Showing papers in "Journal of Epidemiology and Community Health in 2019"

Relationship between childhood socioeconomic position and adverse childhood experiences (ACEs): a systematic review.

Abstract: Background ‘Adverse childhood experiences’ (ACEs) are associated with increased risk of negative outcomes in later life: ACEs have consequently become a policy priority in many countries. Despite ACEs being highly socially patterned, there has been very little discussion in the political discourse regarding the role of childhood socioeconomic position (SEP) in understanding and addressing them. The aim here was to undertake a systematic review of the literature on the relationship between childhood SEP and ACEs. Methods MEDLINE, PsycINFO, ProQuest and Cochrane Library databases were searched. Inclusion criteria were: (1) measurement of SEP in childhood; (2) measurement of multiple ACEs; (3) ACEs were the outcome; and (4) statistical quantification of the relationship between childhood SEP and ACEs. Search terms included ACEs, SEP and synonyms; a second search additionally included ‘maltreatment’. Overall study quality/risk of bias was calculated using a modified version of the Hamilton Tool. Results In the ACEs-based search, only 6 out of 2825 screened papers were eligible for qualitative synthesis. The second search (including maltreatment) increased numbers to: 4562 papers screened and 35 included for synthesis. Eighteen papers were deemed ‘high’ quality, five ‘medium’ and the rest ‘low’. Meaningful statistical associations were observed between childhood SEP and ACEs/maltreatment in the vast majority of studies, including all except one of those deemed to be high quality. Conclusion Lower childhood SEP is associated with a greater risk of ACEs/maltreatment. With UK child poverty levels predicted to increase markedly, any policy approach that ignores the socioeconomic context to ACEs is therefore flawed. PROSPERO registration number CRD42017064781.

Effects of Housing First approaches on health and well-being of adults who are homeless or at risk of homelessness: systematic review and meta-analysis of randomised controlled trials.

Abstract: Background Homelessness is associated with poor health. A policy approach aiming to end homelessness across Europe and North America, the ‘Housing First’ (HF) model, provides rapid housing, not conditional on abstinence from substance use. We aimed to systematically review the evidence from randomised controlled trials for the effects of HF on health and well-being. Methods We searched seven databases for randomised controlled trials of interventions providing rapid access to non-abstinence-contingent, permanent housing. We extracted data on the following outcomes: mental health; self-reported health and quality of life; substance use; non-routine use of healthcare services; housing stability. We assessed risk of bias and calculated standardised effect sizes. Results We included four studies, all with ‘high’ risk of bias. The impact of HF on most short-term health outcomes was imprecisely estimated, with varying effect directions. No clear difference in substance use was seen. Intervention groups experienced fewer emergency department visits (incidence rate ratio (IRR)=0.63; 95% CI 0.48 to 0.82), fewer hospitalisations (IRR=0.76; 95% CI 0.70 to 0.83) and less time spent hospitalised (standardised mean difference (SMD)=−0.14; 95% CI −0.41 to 0.14) than control groups. In all studies intervention participants spent more days housed (SMD=1.24; 95% CI 0.86 to 1.62) and were more likely to be housed at 18–24 months (risk ratio=2.46; 95% CI 1.58 to 3.84). Conclusion HF approaches successfully improve housing stability and may improve some aspects of health. Implementation of HF would likely reduce homelessness and non-routine health service use without an increase in problematic substance use. Impacts on long-term health outcomes require further investigation. Trial registration number CRD42017064457

The rise of hunger among low-income households: an analysis of the risks of food insecurity between 2004 and 2016 in a population-based study of UK adults.

Abstract: Background Rising food bank use in the past decade in the UK raises questions about whether food insecurity has increased. Using the 2016 Food and You survey, we describe the magnitude and severity of the problem, examine characteristics associated with severity of food insecurity, and examine how vulnerability has changed among low-income households by comparing 2016 data to the 2004 Low Income Diet and Nutrition Survey. Methods The Food and You survey is a representative survey of adults living in England, Wales, and Northern Ireland (n=3118). Generalised ordered logistic regression models were used to examine how socioeconomic characteristics related to severity of food insecurity. Coarsened exact matching was used to match respondents to respondents in the 2004 survey. Logistic regression models were used to examine if food insecurity rose between survey years. Results 20.7% (95% CI 18.7% to 22.8%) of adults experienced food insecurity in 2016, and 2.72% (95% CI 2.07% to 3.58%) were severely food insecure. Younger age, non-white ethnicity, low education, disability, unemployment, and low income were all associated with food insecurity, but only the latter three characteristics were associated with severe food insecurity. Controlling for socioeconomic variables, the probability of low-income adults being food insecure rose from 27.7% (95% CI 24.8% to 30.6 %) in 2004 to 45.8% (95% CI 41.6% to 49.9%) in 2016. The rise was most pronounced for people with disabilities. Conclusions Food insecurity affects economically deprived groups in the UK, but unemployment, disability and low income are characteristics specifically associated with severe food insecurity. Vulnerability to food insecurity has worsened among low-income adults since 2004, particularly among those with disabilities.

