Children with more morbidity at age 7 had higher ratios of ill health in adulthood. A chronic condition in childhood was associated not only with excess morbidity in the short term but also with a poor health rating in early adult life (ratio = 1.38). Morbidity was significantly increased for most of the adulthood indices among children with asthma and/or wheezy bronchitis. However most ill health in young adulthood occurred in study members with a relatively healthy childhood. CONCLUSIONS--Although the state of health in childhood has long term implications, it does not form a substantial contribution to ill health in early adult life.

Cerebral palsy: social class differences in prevalence in relation to birthweight and severity of disability.

Abstract: STUDY OBJECTIVE--The aim of the study was to examine the possible influence of social class on the prevalence of cerebral palsy. DESIGN--The study was a retrospective population based survey of all cases of cerebral palsy. SETTING--The study involved all cases of cerebral palsy born to residents in the Eastern Health Board area of the Republic of Ireland between 1976 and 1981 inclusive. PATIENTS--There were 289 cases of cerebral palsy during the study period. Thirty one were excluded because they were attributable to postneonatal brain damage, leaving 258 children for analysis. Cases with uncertain diagnosis were excluded. MAIN RESULTS--There was a clear social class gradient in the overall prevalence of cerebral palsy, also evident in the individual syndromes of hemiplegia and diplegia. No such gradient was detected in the other syndromes, either singly or in combination. Among cases of low birthweight (less than or equal to 2500 g), the prevalence was the same across the social class range after allowing for the increased low birthweight rate in the lower social class categories. Among normal birthweight cases there was a strong positive association with decreasing social class. Intrauterine growth retardation seemed to be a factor in cerebral palsy in all social class groups. Prevalence of cerebral palsy severe enough to prevent walking by the fourth birthday, but not of cases ambulant by this age, increased with socioeconomic disadvantage. CONCLUSIONS--The clear social class gradients in hemiplegia and diplegia suggest that environmental factors play an important role in the aetiology of these syndromes, but there was no evidence of a contribution from this type of factor in the remaining types of cerebral palsy.

Handicaps associated with incontinence: implications for management.

Abstract: STUDY OBJECTIVE--The aim was to explore the relationship between dementia, impairment of mobility, and incontinence and the implications for management. DESIGN--The study was a survey of a sample population drawn from a general practice register. SETTING--A large general practice serving the entire population of Melton Mowbray, Leicestershire, UK. PARTICIPANTS--Of 1329 persons aged 75 or over, 1203 (90%) took part in the survey. Of non-responders, refusers accounted for 5%, deaths 4%, and failure to trace 1%. MEASUREMENTS AND MAIN RESULTS--12% of the population complained of incontinence. No more than 24% of these cases were demented. Dementia and isolated locomotor problems were significantly associated with presence of incontinence, but 31% of cases were completely free of either problem. A minimum estimate of 56% of cases of incontinence were considered to be due to local physical disorders of the bladder. CONCLUSIONS--A search for local disorders causing incontinence is important, and more attention should be paid to the management of locomotor problems and possibly depression in the relief of incontinence.