Showing papers in "Journal of Epidemiology and Community Health in 2000"

Sick but yet at work. An empirical study of sickness presenteeism

Abstract: STUDY OBJECTIVE The study is an empirical investigation of sickness presenteeism in relation to occupation, irreplaceability, ill health, sickness absenteeism, personal income, and slimmed down organisation. DESIGN Cross sectional design. SETTING Swedish workforce. PARTICIPANTS The study group comprised a stratified subsample of 3801 employed persons working at the time of the survey, interviewed by telephone in conjunction with Statistics Sweden9s labour market surveys of August and September 1997. The response rate was 87 per cent. MAIN RESULTS A third of the persons in the total material reported that they had gone to work two or more times during the preceding year despite the feeling that, in the light of their perceived state of health, they should have taken sick leave. The highest presenteeism is largely to be found in the care and welfare and education sectors (nursing and midwifery professionals, registered nurses, nursing home aides, compulsory school teachers and preschool/primary educationalists. All these groups work in sectors that have faced personnel cutbacks during the 1990s). The risk ratio (odds ratio (OR)) for sickness presenteeism in the group that has to re-do work remaining after a period of absence through sickness is 2.29 (95% CI 1.79, 2.93). High proportions of persons with upper back/neck pain and fatigue/slightly depressed are among those with high presenteeism (p CONCLUSIONS Members of occupational groups whose everyday tasks are to provide care or welfare services, or teach or instruct, have a substantially increased risk of being at work when sick. The link between difficulties in replacement or finding a stand in and sickness presenteeism is confirmed by study results. The categories with high sickness presenteeism experience symptoms more often than those without presenteeism. The most common combination is low monthly income, high sickness absenteeism and high sickness presenteeism.

Determinants of leisure time physical activity in rural compared with urban older and ethnically diverse women in the United States

Abstract: STUDY OBJECTIVE Determinants of leisure time physical activity (LTPA) in rural middle aged and older women of diverse racial and ethnic groups are not well understood. This study examined: (1) urban-rural differences in LTPA by sociodemographic factors, (2) urban-rural differences in LTPA determinants, and (3) the pattern of relations between LTPA determinants and LTPA. DESIGN A modified version of the sampling plan of the Behavioral Risk Factor Surveillance Survey (BRFSS) was used. Zip codes were selected with 20% or more of each of the following race/ethnic groups: African American, American Indian/Alaskan Native (AI/AN), and Hispanic. A comparison group of white women were also surveyed using standard BRFSS techniques. PARTICIPANTS Rural (n=1242) and urban (n=1096) women aged 40 years and older from the US Women9s Determinants Study. MAIN RESULTS Rural women, especially Southern and less educated women, were more sedentary than urban women. Rural women reported more personal barriers to LTPA, cited caregiving duties as their top barrier (compared with lack of time for urban women), and had greater body mass indices. Rural women were less likely to report sidewalks, streetlights, high crime, access to facilities, and frequently seeing others exercise in their neighbourhood. Multivariate correlates of sedentary behaviour in rural women were AI/AN and African American race, older age, less education, lack of enjoyable scenery, not frequently seeing others exercise, greater barriers, and less social support (p CONCLUSIONS Rural and urban women seem to face different barriers and enablers to LTPA, and have a different pattern of determinants, thus providing useful information for designing more targeted interventions.

Diabetes prevalence and socioeconomic status: a population based study showing increased prevalence of type 2 diabetes mellitus in deprived areas

Abstract: OBJECTIVE To establish the relation between socioeconomic status and the age-sex specific prevalence of type 1 and type 2 diabetes mellitus. The hypothesis was that prevalence of type 2 diabetes would be inversely related to socioeconomic status but there would be no association with the prevalence of type 1 diabetes and socioeconomic status. SETTING Middlesbrough and East Cleveland, United Kingdom, district population 287 157. PATIENTS 4313 persons with diabetes identified from primary care and hospital records. RESULTS The overall age adjusted prevalence was 15.60 per 1000 population. There was a significant trend between the prevalence of type 2 diabetes and quintile of deprivation score in men and women (χ 2 for linear trend, p CONCLUSION These data confirm an inverse association between socioeconomic status and the prevalence of type 2 diabetes in the middle years of life. This finding suggests that exposure to factors that are implicated in the causation of diabetes is more common in deprived areas.

Marital status and suicide in the National Longitudinal Mortality Study

Abstract: OBJECTIVES—The purpose of the study was to examine the effect of marital status on the risk of suicide, using a large nationally representative sample. A related objective was to investigate the association between marital status and suicide by sex. METHODS—Cox proportional hazards regression models were applied to data from the National Longitudinal Mortality Study, based on the 1979-1989 follow up. In estimating the effect of marital status, adjustments were made for age, sex, race, education, family income, and region of residence. RESULTS—For the entire sample, higher risks of suicide were found in divorced than in married persons. Divorced and separated persons were over twice as likely to commit suicide as married persons (RR=2.08, 95% confidence intervals (95% CI) 1.58, 2.72). Being single or widowed had no significant effect on suicide risk. When data were stratified by sex, it was observed that the risk of suicide among divorced men was over twice that of married men (RR=2.38, CI 1.77, 3.20). Among women, however, there were no statistically significant differentials in the risk of suicide by marital status categories. CONCLUSIONS—Marital status, especially divorce, has strong net effect on mortality from suicide, but only among men. The study showed that in epidemiological research on suicide, more accurate results would be obtained if samples are stratified on the basis of key demographic or social characteristics. The study further observed that failure to control for relevant socioeconomic variables or combining men and women in the same models could produce misleading results. Keywords: suicide; marital status; socioeconomic status; effect modification