Direct healthcare costs of sedentary behaviour in the UK

Abstract: Background Growing evidence indicates that prolonged sedentary behaviour increases the risk of several chronic health conditions and all-cause mortality. Sedentary behaviour is prevalent among adults in the UK. Quantifying the costs associated with sedentary behaviour is an important step in the development of public health policy. Methods National Health Service (NHS) costs associated with prolonged sedentary behaviour (≥6 hours/day) were estimated over a 1-year period in 2016–2017 costs. We calculated a population attributable fraction (PAF) for five health outcomes (type 2 diabetes, cardiovascular disease [CVD], colon cancer, endometrial cancer and lung cancer). Adjustments were made for potential double-counting due to comorbidities. We also calculated the avoidable deaths due to prolonged sedentary behaviour using the PAF for all-cause mortality. Results The total NHS costs attributable to prolonged sedentary behaviour in the UK in 2016–2017 were £0.8 billion, which included expenditure on CVD (£424 million), type 2 diabetes (£281 million), colon cancer (£30 million), lung cancer (£19 million) and endometrial cancer (£7 million). After adjustment for potential double-counting, the estimated total was £0.7 billion. If prolonged sedentary behaviour was eliminated, 69 276 UK deaths might have been avoided in 2016. Conclusions In this conservative estimate of direct healthcare costs, prolonged sedentary behaviour causes a considerable burden to the NHS in the UK. This estimate may be used by decision makers when prioritising healthcare resources and investing in preventative public health programmes.

When and how do 'effective' interventions need to be adapted and/or re-evaluated in new contexts? The need for guidance

Abstract: Rational models of evidence-informed policy have historically centred on an assumption that it is possible to identify ‘effective’ interventions, before recommending wider implementation. However, for population health interventions (which we define as inclusive of public health and health services), transferability to new contexts is often uncertain.1 Some interventions have demonstrated limited effectiveness, or even harm, when used elsewhere. For example, antenatal corticosteroids have reduced neonatal mortality among pregnant women at risk of preterm birth in high-income countries, but increased mortality and maternal infection in low-income and middle-income countries.2 While definitions are contested, context can be defined as a set of active and unique characteristics and circumstances that interact with, modify, facilitate or constrain intervention delivery and effects. It includes geographical, epidemiological, sociocultural, socioeconomic, ethical, legal and political determinants.3 The argument that every context is unique and interventions cannot translate across them should not be overstated however. Some parenting interventions, for instance, have not successfully transferred, while others have been highly resilient to contextual variation, with minimal difference in effects between ‘home-grown’ and transported approaches.4 There is increased recognition then of the need to consider context when making decisions about the transferability of evidence. Population health interventions are increasingly conceived as ‘events in systems’, which aim to modify aspect(s) of a pre-existing context, altering conditions that sustain suboptimal population health outcomes. Effects therefore may be shaped as much by changes to or displacement of prior features of the context, as by properties of the new intervention. Implementation may differ in a new context due to the complexity of the intervention components or ambiguity over its mechanisms, inhibiting high fidelity. Implementation failure may ensue if an intervention …

Intergenerational Social Mobility and Allostatic Load in Great Britain

Abstract: Background Intergenerational social mobility is hypothesised to be a stressful process that has a negative effect on health. By examining the relationship between own socioeconomic position, parental socioeconomic position and allostatic load (AL) in a representative sample of the British population, we test this hypothesis. Methods Our study uses cross-sectional data from 9851 adult participants of waves 2 and 3 of Understanding Society. The relationship between parental occupational class at age 14 years, respondents’ social class at the time of the interview and AL is explored by means of diagonal reference models, which allow us to disentangle the effects of parental social class, own social class and the mobility process. The AL score comprises the following biomarkers: (1) total cholesterol, (2) high-density lipoprotein cholesterol, (3) triglycerides, (4) glycated haemoglobin, (5) C-reactive protein, (6) fibrinogen, (7) systolic blood pressure, (8) diastolic blood pressure, (9) resting heart rate, (10) body mass index and (11) waist circumference. Results AL is particularly high among the stable working class and low among the stable upper class. On average, current class and origin class exert about equal weight on current AL. However, social mobility—regardless of whether upwards or downwards—is not detrimental for AL. Furthermore, we find evidence that class of origin may be less important among those outside the labour market for reasons other than retirement. Conclusion Both own social class and parental social class influence AL to a similar extent. However, we find no evidence that mobility trajectories exert any effects, good or bad, on AL.

Gender-specific risk factors for incident sarcopenia: 8-year follow-up of the English longitudinal study of ageing

Abstract: Background The aetiology of age-related sarcopenia is not known. Objectives To investigate if risk of developing sarcopenia differs by gender and to identify gender-specific risk factors of incident sarcopenia in a large population-based cohort of older English adults. Methods The sample (n=3404; age 63.4 (SD 7.7) years; 54.1% women) comprised older community-dwelling adults recruited from the English Longitudinal Study of Ageing. Sarcopenia was defined as handgrip Results During 8-year follow-up, 208 and 287 cases of sarcopenia were identified in men (n=1564) and women (n=1840), respectively. Women were at 20% (age adjusted OR=1.20, 95% CI 0.98 to 1.47) higher risk of developing sarcopenia than men. The inverse association between physical activity and sarcopenia risk was observed at moderate (OR=0.44, 95% CI 0.27 to 0.67) and vigorous (0.53, 95% CI 0.31 to 0.82) intensities in men and only vigorous (OR=0.44, 95% CI 0.28 to 0.68) intensity in women. Social factors, such as wealth, and chronic health conditions appeared to be more strongly associated with sarcopenia in men. Conclusion Women are at higher risk of developing incident sarcopenia than men, and this is likely explained by a range of gender-specific risk factors.

