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Background: Hypertension is one of the leading causes of avoidable mortality in the former Soviet Union (fSU). In previous work, the authors described patterns of irregular hypertension treatment in eight countries of the fSU in 2001. This paper presents new data on changes in the use of hypertension treatment in the same countries. Methods: Using household survey data from 18 420 (2001) and 17 914 (2010) respondents from Armenia, Azerbaijan (2010 only), Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia and Ukraine, the authors describe changes in rates of irregular treatment use (less than daily) between 2001 and 2010. Multivariate logistic regression was also used to analyse the characteristics associated with irregular treatment. Results: Irregular treatment was extremely high at 74% in 2001 and only fell to 68% in 2010 (all countries combined). Irregular treatment remained particularly high in 2010 in Armenia (79%), Kazakhstan (73%) and Moldova (73%). Recurring characteristics associated with irregular treatment included gender (men), younger age, higher fitness levels, and consuming alcohol and tobacco. Conclusions: Irregular hypertension treatment continues to be a major problem in the countries of the fSU and requires an urgent response. [ABSTRACT FROM AUTHOR]

Background Community mobilisation interventions for HIV prevention among female sex workers (FSWs) aim to organise FSWs for collective action and challenge the structures of power that underlie HIV risk. Assessing intervention impact is challenging because the importance of direct individual exposure to intervention components may decrease over time as change occurs at social-normative, policy and other structural levels. In this paper, the authors examine changes over time in consistent condom use among FSWs in Rajahmundry, Andhra Pradesh, the location of a long-standing community mobilisation intervention. Methods The authors analyse cross-sectional data collected among FSWs at three time points (n=2276) using respondent-driven sampling. Multiple logistic regression was used to assess the association of programme exposure with consistent condom use and whether this association varied over time. Results The proportion of FSWs having no exposure or only receptive exposure to the intervention decreased over time, while active utilisation increased from 19.4% in 2006 to 48.5% in 2009-2010. Consistent condom use with clients also increased from 56.3% in 2006 to 75.3% in 2009-2010. Multivariate analysis showed that age, age at start of sex work, venue, living conditions and programme exposure were significantly associated with condom use. The positive association between programme exposure and consistent condom use did not vary significantly over time. Conclusions Findings indicate improvements in HIV risk reduction behaviour among FSWs and suggest that the intervention has substantial reach in the FSW population. The intervention's strategies may be contributing to population-level HIV risk reduction among FSWs. [ABSTRACT FROM AUTHOR]

Objectives This paper aims to examine ethnic differences in financial barriers to access to prescriptionmedication in New Zealand. Methods Data from SoFIE-Health (wave 3), which is an add-on to the Statistics New Zealand-led longitudinal Survey of Family, Income and Employment (SoFIE) (N¼18 320), were analysed using logistic regression, adjusting for demographic, socioeconomic, health behaviour and health variables. Financial barriers to access to prescription items were measured by the following question: 'In the past 12 months, have there been any times when a doctor gave you a prescription, but you didn't collect one or more of these items because you could not afford the cost?'. Results The odds of deferring buying a prescription at least once during the preceding 12 months because they could not afford the cost of the prescription were greater for Maori and Pacific people than for NZ Europeans (OR 2.98, 95% CI 2.56 to 3.47 vs OR 3.52, 95% CI 2.85 to 4.35). Adjusting for potential confounders attenuated the ORs to 1.31 (95% CI 1.08 to 1.58) for Maori people and to 2.17 (95% CI 1.68 to 2.81) for Pacific people. Deferring buying medications because of cost was also associated with increased odds of poor self-reported health status, high/very high psychological stress and the presence of two or more comorbid conditions. Conclusion Ethnicity plays a critical role in facilitating or impeding access to primary health care. This suggests that policy measures to further reduce financial barriers to buying medication may improve access to care for everyone including Maori and Pacific people and may have positive health implications. [ABSTRACT FROM AUTHOR]

Background Although long-term trends in local labour market conditions are likely to influence health, few studies have assessed whether this is so. This paper examines whether (1) trends in local employment rates have relevance for mortality and morbidity outcomes in England and (2) trends are stronger predictors of these outcomes than employment rates measured at one point in time. Methods Using latent class growth models, local areas were classified into eight groups following distinct trends in employment rates between 1981 and 2008. Areas were also categorised in 'octile' groups by rank of employment rates in 2001. These area groupings were linked to a sample of 207 959 individuals from the Office of National Statistics Longitudinal Study. Associations between area groupings and risk of all-cause mortality and of reporting a limiting long-term illness at the end of the period were measured using logistic regression. Models were adjusted for individuals' socio-demographic characteristics measured in 1981 and for their residential mobility between 1981 and 2001. Results Compared to areas with continuously high employment rates over the period, risk of mortality and morbidity was higher in areas with persistently low or declining employment rates. Findings suggest that longterm trends in local employment rates are useful as predictors of mortality and morbidity differences. These are not so clearly distinguished by only considering employment rates at one point in time. Conclusion Poor health outcomes are associated with long-term economic disadvantage in some areas of England, reflected in employment rates, underlining the importance of efforts to improve health in areas with especially 'deep-seated' deprivation. [ABSTRACT FROM AUTHOR]