Validity of rapid estimates of household wealth and income for health surveys in rural Africa

Abstract: STUDY OBJECTIVE To test the validity of proxy measures of household wealth and income that can be readily implemented in health surveys in rural Africa. DESIGN Data are drawn from four different integrated household surveys. The assumptions underlying the choice of wealth proxy are described, and correlations with the true value are assessed in two different settings. The expenditure proxy is developed and then tested for replicability in two independent datasets representing the same population. SETTING Rural areas of Mali, Malawi, and Cote d9Ivoire (two national surveys). PARTICIPANTS Random sample of rural households in each setting (n=275, 707, 910, and 856, respectively). MAIN RESULTS In both Mali and Malawi, the wealth proxy correlated highly ( r ⩾0.74) with the more complex monetary value method. For rural areas of Cote d9Ivoire, it was possible to generate a list of just 10 expenditure items, the values of which when summed correlated highly with expenditures on all items combined ( r =0.74, development dataset, r =0.72, validation dataset). Total household expenditure is an accepted alternative to household income in developing country settings. CONCLUSIONS It is feasible to approximate both household wealth and expenditures in rural African settings without dramatically lengthening questionnaires that have a primary focus on health outcomes.

How do types of employment relate to health indicators? Findings from the Second European Survey on Working Conditions

Abstract: Study objective—To investigate the associations of various types of employment with six self reported health indicators, taking into account the part played by demographic variables, individual working conditions and four ecological indicators at the country level. Design—Cross sectional survey (structured interview) of a sample of the active population of 15 European countries aged 15 years or over. Main independent variables were nine types of employment categorised as follows: small employers, full and part time permanent employees, full and part time fixed term employees, full and part time sole traders and full and part time temporary contracts. Main outcome measures were three self reported health related outcomes (job satisfaction, health related absenteeism, and stress) and three self reported health problems (overall fatigue, backache, and muscular pains). Logistic regression and multilevel models were used in the analyses. Setting—15 countries of the European Union. Participants—15 146 employed persons aged 15 or over.

The predictive value of self assessed general, physical, and mental health on functional decline and mortality in older adults

Abstract: Objective—To examine the extent to which older people’s self assessments of general health, physical health, and mental health predict functional decline and mortality. Design—The study uses population-based secondary data from the US Longitudinal Study of Aging (LSOA). Participants—A total of 7527 persons aged 70 years or above living in the community. Methods—Eight diVerent measures on self reported general, physical, and mental health were used. Change in functional status was measured using a composite index of ADLs and IADLs over a period of six years. Duration of survival was calculated over a period of seven years. Adjusting for age and gender, multiple logistic regression was used in analysing functional decline, and Cox proportional hazard model, for mortality. Then all of the self assessed health measures were incorporated into the final model—controlling for baseline sociodemographic characteristics, functional status, disease/ conditions, and use of health and social services—to assess the independent contribution of each measure in predicting future health outcomes. Main results—Overall, older people’s self assessed general, physical, and mental health were predictive of functional decline and mortality. In multivariate analyses, older people who assessed their global health, self care ability, and physical activity less favourably were more likely to experience poor health outcomes. Gender disparity, however, was observed with poor global health aVecting functional decline in men only. Self care ability was predictive of functioning in women only, whereas it was predictive of mortality in men only. Conclusions—Self assessed global health, as well as, specific dimensions of health act as significant, independent predictors of functioning and mortality in a community dwelling older people. (J Epidemiol Community Health 2000;54:123‐129)

Ecological effects in multi-level studies

Abstract: Multi-level research that attempts to describe ecological effects in themselves (for example, the effect on individual health from living in deprived communities), while also including individual level effects (for example, the effect of personal socioeconomic disadvantage), is now prominent in research on the socioeconomic determinants of health and disease. Such research often involves the application of advanced statistical multi-level methods. It is hypothesised that such research is at risk of reaching beyond an epidemiological understanding of what constitutes an ecological effect, and what sources of error may be influencing any observed ecological effect. This paper aims to present such an epidemiological understanding. Three basic types of ecological effect are described: a direct cross level effect (for example, living in a deprived community directly affects individual personal health), cross level effect modification (for example, living in a deprived community modifies the effect of individual socioeconomic status on individual health), and an indirect cross level effect (for example, living in a deprived community increases the risk of smoking, which in turn affects individual health). Sources of error and weaknesses in study design that may affect estimates of ecological effects include: a lack of variation in the ecological exposure (and health outcome) in the available data; not allowing for intraclass correlation; selection bias; confounding at both the ecological and individual level; misclassification of variables; misclassification of units of analysis and assignment of individuals to those units; model mis-specification; and multicollinearity. Identification of ecological effects requires the minimisation of these sources of error, and a study design that captures sufficient variation in the ecological exposure of interest.