Contribution of smoking and alcohol consumption to income differences in life expectancy: evidence using Danish, Finnish, Norwegian and Swedish register data.

Abstract: Background Despite being comparatively egalitarian welfare states, the Nordic countries have not been successful in reducing health inequalities. Previous studies have suggested that smoking and alcohol contribute to this pattern. Few studies have focused on variations in alcohol-related and smoking-related mortality within the Nordic countries. We assess the contribution of smoking and alcohol to differences in life expectancy between countries and between income quintiles within countries. Methods We collected data from registers in Denmark, Finland, Norway and Sweden comprising men and women aged 25–79 years during 1995–2007. Estimations of alcohol-related mortality were based on underlying and contributory causes of death on individual death certificates, and smoking-related mortality was based on an indirect method that used lung cancer mortality as an indicator for the population-level impact of smoking on mortality. Results About 40%–70% of the between-country differences in life expectancy in the Nordic countries can be attributed to smoking and alcohol. Alcohol-related and smoking-related mortality also made substantial contributions to income differences in life expectancy within countries. The magnitude of the contributions were about 30% in Norway, Sweden and among Finnish women to around 50% among Finnish men and in Denmark. Conclusions Smoking and alcohol consumption make substantial contributions to both between-country differences in mortality among the Nordic countries and within-country differences in mortality by income. The size of these contributions vary by country and sex.

Association between suicide attempts and homelessness in a population-based sample of US veterans and non-veterans.

Abstract: Background Suicide and homelessness share many of the same risk factors, but there is little understanding of how they are related to each other. Methods Data on 36 155 US adults (3101 veterans and 33 024 non-veterans) in the National Epidemiological Survey of Alcohol and Related Conditions-III were analysed to examine the association between lifetime homelessness and suicide, net of other factors, in a nationally representative US sample. Results US veterans with homeless histories were 7.8 times more likely to have attempted suicide than veterans with no homeless histories (24.5% vs 2.8%). Non-veterans with homeless histories were 4.1 times more likely to have attempted suicide than those with no homeless histories (23.1% vs 4.5%). Lifetime homelessness was independently associated with lifetime suicide attempts in veterans (AOR=3.75, 95% CI 3.72 to 3.77) and non-veterans (AOR=1.83, 95% CI 1.83 to 1.84). Conclusion The findings suggest a unique link between homelessness and suicide, especially among US veterans. Strategies to synergise homeless and suicide prevention services, particularly in the Veterans Health Administration, may benefit high-risk individuals.

How do early-life factors explain social inequalities in adolescent mental health? Findings from the UK Millennium Cohort Study

Abstract: Background Reducing inequalities in adolescent mental health is a public health priority, yet the pathways that link social conditions to mental health outcomes in the early years are unclear. We aimed to evaluate the extent to which early years risk factors explain social inequalities in adolescent mental health in the UK. Methods We analysed data from 6509 children captured in the UK Millennium Cohort Study. Mental health was assessed through the socioemotional behavioural problems at age 14 (Strengths and Difficulties Questionnaire). The main exposure was maternal education at birth, used as a measure of childhood socioeconomic conditions (SECs), and used to calculate the relative index of inequality. Using causal mediation analysis, we assessed how perinatal, individual child, family, peer relation and neighbourhood-level factors measured up to age 3-mediated the total effect (TE) of SECs on adolescent socioemotional behavioural problems, estimating the proportion mediated and natural indirect effect (NIE) via each block of mediators, and all mediators together. Results Children of mothers with no qualification were almost four times as likely to have socioemotional behavioural problems compared with degree plus level (relative risk (RR) 3.82, 95% CI 2.48 to 5.88). Overall, 63.9% (95% CI 50.2% to 77.6%) (NIE RR 1.97, 95% CI 1.63 to 2.37) of the TE (RR 4.40, 95% CI 3.18 to 6.07) of social inequalities on risk of adolescent socioemotional behavioural problems was mediated by early-life factors. Conclusions About two-thirds of the social inequality in adolescent mental health was explained by early risk factors measured by age 3, highlighting the importance of public health interventions in this period.

Socioeconomic disparities in life expectancy gains among retired German men, 1997–2016

Abstract: Background Although estimates of socioeconomic mortality disparities in Germany exist, the trends in these disparities since the 1990s are still unknown. This study examines mortality trends across socioeconomic groups since the late 1990s among retired German men aged 65 and above. Methods Large administrative data sets were used to estimate mortality among retired German men, grouped according to their working-life biographies. The data covered the years 1997–2016 and included more than 84.1 million person-years and 4.3 million deaths. Individual pension entitlements served as a measure of lifetime income. Changes in total life expectancy at age 65 over time were decomposed into effects of group-specific mortality improvements and effects of compositional change. Results Over the two decades studied, male mortality declined in all income groups in both German regions. As mortality improved more rapidly among higher status groups, the social gradient in mortality widened. Since 1997, the distribution of pension entitlements of retired East German men has shifted substantially downwards. As a result, the impact of the most disadvantaged group on total mortality has increased and has partly attenuated the overall improvement. Conclusion Our results demonstrate that socioeconomic deprivation has substantial effects on levels of mortality in postreunification Germany. While East German retirees initially profited from the transition to the West German pension system, subsequent cohorts had to face challenges associated with the transition to the market economy. The results suggest that postreunification unemployment and status decline had delayed effects on old-age mortality in East Germany.

Public health responses to the opioid crisis in North America

Abstract: The opioid overdose epidemic in North America remains among the most challenging public health issues of recent times. Sadly, all evidence points to a worsening of the epidemic,1 2 despite growing investment in responses that span policy and legislative changes, scale-up of evidence-based overdose interventions, and the implementation and evaluation of novel interventions. This has prompted concerns about what is and what is not being done to address this epidemic that has resulted in reductions in life expectancy in both the USA and Canada. Given the well-described problem of the overprescribing of opioids for pain, governments and medical bodies have sought to reduce opioid prescribing through guideline development, physician education and monitoring efforts. While the rate of prescribing in the USA dropped from a high of 81.3 per 100 persons in 2012 to 58.5 per 100 persons in 2017,3 the death rate attributable to opioids continues to rise, and prescription opioid misuse has remained fairly stable since 2010.3 While this result may seem unexpected, it is not entirely surprising given observed transitions from prescription opioid to heroin use in the USA, as well as evidence from Canada indicating that many individuals acquire heroin or diverted opioids from drug markets when denied opioids from physicians.4 These dynamics are consistent with evidence from a range of settings indicating that when access to one substance is restricted, most individuals will transition to using an alternative, which in many cases will be more dangerous than standardised doses of prescription opioids. While many have attributed the overdose crisis to opioid prescribing, this is an obvious oversimplification of this epidemic. There is now clear evidence of an increasing role of illicitly manufactured opioids, such as fentanyl and related analogues, in the continued rise in overdose deaths. In the USA, overdose deaths attributable to …

The impact of New Labour's English health inequalities strategy on geographical inequalities in infant mortality: a time-trend analysis.

Abstract: Background The English health inequalities strategy (1999–2010) aimed to reduce health inequalities between the most deprived local authorities and the rest of England. The multifaceted strategy included increased investment in healthcare, the early years, education and neighbourhood renewal. The objective of this study was to investigate whether the strategy was associated with a reduction in geographical inequalities in the infant mortality rate (IMR). Methods We used segmented regression analysis to measure inequalities in the IMR between the most deprived local authorities and the rest of England before, during and after the health inequalities strategy period. Results Before the strategy was implemented (1983–1998), absolute inequalities in the IMR increased between the most deprived local authorities and the rest of England at a rate of 0.034 annually (95% CI 0.001 to 0.067). Once the strategy had been implemented (1999–2010), absolute inequalities decreased at a rate of −0.116 annually (95% CI −0.178 to −0.053). After the strategy period ended (2011–2017), absolute inequalities increased at a rate of 0.042 annually (95% CI −0.042 to 0.125). Relative inequalities also marginally decreased during the strategy period. Conclusion The English health inequalities strategy period was associated with a decline in geographical inequalities in the IMR. This research adds to the evidence base suggesting that the English health inequalities strategy was at least partially effective in reducing health inequalities, and that current austerity policies may undermine these gains.

Financial stress and mental health among higher education students in the UK up to 2018: rapid review of evidence

Abstract: Introduction In the United Kingdom and many other countries, debt accrued during higher education has increased substantially in recent decades. The prevalence of common mental health problems has also increased alongside these changes. However, it is as yet unclear whether there is an association between financial stress and mental health among higher education students. Methods We conducted a rapid review of the peer-reviewed scientific literature. Eligible studies were English-language publications testing the association between any indicator of financial stress and mental health among higher education students in the UK. Papers were located through a systematic search of PsychINFO, PubMed and Embase up to November 2018. Results The search strategy yielded 1272 studies—9 met the inclusion criteria. A further two were identified through hand-searching. The median sample size was 408. Only three of seven studies found an association between higher debt and worse mental health. There was a consistent cross-sectional relationship between worse mental health and both experience of financial difficulties (seven of seven studies) and debt worry/financial concern (four of five studies), though longitudinal evidence was mixed and limited to six studies. Conclusion Among higher education students in the UK, there is little evidence that the amount of debt is associated with mental health. However, more subjective measures of increased financial stress were more consistently associated with worse mental health outcomes. Nevertheless, the identified evidence was judged to be weak; further research is required to examine whether links between financial stress and mental health outcomes are robust and causal in nature.

Long work hours, weekend working and depressive symptoms in men and women: findings from a UK population-based study.