Time series analysis of air pollution and mortality: effects by cause, age and socioeconomic status

Abstract: OBJECTIVE—To investigate the association between outdoor air pollution and mortality in Sao Paulo, Brazil. DESIGN—Time series study METHODS—All causes, respiratory and cardiovascular mortality were analysed and the role of age and socioeconomic status in modifying associations between mortality and air pollution were investigated. Models used Poisson regression and included terms for temporal patterns, meteorology, and autocorrelation. MAIN RESULTS—All causes all ages mortality showed much smaller associations with air pollution than mortality for specific causes and age groups. In the elderly, a 3-4% increase in daily deaths for all causes and for cardiovascular diseases was associated with an increase in fine particulate matter and in sulphur dioxide from the 10th to the 90th percentile. For respiratory deaths the increase in mortality was higher (6%). Cardiovascular deaths were additionally associated with levels of carbon monoxide (4% increase in daily deaths). The associations between air pollutants and mortality in children under 5 years of age were not statistically significant. There was a significant trend of increasing risk of death according to age with effects most evident for subjects over 65 years old. The effect of air pollution was also larger in areas of higher socioeconomic level. CONCLUSIONS—These results show further evidence of an association between air pollution and mortality but of smaller magnitude than found in other similar studies. In addition, it seems that older age groups are at a higher risk of mortality associated with air pollution. Such complexity should be taken into account in health risk assessment based on time series studies. Keywords: air pollution; mortality; socioeconomic status

Socioeconomic status and injury mortality: individual and neighbourhood determinants

Abstract: STUDY OBJECTIVE This study examined both individual and neighbourhood correlates of injury mortality to better understand the contribution of socioeconomic status to cause specific injury mortality. Of particular interest was whether neighbourhood effects remained after adjusting for individual demographic characteristics and socioeconomic status. DESIGN Census tract data (measuring small area socioeconomic status, racial concentration, residential stability, urbanisation, and family structure) was merged with the National Health Interview Survey (NHIS) and a file that links the respondents to subsequent follow up of vital status and cause of death data. Cox proportional hazards models were specified to determine individual and neighbourhood effects on homicide, suicide, motor vehicle deaths, and other external causes. Variances are adjusted for the clustered sample design of the NHIS. SETTING United States, 1987–1994, with follow up to the end of 1995. PARTICIPANTS From a sample of 472 364 persons ages 18–64, there were 1195 injury related deaths over the follow up period. MAIN RESULTS Individual level effects were generally robust to the inclusion of neighbourhood level variables in the models. Neighbourhood characteristics had independent effects on the outcome even after adjustment for individual variability. For example, there was approximately a twofold increased risk of homicide associated with living in a neighborhood characterised by low socioeconomic status, after adjusting for individual demographic and socioeconomic characteristics. CONCLUSIONS Social inequalities in injury mortality exist for both persons and places. Policies or interventions aimed at preventing or controlling injuries should take into account not only the socioeconomic characteristics of people but also of the places in which they live.

Effect of change in the psychosocial work environment on sickness absence: a seven year follow up of initially healthy employees

Abstract: Study objective—To investigate the impact of changes in psychosocial work environment on subsequent sickness absence. Design—Analysis of questionnaire and sickness absence data collected in three time periods: 1990‐1991, before the recession; 1993, worst slump during the recession; and 1993‐1997, a period after changes. Setting—Raisio, a town in south western Finland, during and after a period of economic decline. Participants—530 municipal employees (138 men, 392 women) working during 1990‐1997 who had no medically certified sick leaves in 1991. Mean length of follow up was 6.7 years. Main results—After adjustment for the pre-recession levels,the changes in the job characteristics of the workers during the recession predicted their subsequent sick leaves. Lowered job control caused a 1.30 (95% CI = 1.19, 1.41) times higher risk of sick leave than an increase in job control. The corresponding figures in relation to decreased social support and increased job demands were 1.30 (95% CI = 1.20, 1.41) and 1.10 (95% CI = 1.03, 1.17), respectively. In some cases there was an interaction with socioeconomic status, changes in the job characteristics being stronger predictors of sick leaves for employees with a high income than for the others. The highest risks of sick leave (ranging from 1.40 to 1.90) were associated with combined eVects related to poor levels of and negative changes in job control, job demands and social support. Conclusion—Negative changes in psychosocial work environment have adverse eVects on the health of employees. Those working in an unfavourable psychosocial environment before changes are at greatest risk. (J Epidemiol Community Health 2000;54:484‐493)

Height and risk of death among men and women: aetiological implications of associations with cardiorespiratory disease and cancer mortality

Abstract: OBJECTIVES—Height is inversely associated with cardiovascular disease mortality risk and has shown variable associations with cancer incidence and mortality. The interpretation of findings from previous studies has been constrained by data limitations. Associations between height and specific causes of death were investigated in a large general population cohort of men and women from the West of Scotland. DESIGN—Prospective observational study. SETTING—Renfrew and Paisley, in the West of Scotland. SUBJECTS—7052 men and 8354 women aged 45-64 were recruited into a study in Renfrew and Paisley, in the West of Scotland, between 1972 and 1976. Detailed assessments of cardiovascular disease risk factors, morbidity and socioeconomic circumstances were made at baseline. MAIN OUTCOME MEASURES—Deaths during 20 years of follow up classified into specific causes. RESULTS—Over the follow up period 3347 men and 2638 women died. Height is inversely associated with all cause, coronary heart disease, stroke, and respiratory disease mortality among men and women. Adjustment for socioeconomic position and cardiovascular risk factors had little influence on these associations. Height is strongly associated with forced expiratory volume in one second (FEV1) and adjustment for FEV1 considerably attenuated the association between height and cardiorespiratory mortality. Smoking related cancer mortality is not associated with height. The risk of deaths from cancer unrelated to smoking tended to increase with height, particularly for haematopoietic, colorectal and prostate cancers. Stomach cancer mortality was inversely associated with height. Adjustment for socioeconomic position had little influence on these associations. CONCLUSION—Height serves partly as an indicator of socioeconomic circumstances and nutritional status in childhood and this may underlie the inverse associations between height and adulthood cardiorespiratory mortality. Much of the association between height and cardiorespiratory mortality was accounted for by lung function, which is also partly determined by exposures acting in childhood. The inverse association between height and stomach cancer mortality probably reflects Helicobacter pylori infection in childhood resulting in—or being associated with—shorter height. The positive associations between height and several cancers unrelated to smoking could reflect the influence of calorie intake during childhood on the risk of these cancers. Keywords: height; cancer; cardiorespiratory disease