Abstract: Background Globalised and 24/7 business operations have fuelled demands for people to work long hours and weekends. Research on the mental health effects of these intensive temporal work patterns is sparse, contradictory or has not considered gender differences. Our objective was to examine the relationship between these work patterns and depressive symptoms in a large nationally representative sample of working men and women in the UK. Method The current study analysed data from Understanding Society, the UK Household Longitudinal Study, of 11 215 men and 12 188 women in employment or self-employment at the time of the study. Ordinary least squares regression models, adjusted for potential confounders and psychosocial work factors, were used to estimate depressive symptoms across categories of work hours and weekend work patterns. Results Relative to a standard 35-40 hours/week, working 55 hours/week or more related to more depressive symptoms among women (s=0.75, 95% CI 0.12 to 1.39), but not for men (s=0.24, 95% CI -0.10 to 0.58). Compared with not working weekends, working most or all weekends related to more depressive symptoms for both men (s=0.34, 95% CI 0.08 to 0.61) and women (s=0.50, 95% CI 0.20 to 0.79); however, working some weekends only related to more depressive symptoms for men (s=0.33, 95% CI 0.11 to 0.55), not women (s=0.17, 95% CI -0.09 to 0.42). Conclusion Increased depressive symptoms were independently linked to working extra-long hours for women, whereas increased depressive symptoms were associated with working weekends for both genders, suggesting these work patterns may contribute to worse mental health.

High school personality traits and 48-year all-cause mortality risk: results from a national sample of 26 845 baby boomers

Abstract: Background It is unclear if adolescent personality predicts mortality into late life, independent of adolescent socioeconomic status (SES). Methods Over 26 000 members of Project Talent, a US population cohort of high school students, completed a survey including 10 personality scales and SES in 1960. Multi-source mortality follow-up obtained vital status data through an average 48-year period ending in 2009. Cox proportional hazard models examined the relative risk associated with personality traits, as well as confounding by both a measure of SES and by race/ethnicity. Results Adjusted for sex and grade, higher levels of vigour, calm, culture, maturity and social sensitivity in high school were associated with reduced mortality risk (HRs=0.92 to. 96), while higher levels of impulsivity were associated with greater mortality risk. Further adjustment for SES and school racial/ethnic composition mildly attenuated (eg, 12%), but did not eliminate these associations. Final HRs for a 1 SD change in personality traits were similar to that for a 1 SD change in SES. Conclusions Adaptive personality traits in high school are associated with all-cause mortality in the USA as far into the future as the seventh decade, and to a degree similar to high school socioeconomic disadvantage.

Exposure to environmental chemicals and type 1 diabetes: an update

Abstract: This narrative review summarises recently published epidemiological and in vivo experimental studies on exposure to environmental chemicals and their potential role in the development of type 1 diabetes mellitus (T1DM). These studies focus on a variety of environmental chemical exposures, including to air pollution, arsenic, some persistent organic pollutants, pesticides, bisphenol A and phthalates. Of the 15 epidemiological studies identified, 14 include measurements of exposures during childhood, 2 include prenatal exposures and 1 includes adults over age 21. Together, they illustrate that the role of chemicals in T1DM may be complex and may depend on a variety of factors, such as exposure level, timing of exposure, nutritional status and chemical metabolism. While the evidence that these exposures may increase the risk of T1DM is still preliminary, it is critical to investigate this possibility further as a means of preventing T1DM.

Mortality inequalities by occupational class among men in Japan, South Korea and eight European countries: a national register-based study, 1990-2015.

Abstract: Background We compared mortality inequalities by occupational class in Japan and South Korea with those in European countries, in order to determine whether patterns are similar. Methods National register-based data from Japan, South Korea and eight European countries (Finland, Denmark, England/Wales, France, Switzerland, Italy (Turin), Estonia, Lithuania) covering the period between 1990 and 2015 were collected and harmonised. We calculated age-standardised all-cause and cause-specific mortality among men aged 35–64 by occupational class and measured the magnitude of inequality with rate differences, rate ratios and the average inter-group difference. Results Clear gradients in mortality were found in all European countries throughout the study period: manual workers had 1.6–2.5 times higher mortality than upper non-manual workers. However, in the most recent time-period, upper non-manual workers had higher mortality than manual workers in Japan and South Korea. This pattern emerged as a result of a rise in mortality among the upper non-manual group in Japan during the late 1990s, and in South Korea during the late 2000s, due to rising mortality from cancer and external causes (including suicide), in addition to strong mortality declines among lower non-manual and manual workers. Conclusion Patterns of mortality by occupational class are remarkably different between European countries and Japan and South Korea. The recently observed patterns in the latter two countries may be related to a larger impact on the higher occupational classes of the economic crisis of the late 1990s and the late 2000s, respectively, and show that a high socioeconomic position does not guarantee better health.

Housing and health: New evidence using biomarker data

Abstract: Background The link between housing and health is well established and long-standing, however much of the evidence relies on self-reported health measures. While these are useful, the availability of biomarker data allows us to add to this evidence using objective indicators of health. Methods In this paper, we use C-reactive protein (CRP), a biomarker associated with infection and stress, alongside information relating to housing details, demographic characteristics and health behaviours taken from the UK Household Longitudinal Study. Hierarchical linear regression models estimate CRP for individual housing characteristics, and all available housing characteristics, controlling for confounders. Results Results indicate that housing tenure, type, cost burden and desire to stay in current home are associated with CRP. Private renters have significantly higher (worse) CRP than owners with a mortgage. In terms of housing type, respondents living in detached homes had lower CRP than those in semidetached or terraced houses, or those living in flats. Housing cost burden is associated with lower CRP, although further analysis indicates that this is the case only for low-income renters. Desire to stay in current home is significantly associated with higher CRP. Conclusions A number of housing characteristics were associated with CRP. These results further support an important role for housing in health.

High-sensitivity C reactive protein and risk of cardiovascular disease in China-CVD study

Abstract: Background This study aimed to assess the association of high sensitivity C-reactive protein (hs-CRP) with cardiovascular disease (CVD) in middle-aged Chinese population. Methods The baseline was collected 2009–2010, and follow-up was conducted in 2016–2017. Data of hs-CRP were from baseline examination and re-examination in 2016–2017 using transmission turbidimetry with a measurement range of 0–42 000. The primary outcome was CVD including coronary heart disease events and stroke events. Results Among 8688 participants free from CVD (at baseline, mean age, 50.1 years, 3897 were males), there were 189 CVD events, occurred during a median follow-up of 6.34 years (54 685 person-years at risk). From the Kaplan-Meier curve, we found that there was a progressive increase in CVD event rates by hs-CRP tertiles (log-rank test, p Conclusions In the middle-aged Chinese population, hs-CRP was associated with increased risk of developing CVD. Although there was no correlation between hs-CRP change and CVD, the level of hs-CRP was higher at follow-up than baseline even among those with CVD. More attention should be given to those with higher level of hs-CRP for CVD prevention.

Socioeconomic inequality in recent adverse all-cause mortality trends in Scotland.

Abstract: Background Gains in life expectancies have stalled in Scotland, as in several other countries, since around 2012. The relationship between stalling mortality improvements and socioeconomic inequalities in health is unclear. Methods We calculate the difference, as percentage change, in all-cause, all-age, age-standardised mortality rates (ASMR) between 2006 and 2011 (period 1) and between 2012 and 2017 (period 2), for Scotland overall, by sex, and by Scottish Index of Multiple Deprivation (SIMD) quintile. Linear regression is used to summarise the relationship between SIMD quintile and mortality rate change in each period. Results Between 2006 and 2011, the overall ASMR fell by 10.6% (138/100 000), by 10.1% in women, and 11.8% in men, but between 2012 and 2017 the overall ASMR fell by only 2.6% (30/100 000), by 3.5% in women, and by 2.0% in men. Within the most deprived quintile, the overall ASMR fell by 8.6% (143/100 000) from 2006 to 2011 (7.2% in women; 9.8% in men), but rose by 1.5% (21/100 000) from 2012 to 2017 (0.7% in women; 2.1% in men).The socioeconomic gradient in ASMR improvement more than quadrupled, from 0.4% per quintile in period 1, to 1.7% per quintile in period 2. Conclusion From 2012 to 2017, socioeconomic gradients in mortality improvement in Scotland were markedly steeper than over the preceding 6 years. As a result, there has not only been a slowdown in overall reductions in mortality, but a widening of socioeconomic mortality inequalities.

Inequalities in adolescent self-rated health and smoking in Europe: comparing different indicators of socioeconomic status.

Abstract: Background Although there is evidence for socioeconomic inequalities in health and health behaviour in adolescents, different indicators of socioeconomic status (SES) have rarely been compared within one data sample. We examined associations of five SES indicators with self-rated health (SRH) and smoking (ie, a leading cause of health inequalities) in Europe. Methods Data of adolescents aged 14–17 years old were obtained from the 2013 SILNE survey (smoking inequalities: learning from natural experiments), carried out in 50 schools in 6 European cities (N=10 900). Capturing subjective perceptions of relative SES and objective measures of education and wealth, we measured adolescents’ own SES (academic performance, pocket money), parental SES (parental educational level) and family SES (Family Affluence Scale, subjective social status (SSS)). Logistic regression models with SRH and smoking as dependent variables included all SES indicators, age and gender. Results Correlations between SES indicators were weak to moderate. Low academic performance (OR=1.96, 95% CI 1.53 to 2.51) and low SSS (OR=2.75, 95% CI 2.12 to 3.55) were the strongest indicators of poor SRH after adjusting for other SES-indicators. Results for SSS were consistent across countries, while associations with academic performance varied. Low academic performance (OR=5.71, 95% CI 4.63 to 7.06) and more pocket money (OR=0.21, 95% CI 0.18 to 0.26) were most strongly associated with smoking in all countries. Conclusions Socioeconomic inequalities in adolescent health were largest according to SES indicators more closely related to the adolescent’s education as well as the adolescent’s perception of relative family SES, rather than objective indicators of parental education and material family affluence. For future studies on adolescent health inequalities, consideration of adolescent-related SES indicators was recommended.

Quantifying the impact of the Public Health Responsibility Deal on salt intake, cardiovascular disease and gastric cancer burdens: interrupted time series and microsimulation study.