Relation of weight gain and weight loss on subsequent diabetes risk in overweight adults

Abstract: STUDY OBJECTIVE To determine whether long term weight gain and weight loss are associated with subsequent risk of type 2 diabetes in overweight, non-diabetic adults. DESIGN Prospective cohort. Baseline overweight was defined as BMI⩾27.3 for women and BMI⩾27.8 for men. Annual weight change (kg/year) over 10 years was calculated using measured weight at subjects9 baseline and first follow up examinations. In the 10 years after measurement of weight change, incident cases of diabetes were ascertained by self report, hospital discharge records, and death certificates. SETTING Community. PARTICIPANTS 1929 overweight, non-diabetic adults. MAIN RESULTS Incident diabetes was ascertained in 251 subjects. Age adjusted cumulative incidence increased from 9.6% for BMI CONCLUSIONS Weight gain was associated with substantially increased risk of diabetes among overweight adults, and even modest weight loss was associated with significantly reduced diabetes risk. Minor weight reductions may have major beneficial effects on subsequent diabetes risk in overweight adults at high risk of developing diabetes.

Social capital—Is it a good investment strategy for public health?

Abstract: In a recent commentary in the Journal , Fran Baum raised the question, whether social capital is “good for your health?”1While the concept of social capital has had a meteoric rise in political, economic and public health rhetoric it remains to be fully defined and understood.2 3 Despite this lack of clarity, there has been the release of government and World Bank discussion papers, the staging of theme conferences and the growing use of the terms social capital, social cohesion, and civil society—all being promoted as beacons to guide public health research and practice—even though no clear, shared definition exists about what the concepts actually mean. In the sociological literature the domain covered by the term “social capital” has been highly elastic.3 In some instances, social capital has by definition been beneficial or “good” in some way, while in others, the idea that one group's social capital can be another group's oppression has been accepted. Social capital has been used to refer to both formal and informal reciprocal links among people in all sorts of family, friendship, business and community networks. Where social capital resides—in the persons or groups linked by these networks? in the networks themselves? in the communities within which these networks exist?—is unclear. Ironically, the discourse around social capital in the health field often has a less fully socialised perspective than classic ideas about physical and financial capital being rooted in social relations of production.4 Such under-theorised applications in health research have lead to social capital being applied as a new and more fashionable label for investigations in what used to be called the “social support” field.5 Nevertheless, social capital and social cohesion have been proposed as the most important mediators of the association between income inequality and health.6 7 …

Infant mortality and congenital anomalies from 1950 to 1994: an international perspective

Abstract: STUDY OBJECTIVE—To provide an international perspective on the impact of congenital anomalies on infant mortality from 1950 to 1994. DESIGN—Population-based study based on data obtained from vital statistics reported to the World Health Organisation. SETTINGS—36 countries from Europe, the Middle East, the Americas, Asia, and the South Pacific. RESULTS—On average, infant mortality declined 68.8 per cent from 1950 to 1994. In the countries studied, infant mortality attributable to congenital anomalies decreased by 33.4 per cent, although it recently increased in some countries in Central and Latin America and in Eastern Europe. Anomalies of the heart and of the central nervous system accounted for 48.9 per cent of infant deaths attributable to congenital anomalies. During 1990-1994, infant mortality attributable to congenital anomalies was inversely correlated to the per capita gross domestic product in the countries studied. At the same time, the proportion of infant deaths attributable to congenital malformations was directly correlated with the per capita gross domestic product. CONCLUSIONS—Congenital malformations account for an increasing proportion of infant deaths in both developed and developing countries. Infant mortality attributable to congenital anomalies is higher in poorer countries although as a proportion of infant deaths it is greater in wealthier countries. Conditions such as spina bifida, whose occurrence can be reduced through preventive strategies, still cause many infant deaths. The apparent increase of infant mortality because of congenital anomalies in some countries should be investigated to confirm the finding, find the causes, and provide prevention opportunities. Keywords: congenital anomalies; infant mortality; spina bifida

The health of the Roma people: a review of the published literature

Abstract: BACKGROUND—The Roma people originated in northern India and have been known in Europe for nearly a thousand years. For much of that time they have been the subjects of discrimination and oppression, culminating in the extermination of half a million Roma in the Nazi death camps. While it is widely believed that the health of Roma people is often poorer than the majority population, these inequalities remain largely unresearched. METHODS—Published literature on the health of the Roma people was identified using Medline. Opinion pieces were excluded, as were papers relating to anthropometry and to genetic markers. The resultant papers were analysed by country of study and by disease type or care group. RESULTS—Some 70% of papers identified related to just three countries; Spain and the Czech and Slovak Republics. Much literature concentrates upon communicable disease or reproductive health. The limited evidence suggests increased morbidity from non-communicable disease, but there is little published on this topic. Evidence on health care, though fragmentary, suggests poorer access to health services and uptake of preventative care. DISCUSSION—Published research on the health needs of the Roma population is sparse. The topics that have received attention suggest a focus on concepts of contagion or social Darwinism, indicating a greater concern with the health needs of the majority populations with which they live. There is a need for both further research into the health of Roma people; with particular emphasis on non-communicable disease; and also for interventions that improve Roma health. Such research must, however, be handled with sensitivity, recognising the social and political context of the society concerned. Keywords: gypsies; inequalities; ethnicity; social exclusion