Abstract: Background In 2011, England introduced the Public Health Responsibility Deal (RD), a public-private partnership (PPP) which gave greater freedom to the food industry to set and monitor targets for salt intakes. We estimated the impact of the RD on trends in salt intake and associated changes in cardiovascular disease (CVD) and gastric cancer (GCa) incidence, mortality and economic costs in England from 2011–2025. Methods We used interrupted time series models with 24 hours9 urine sample data and the IMPACTNCD microsimulation model to estimate impacts of changes in salt consumption on CVD and GCa incidence, mortality and economic impacts, as well as equity impacts. Results Between 2003 and 2010 mean salt intake was falling annually by 0.20 grams/day among men and 0.12 g/d among women (P-value for trend both Interpretation Public-private partnerships such as the RD which lack robust and independent target setting, monitoring and enforcement are unlikely to produce optimal health gains.

Neighbourhood racial/ethnic residential segregation and cardiometabolic risk: the multiethnic study of atherosclerosis

Abstract: Background Racial residential segregation has been linked to adverse health outcomes, but associations may operate through multiple pathways. Prior studies have not examined associations of neighbourhood-level racial segregation with an index of cardiometabolic risk (CMR) and whether associations differ by race/ethnicity. Methods We used data from the Multi-Ethnic Study of Atherosclerosis to estimate cross-sectional and longitudinal associations of baseline neighbourhood-level racial residential segregation with a composite measure of CMR. Participants included 5015 non-Hispanic black, non-Hispanic white and Hispanic participants aged 45–84 years old over 12 years of follow-up (2000–2012). We used linear mixed effects models to estimate race-stratified associations of own-group segregation with CMR at baseline and with the rate of annual change in CMR. Models were adjusted for sociodemographics, medication use and individual-level and neighbourhood-level socioeconomic status (SES). Results In models adjusted for sociodemographics and medication use, high baseline segregation was associated with higher baseline CMR among blacks and Hispanics but lower baseline CMR among whites. Individual and neighbourhood-level SES fully explained observed associations between segregation and CMR for whites and Hispanics. However, associations of segregation with CMR among blacks remained (high vs low segregation: mean difference 0.17 SD units, 95% CI 0.02 to 0.32; medium vs low segregation: mean difference 0.18 SD units, 95% CI 0.03 to 0.33). Baseline segregation was not associated with change in CMR index scores over time. Conclusion Associations of own-group racial residential segregation with CMR varied by race/ethnicity. After accounting for SES, living in a more segregated neighbourhood was associated with greater risk among black participants only.

Can green space quantity and quality help prevent postpartum weight gain? A longitudinal study.

Abstract: Background Postpartum weight gain is a well-known challenge for many mothers, but associations with green space quantity and quality have not been investigated. Methods This longitudinal study used data on 3843 mothers living in Australia tracked biennially for 15 years post partum from 2004 onwards. Multilevel growth curve models adjusted for confounding were used to examine the patterning of body mass index (BMI) in relation to green space quantity, measured by percentage land use, and green space quality, measured by self-report. Two-way interaction terms were fitted to investigate time-contingent associations between BMI and green space. Results Compared with mothers in areas with ≤5% green space, adjusted BMI coefficients were −0.43 kg/m 2 (SE 0.37), −0.69 kg/m 2 (SE 0.32) −0.86 kg/m 2 (SE 0.33) and −0.80 kg/m 2 (SE 0.41) among mothers in areas with 6%–10%, 11%–20%, 21%–40% and ≥41% green space, respectively. There were no independent associations between BMI and green space quality. Evidence suggested mothers living in areas with 21%–40% green space had the lowest BMI, whether they agreed that local parks were good quality (−0.89 kg/m 2 (SE 0.34)) or not (−0.93 kg/m 2 (SE 0.35)). Mothers in the greenest areas only had statistically significantly lower BMI if they perceived local parks as high quality (−0.89 kg/m 2 (SE 0.41)). There was limited evidence that these associations varied with respect to the number of years post partum. Conclusion These findings may suggest that urban greening strategies to achieve a threshold of at least 21% or more green space in an area may help reduce, but not fully prevent postpartum weight gain. Potential mechanisms warrant investigation.

Cigarette smoking and oral microbiota in low-income and African-American populations

Abstract: Background Cigarette smoking is a common risk factor for diseases and cancers. Oral microbiota is also associated with diseases and cancers. However, little is known about the impact of cigarette smoking on the oral microbiota, especially among ethnic minority populations. Methods We investigated cigarette smoking in relationship with the oral microbiota in a large population of predominately low-income and African-American participants. Mouth rinse samples were collected from 1616 participants within the Southern Community Cohort Study, including 592 current-smokers, 477 former-smokers and 547 never-smokers. Oral microbiota was profiled by 16S ribosomal RNA gene deep sequencing. Results Current-smokers showed a different overall microbial composition from former-smokers (p=6.62×10−7) and never-smokers (p=6.00×10−8). The two probiotic genera, Bifidobacterium and Lactobacillus, were enriched among current-smokers when compared with never-smokers, with Bonferroni-corrected p values (PBonferroni) of 1.28×10−4 and 5.89×10−7, respectively. The phylum Actinobacteria was also enriched in current-smokers when compared with never-smokers, with a median relative abundance of 12.35% versus 9.36%, respectively, and with a PBonferroni=9.11×10−11. In contrast, the phylum Proteobacteria was depleted in current smokers (PBonferroni=5.57×10−13), with the relative abundance being almost three times that of never-smokers (7.22%) when compared with that of current-smokers (2.47%). Multiple taxa within these two phyla showed differences in abundance/prevalence between current-smokers and never-smokers at PBonferroni Conclusion Smoking has strong impacts on oral microbial community, which was recovered after smoking cessation.

Interdisciplinary research in public health: the 'why' and the 'how'.

Abstract: Public health constitutes a field of choice for developing interdisciplinary research. Targeting population health improvement necessarily entails embedding research and intervention within a variety of complementary disciplinary approaches. Medicine (and its scientific and professional domains), psychology, epidemiology, economics, social and political sciences, health services research, humanities, geography and legal science all involve research perspectives conducive to the observation, analysis, understanding and interpretation of health facts. When implementing and directing efficient and positive health actions for population, communities and people, the fact of working across disciplines—whether health be their main research focus and health improvement their aim—provides rich, innovative and relevant data for public health intervention. A number of definitions of interdisciplinarity are available in the literature.1 From these definitions, we retain two key characteristics: the encounter of two or more scientific disciplines and the interactive nature of the research process. The need for interdisciplinary research and action today is supported by two main arguments. First, the prominence of population health intervention research2 calls for evidence-based data on the effectiveness and efficiency of interventions that are useful to decision makers and meet the needs and expectations of populations. It implies adopting a multiperspective approach to health problems, their multidimensional factors and possible levers of intervention, as well as embracing the complex dimension of health problems1; only joint work between disciplines can help …

Labour market marginalisation among refugees from different countries of birth: a prospective cohort study on refugees to Sweden

Abstract: Background The aim was to elucidate if the risk of labour market marginalisation (LMM), measured as long-term unemployment, long-term sickness absence, disability pension and a combined measure of these three measures, differed between refugees and non-refugee migrants with different regions of birth compared with native Swedes. Methods All non-pensioned individuals aged 19–60 years who were resident in Sweden on 31 December 2009 were included (n=4 441 813, whereof 216 930 refugees). HRs with 95% CIs were computed by Cox regression models with competing risks and time-dependent covariates with a follow-up period of 2010–2013. Results Refugees had in general a doubled risk (HR: 2.0, 95% CI 1.9 to 2.0) and non-refugee migrants had 70% increased risk (HR: 1.7, 95% CI 1.7 to 1.7) of the combined measure of LMM compared with native Swedes. Refugees from Somalia (HR: 2.7, 95% CI 2.6 to 2.8) and Syria (HR: 2.5, 95% CI 2.5 to 2.6) had especially high risk estimates of LMM, mostly due to high risk estimates of long-term unemployment (HR: 3.4, 95% CI 3.3 to 3.5 and HR: 3.2, 95% CI 3.1 to 3.2). African (HR: 0.7, 95% CI 0.6 to 0.7) and Asian (HR: 1.0, 95% CI 1.0 to 1.1) refugees had relatively low risk estimates of long-term sickness absence compared with other refugee groups. Refugees from Europe had the highest risk estimates of disability pension (HR: 1.9, 95% CI 1.8 to 2.0) compared with native Swedes. Conclusion Refugees had in general a higher risk of all measures of LMM compared with native Swedes. There were, however, large differences in risk estimates of LMM between subgroups of refugees and with regard to type of LMM. Actions addressing differences between subgroups of refugees is therefore crucial in order to ensure that refugees can obtain as well as retain a position on the labour market.

Walk Score and objectively measured physical activity within a national cohort.

Abstract: Background There have been mixed findings regarding the relationship between walkability and level of physical activity in adults. Methods Participants from The REasons for Geographic and Racial Differences in Stroke (REGARDS) national cohort (N=7561) were used to examine the association between Walk Score and physical activity measured via accelerometry. The subsample included geographically diverse adults, who identified as black or white, and were over the age of 45. Linear regression was used to examine the direct effects, as well as the interaction, of Walk Score by sex, age and race. Results The majority of participants lived in a ‘Very Car-Dependent’ location (N=4115). Only 527 lived in a location that was ‘Very Walkable/Walker’s Paradise’. Living in a location with a Walk Score of ‘Very Car-Dependent’ compared with ‘Very Walkable/Walker’s Paradise’ was associated with 19% (0.81; 95% CI 0.73 to 0.90) lower predicted minutes of moderate to vigorous physical activity per day, after adjustment for covariates. There was no evidence of statistically significant interactions between Walk Score and sex, age or race (p>0.05). Conclusion Accumulated daily time in moderate to vigorous physical activity was higher for participants living in neighbourhoods designated as ‘Very Walkable/Walker’s Paradise’. This effect was not moderated by sex, age or race of participants.

Developmental origins of endometriosis: a Swedish cohort study

Abstract: BACKGROUND: Endometriosis is a chronic condition affecting women of reproductive age and is associated with multiple health burdens. Yet, findings regarding its 'developmental origins' are inconsis ...