Accuracy of the estimated prevalence of obesity from self reported height and weight in an adult Scottish population

Abstract: STUDY OBJECTIVE To determine whether self reported heights and weights from Scottish adults can provide an accurate assessment of obesity prevalence in the population. DESIGN Standardised clinic measurements of weight and height were compared against self reported values on a postal questionnaire in the fourth Scottish MONICA cross sectional study. SETTING A sex and five year age band stratified random population sample drawn from general practitioner registers in north Glasgow in 1995. Response rate 63% for men and 62% for women. PARTICIPANTS A total of 865 men and 971 women aged between 25 and 64 years. RESULTS Men and women under-reported their weight by a mean (SD) of 0.63 (3.45) kg and 0.95 (2.64) kg respectively, and their height by a mean (SD) of 1.3 (2.50) cm and 1.7 (2.37) cm respectively. Estimated body mass index, BMI (kg/m2) varied from true (measured) BMI by +0.19 (1.40) for men and by +0.17 (1.34) for women. The only age/sex group in which BMI was under-estimated from self reports (mean 0.2) was the 55–64 year old women. Prediction equations that explained 90% (men) and 88% (women) of the difference between self reported and measured height included age and self reported weight. The equivalent prediction equations for weight explained 93% of the difference between self reported and measured weight for men and included smoking and diabetic status, while for women 96% of the variance was explained with no further variables being significant. Sensitivity and specificity for determining clinical obesity (BMI⩾30) were 83% and 96% respectively for men, and 89% and 97% for women. CONCLUSIONS This Scottish population was unique in the under-reporting of height as well as weight, which resulted in BMI estimates with low error. These data suggest that self reported weights and heights would be satisfactory for the monitoring of obesity prevalence in Scotland.

The relation between alcohol and cardiovascular disease in Eastern Europe: explaining the paradox

Abstract: BACKGROUND—Recent evidence from Eastern Europe of a positive association between alcohol and cardiovascular disease has challenged the prevailing view that drinking is cardioprotective. Consuming amounts of alcohol comparable to those consumed in France has been linked to detrimental cardiovascular effects. One possibility is that this could be related to the particular consequences of binge drinking, which is common in Russia. METHODS—A systematic review of literature on the relation between cardiovascular disease and heavy drinking and irregular (binge) drinking. RESULTS—Most existing reviews of the relation between alcohol and cardiovascular disease have examined the amount drunk per week or month and have not looked at the pattern of drinking. These have consistently shown that alcohol has a cardioprotective effect, even at high levels of consumption. In contrast, studies that have looked at pattern of drinking, either directly, or indirectly, using indicators such as frequency of hangovers or reports of the consequences of drunkenness, have consistently found an invcreased risk of cardiovascular death, particularly sudden death. A separate review of the physiological basis for a difference between regular heavy drinking and heavy binge drinking demonstrates that the two types of drinking have quite different effects. CONCLUSION—An association between binge drinking and cardiovascular death meets the standard criteria for causality. It is important that future studies of alcohol related harm examine the pattern of drinking as well as the amount drunk. Keywords: alcohol; cardiovascular disease

Why reduce health inequalities

Abstract: It is well known that social, cultural and economic factors cause substantial inequalities in health. Should we strive to achieve a more even share of good health, beyond improving the average health status of the population? We examine four arguments for the reduction of health inequalities.1 Inequalities are unfair. Inequalities in health are undesirable to the extent that they are unfair, or unjust. Distinguishing between health inequalities and health inequities can be contentious. Our view is that inequalities become "unfair" when poor health is itself the consequence of an unjust distribution of the underlying social determinants of health (for example, unequal opportunities in education or employment).2 Inequalities affect everyone. Conditions that lead to marked health disparities are detrimental to all members of society. Some types of health inequalities have obvious spillover effects on the rest of society, for example, the spread of infectious diseases, the consequences of alcohol and drug misuse, or the occurrence of violence and crime.3 Inequalities are avoidable. Disparities in health are avoidable to the extent that they stem from identifiable policy options exercised by governments, such as tax policy, regulation of business and labour, welfare benefits and health care funding. It follows that health inequalities are, in principle, amenable to policy interventions. A government that cares about improving the health of the population ought therefore to incorporate considerations of the health impact of alternative options in its policy setting process.3 Interventions to reduce health inequalities are cost effective. Public health programmes that reduce health inequalities can also be cost effective. The case can be made to give priority to such programmes (for example, improving access to cervical cancer screening in low income women) on efficiency grounds. On the other hand, few programmes designed to reduce health inequalities have been formally evaluated using cost effectiveness analysis. We conclude that fairness is likely to be the most influential argument in favour of acting to reduce disparities in health, but the concept of equity is contested and susceptible to different interpretations. There is persuasive evidence for some outcomes that reducing inequalities will diminish "spill over" effects on the health of society at large. In principle, you would expect that differences in health status that are not biologically determined are avoidable. However, the mechanisms giving rise to inequalities are still imperfectly understood, and evidence remains to be gathered on the effectiveness of interventions to reduce such inequalities.

How are policy makers using evidence? Models of research utilisation and local NHS policy making

Abstract: Study objective—This paper is based on a qualitative study that aimed to identify factors that facilitate or impede evidencebased policy making at a local level in the UK National Health Service (NHS). It considers how models of research utilisation drawn from the social sciences map onto empirical evidence from this study. Design—A literature review and case studies of social research projects that were initiated by NHS health authority managers or GP fundholders in one region of the NHS. In depth interviews and document analysis were used. Setting—One NHS region in England. Participants—Policy makers, GPs and researchers working on each of the social research projects selected as case studies. Main results—The direct influence of research evidence on decision making was tempered by factors such as financial constraints, shifting timescales and decision makers’ own experiential knowledge. Research was more likely to impact on policy in indirect ways, including shaping policy debate and mediating dialogue between service providers and users. Conclusions—The study highlights the role of sustained dialogue between researchers and the users of research in improving the utilisation of researchbased evidence in the policy process. (J Epidemiol Community Health 2000;54:461‐468)

Epidemiology of participation: an Australian community study

Abstract: STUDY OBJECTIVE To determine the levels of participation in social and civic community life in a metropolitan region, and to assess differential levels of participation according to demographic, socioeonomic and health status. To contribute to policy debates on community participation, social capital and health using these empirical data. DESIGN Cross sectional, postal, self completed survey on health and participation. SETTING Random sample of the population from the western suburbs of Adelaide, the capital city of South Australia, a population of approximately 210 000. PARTICIPANTS 2542 respondents from a sample of 4000 people aged 18 years and over who were registered on the electoral roll. MAIN RESULTS The response rate to the survey was 63.6% (n=2542). Six indices of participation, on range of social and civic activities, with a number of items in each, were created. Levels of participation were highest in the informal social activities index (46.7–83.7% for individual items), and lowest in the index of civic activities of a collective nature (2.4–5.9% for individual items). Low levels of involvement in social and civic activities were reported more frequently by people of low income and low education levels. CONCLUSIONS Levels of participation in social and civic community life in an urban setting are significantly influenced by individual socioeconomic status, health and other demographic characteristics. An understanding of the pattern of participation is important to inform social and health policy making. Increasing levels of participation will reduce social exclusion and is likely to improve the overall quality of community life.

Fatigue in the Danish general population. Influence of sociodemographic factors and disease.

Abstract: Objective—To measure the levels of fatigue in the general population, and to examine how disease and sociodemographic factors influence fatigue. Design—Cross sectional questionnaire study in the Danish general population. Subjects—A random, age stratified sample of 1608 people aged 20‐77 with an equal gender distribution (response rate 67%). Main outcome measures—Five fatigue scales from the questionnaire Multidimensional Fatigue Inventory: General Fatigue, Physical Fatigue, Reduced Activity, Reduced Motivation and Mental Fatigue. Results—Fatigue scores were skewed towards absence of fatigue. The General Fatigue and Physical Fatigue scales showed the highest fatigue levels while the Reduced Motivation scale showed lowest levels.Gender diVerences in fatigue scores were small, but the variability among women was higher—that is, more women had high scores. A multiple linear regression analysis showed that respondents of low social status and respondents with a depression had high fatigue scores on all scales, independent of other factors. Chronic somatic disease had an independent direct eVect on Mental Fatigue, but for the rest of the scales, the eVect of somatic disease depended on age, gender and/or whether the person was living alone. For example, General and Physical Fatigue decreased with age among healthy people, whereas scores on these scales increased with age among those with a somatic disease. Conclusions—Physical and mental diseases play essential parts for the level of fatigue and as modulators of the associations between sociodemographic factors and fatigue. These interactions should be taken into account in future research on fatigue and sociodemographic factors and when data from clinical studies are compared with normative data from the general population. (J Epidemiol Community Health 2000;54:827‐833)

Cigarette smoking gives more respiratory symptoms among women than among men The Nord-Trøndelag Health Study (HUNT)

Abstract: Study objective—Studies have indicated that women are more vulnerable to the eVect of tobacco smoking compared with men. The aim of this study was to explore the prevalence of reported respiratory symptoms and diseases according to smoking burden, age and sex. Design—Questionnaire in a cross sectional population based study. Setting—The BONT (Bronchial obstruction in Nord-Trondelag) study is part of a comprehensive health survey of all inhabitants aged above 19 years in the county of Nord-Trondelag, Norway, which was carried out from 1995 to 1997. Participants—A total of 65 717 subjects, 71.3% of the total population aged 20‐100, answered the main questionnaire. Main results—In all, 12.7% men and 12.1% women reported episodes of wheezing or breathlessness during the past 12 months, 8.8% men and 8.4% women reported that they had or had had asthma, 7.5% men and 8.2% women had ever used asthma medication, and 4.0% men and 3.0% women reported chronic bronchitis. Thirty per cent of men and 31% of women were smokers, and average pack years of smoking were 15.9 and 10.3, respectively. Among previous and current smokers, significant more women reported episodes of wheezing or breathlessness, current asthma and persistent coughing compared with men with the same smoke burden (pack years) and daily number of cigarettes. Conclusion—The prevalence of reported asthma and use of asthma medication was higher than reported in previous Scandinavian studies. Respiratory symptoms increased by smoking burden. Comparing the prevalence of symptoms and current asthma among women and men with the same smoke burden or daily cigarette consumption, women seemed to be more susceptible to the eVect of tobacco smoking than men. (J Epidemiol Community Health 2000;54:917‐922)

Deprivation and childhood obesity: a cross sectional study of 20 973 children in Plymouth, United Kingdom

Abstract: OBJECTIVE To study the association between socioeconomic deprivation and childhood obesity. DESIGN Cross sectional study. SETTING All state primary schools in Plymouth. Plymouth is a relatively deprived city in the United Kingdom, ranking 338th of 366 local authorities on the Department of the Environment Index of Local Conditions. SUBJECTS 20 973 children between the ages of 5 and 14 years, 1994–96. MAIN OUTCOME MEASURE Numbers of obese children (body mass index (BMI) above the 98th centile) by quarters of Townsend score. RESULTS Plymouth had a rate of childhood obesity two and half times that expected nationally (5% v 2%). The obesity prevalence increased with age, being almost double in the oldest age quarter (boys 6.2%; girls 7.0%), compared with the youngest age quarter. Within Plymouth, there was a significant trend for higher rates of obesity related to increasing deprivation in both boys (p=0.017) and girls (p=0.018). The odds ratio (OR) for childhood obesity (highest-lowest quarter of Townsend scores) had borderline significance in boys (OR 1.29, 95% confidence intervals (CI) 1.00 to 1.65, p=0.049) but was larger and more significant in the girls (OR 1.39, 95% CI 1.08 to 1.80, p=0.011). Unlike boys, the association between obesity in girls and Townsend scores became stronger with age such that in the oldest age quarter (over 11.7 years), girls in the highest quarter of Townsend scores were nearly twice as likely be obese, as compared with the lowest quarter (OR 1.95, 95% CI 1.23 to 3.08, p=0.005). State of pubertal development could not be accounted for as this information was not available. CONCLUSIONS This study provides evidence for an association between deprivation and childhood obesity in this English population. The health of children from deprived households is affected by a number of adverse influences. The high prevalence of obesity in these children is yet another factor that could predispose to greater morbidity in adult life.

The ecological fallacy strikes back

Abstract: When I first started studying epidemiology, ecological studies were briefly discussed as an inexpensive but unreliable method for studying individual level risk factors for disease. For example, rather than go to the time and expense to establish a cohort study or case-control study of fat intake and breast cancer, you could simply use national dietary and cancer incidence data and, with minimal time and expense, show a strong correlation internationally between fat intake and breast cancer. This approach was quite rightly regarded as inadequate and unreliable because of the many additional forms of bias that can occur in such studies compared with studies of individuals within a population. In particular, the “ecological fallacy” can occur in that factors that are associated with national disease rates may not be associated with disease in individuals.1 For example, almost any disease that is associated with affluence and Westernisation has in the past been associated at the national level with sales of television sets, and nowadays is probably associated at the national level with rates of internet use. Thus, ecological studies were not a good thing to do, and were a relic of the “pre-modern” phase of epidemiology before it became firmly established with a methodologic paradigm based on the theory of randomised controlled trials of individuals. This paradigm, which is very powerful when used appropriately, gave rise to increasingly sophisticated methods of study design and data analysis. In particular, biostatistical methods that were developed for randomised trials involving a single individual level exposure were used to reformulate and make more rigorous the previously ad hoc epidemiological methods of study design and data analysis.2 3 Thus, epidemiology courses have increasingly become restricted to discussing cohort and case-control studies and the methods of data analysis that fit the clinical trial paradigm on which …

Employment grade differences in cause specific mortality. A 25 year follow up of civil servants from the first Whitehall study

Abstract: STUDY OBJECTIVE To test the hypothesis that the association between socioeconomic status and mortality rates cuts across the major causes of death for middle aged and elderly men. DESIGN 25 year follow up of mortality in relation to employment grade. SETTING The first Whitehall study. PARTICIPANTS 18 001 male civil servants aged 40–69 years who attended the initial screening between 1967 and 1970 and were followed up for at least 25 years. MAIN OUTCOME MEASURE Specific causes of death. RESULTS After more than 25 years of follow up of civil servants, aged 40–69 years at entry to the study, employment grade differences still exist in total mortality and for nearly all specific causes of death. Main risk factors (cholesterol, smoking, systolic blood pressure, glucose intolerance and diabetes) could only explain one third of this gradient. Comparing the older retired group with the younger pre-retirement group, the differentials in mortality remained but were less pronounced. The largest decline was seen for chronic bronchitis, gastrointestinal diseases and genitourinary diseases. CONCLUSIONS Differentials in mortality persist at older ages for almost all causes of death.

A sustainable programme to prevent falls and near falls in community dwelling older people: results of a randomised trial

Abstract: STUDY OBJECTIVE In the causative mechanism of falls among older community dwellers, slips and trips have been found to be significant precursors. The purpose of the two year trial was to assess the effectiveness of multi-component interventions targeting major risk factors for falls in reducing the incidence of slips, trips and falls among the well, older community. DESIGN Four groups with approximately equal numbers of participants were randomly allocated to interventions. The prevention strategies included education and awareness raising of falls risk factors, exercise sessions to improve strength and balance, home safety advice to modify environmental hazards, and medical assessment to optimise health. The interventions combined the strategies in an add on approach. The first intervention group receiving the information session only was regarded as the control. The outcome of interest was the occurrence of a slip, trip or fall, monitored prospectively using a daily calendar diary. PARTICIPANTS AND SETTING Two hundred and fifty two members of the National Seniors Association in the Brisbane district agreed to participate. National Seniors clubs provide a forum for active, community dwelling Australians aged 50 and over to participate in policy, personal development and recreation. MAIN RESULTS Using Cox's proportional hazards regression model, adjusted hazard ratios comparing intervention groups with the control ranged from 0.35 (95% CI 0.17, 0.73) to 0.48 (0.25, 0.91) for slips; 0.29 (0.16, 0.51) to 0.45 (0.27, 0.74) for trips; and 0.60 (0.36, 1.01) to 0.82 (0.51, 1.31) for falls. While calendar monitoring recorded outcome, it was also assessed as a prevention strategy by comparing the intervention groups with a hypothetical non-intervened group. At one year after intervention, reductions in the probability of slips, trips and falls (61(95%CI 54, 66)%; 56 (49, 63)%; 29 (22, 36)% respectively) were demonstrated. CONCLUSIONS This study makes an important contribution to the priority community health issue of falls prevention by showing that effective, sustainable, low cost programmes can be introduced through community-based organisations to reduce the incidence of slips, trips and falls in well, older people.

Income non-reporting: implications for health inequalities research

Abstract: OBJECTIVES—To determine whether, in the context of a face to face interview, socioeconomic groups differ in their propensity to provide details about the amount of their personal income, and to discuss the likely consequences of any differences for studies that use income based measures of socioeconomic position. DESIGN AND SETTING—The study used data from the 1995 Australian Health Survey. The sample was selected using a stratified multi-stage area design that covered urban and rural areas across all States and Territories and included non-institutionalised residents of private and non-private dwellings. The response rate was 91.5% for selected dwellings and 97.0% for persons within dwellings. Data were collected using face to face interviews. Income response, the dependent measure, was binary coded (0 if income was reported and 1 for refusals, "don't knows" and insufficient information). Socioeconomic position was measured using employment status, occupation, education and main income source. The socioeconomic characteristics of income non-reporters were initially examined using sex specific age adjusted proportions with 95% confidence intervals. Multivariate analysis was performed using logistic regression. PARTICIPANTS—Persons aged 15-64 (n=33 434) who were reportedly in receipt of an income from one or more sources during the data collection reference period. RESULTS—The overall rate of income non-response was 9.8%. Propensity to not report income increased with age (15-29 years 5.8%, 30-49 10.6%, 50-64 13.8%). No gender differences were found (men 10.2%, women 9.3%). Income non-response was not strongly nor consistently related to education or occupation for men, although there was a suggested association among these variables for women, with highly educated women and those in professional occupations being less likely to report their income. Strong associations were evident between income non-response, labour force status and main income source. Rates were highest among the employed and those in receipt of an income from their own business or partnership, and lowest among the unemployed and those in receipt of a government pension or benefit (which excluded the unemployed). CONCLUSION—Given that differences in income non-reporting were small to moderate across levels of the education and occupation variables, and that propensity to not report income was greater among higher socioeconomic groups, estimates of the relation between income and health are unlikely to be affected by socioeconomic variability in income non-response. Probability estimates from a logistic regression suggested that higher rates of income non-reporting among employed persons who received their income from a business or partnership were not attributable to socioeconomic factors. Rather, it is proposed that these higher rates were attributable to recall effects, or concerns about having one's income information disclosed to taxation authorities. Future studies need to replicate this analysis to determine whether the results can be inferred to other survey and data collection contexts. The analysis should also be extended to include an examination of the relation between socioeconomic position and accuracy of income reporting. Little is known about this issue, yet it represents a potential source of bias that may have important implications for studies that investigate the association between income and health. Keywords: socioeconomic position; income non-response; data quality

A minimum income for healthy living

Abstract: Background—Half a century of research has provided consensual evidence of major personal requisites of adult health in nutrition, physical activity and psychosocial relations. Their minimal money costs, together with those of a home and other basic necessities, indicate disposable income that is now essential for health. Methods—In a first application we identified such representative minimal costs for healthy, single, working men aged 18‐30, in the UK. Costs were derived from ad hoc survey, relevant figures in the national Family Expenditure Survey, and by pragmatic decision for the few minor items where survey data were not available. Results—Minimum costs were assessed at £131.86 per week (UK April 1999 prices). Component costs, especially those of housing (which represents around 40% of this total), depend on region and on several assumptions. By varying these a range of totals from £106.47 to £163.86 per week was detailed. These figures compare, 1999, with the new UK national minimum wage, after statutory deductions, of £105.84 at 18‐21 years and £121.12 at 22+ years for a 38 hour working week. Corresponding basic social security rates are £40.70‐£51.40 per week. Interpretation—Accumulating science means that absolute standards of living, “poverty”, minimal oYcial incomes and the like, can now be assessed by objective measurement of the personal capacity to meet the costs of major requisites of healthy living. A realistic assessment of these costs is presented as an impetus to public discussion. It is a historical role of public health as social medicine to lead in public advocacy of such a national agenda. (J Epidemiol Community Health 2000;54:885‐889)

What is the lag time between income inequality and health status

Abstract: Income inequality has been associated with poorer self rated health in the United States.1 Possible mechanisms linking income distribution to health include: variations in a person's access to life opportunities and material resources (for example, health care, education); social cohesion, whereby mutual support and cooperation secure better health outcomes; and possible direct psychosocial processes related to relative perceptions of position on the socioeconomic hierarchy.2 It seems implausible that these mechanisms of action are instantaneous—there should be a lag time during which income inequality affects these intermediary factors, which in turn affect health. In this study, we provide a test of the potential time lags between income inequality and self rated health. We used data for 213 695 people aged 15 years and older sampled by the 1995 and 1997 Current Population Survey (CPS) in the United States.3 Two reasons dictated using just 1995 and 1997 data. Firstly, the CPS has only collected self rated health data since 1995. Secondly, each CPS respondent stays in the CPS sample for two consecutive years—additionally including 1996 and 1998 data would only lead to double counting the same people. The individual level covariates …