Background This paper examines the association between degree of confidence in collective efficacy and self-efficacy for condom use and empowerment among heterogeneous female sex workers (FSWs) in two metropolitan Indian cities with high HIV prevalence. Methods The study utilises data from the Behavioural Tracking Survey, a cross-sectional behavioural study with 2106 FSWs recruited from 411 intervention sites in Mumbai and Thane. The key independent measures used determine the degree of confidence in collective efficacy (belief in the power to achieve goals and address problems together) and outcome measures included: self-efficacy for condom use with occasional clients and condom use with regular partners, self-confidence in handling a crisis situation and public speaking ability. Univariate and multivariate statistical methods were used to examine the study objectives. Results Of the analytical sample of 2106 FSWs, 532 (25.3%) reported high degree of collective efficacy for achieving certain goals and 1534 (72.8%) reported collective efficacy for addressing specific problems. FSWs reporting a higher collective efficacy as compared with those reporting lower collective efficacy were as follows: more likely to negotiate condom use with occasional clients (60.3% vs 19.7%; adjusted OR (AOR) =6.3, 95% CI 4.8 to 8.4) as well as regular partners (62.8% vs 20.2%; AOR =6.4, 95% CI 4.9 to 8.4); confident in facing troublesome stakeholders (73.5% vs 38.8%; AOR =4.3, 95% CI 3.3 to 5.6), confident in supporting fellow FSWs in a crisis (76.1% vs 49.6%; AOR =2.9, 95% CI 2.2 to 3.7), received help from other FSWs when a client or partner was violent (73.9% vs 46.3%; AOR =3.5, 95% CI 2.7 to 4.5) and had stood up to the police or madams/brokers to help fellow FSWs in the past 1 year (5.8% vs 3.3%; AOR =2.7, 95% CI 1.5 to 4.9). Conclusion The results suggest that the strategy of collectivisation in HIV prevention programme has much broader benefits than merely the promotion of safer sex practices. Future HIV prevention interventions in India and elsewhere may include collectivisation as the core strategy within HIV prevention programmes. [ABSTRACT FROM AUTHOR]

Background Whether the quality of life (QOL) impacts longevity is an interesting research question that has been investigated only in the context of disease and health-related QOL. This paper aims to examine prospectively whether Control, Autonomy, Selfrealisation, and Pleasure (CASP) scores, a measure of generic QOL, can predict mortality in the British Household Panel Survey sample during 2001-2006. Methods The authors used data from the British Household Panel Survey wave 11 (2001-2002) when CASP was first presented to the participants in the survey. The authors selected all those who were interviewed directly and face to face and who were 40 years or older (N=10 291). The authors followed them for the next five waves (waves 12-16) and in this study primary outcome was all-cause mortality. Other covariates used were age, sex, socioeconomic position, household income, self-rated health, limiting longstanding illness and medical conditions. Results Compared with a mortality of 12/1000 personyears in those having average QOL (CASP score 29.4-45.8), those with below-average QOL had more than twice (27/1000 person-years) and those above average had a third less (8/1000 person-years) mortality. This gradient was retained for the most part when age and sex strata were examined separately. Regression models adjusted for covariates confirmed the protective effect of QOL on mortality. Domain-specific analysis showed that only control and self-realisation had this effect. Conclusion CASP predicted 5-year all-cause mortality significantly. Improvement in the QOL reduced the probability of death. [ABSTRACT FROM AUTHOR]

Background Prior evidence suggests that caregiving may increase risk of cardiovascular disease (CVD) onset. This association has never been examined in a nationally (USA) representative sample, and prior studies could not fully control for socioeconomic confounders. This paper seeks to estimate the association between spousal caregiving and incident CVD in older Americans. Methods Married, CVD-free Health and Retirement Study respondents aged 50+ years (n=8472) were followed up to 8 years (1669 new stroke or heart disease diagnoses). Current caregiving exposure was defined as assisting a spouse with basic or instrumental activities of daily living ≥14 h/week according to the care recipients' report in the most recent prior biennial survey; we define providing ≥14 h/week of care at two consecutive biennial surveys as 'long-term caregiving'. Inverse probability weighted discrete-time hazard models with time-updated exposure and covariate information (including socioeconomic and cardiovascular risk factors) were used to estimate the effect of caregiving on incident CVD. Results Caregiving significantly predicted CVD incidence (HR=1.35, 95% CI 1.06 to 1.68) in the population overall. Long-term caregiving was associated with double the risk of CVD onset (HR=1.95, 95% CI 1.19 to 3.18). This association for long-term care givers varied significantly by race (p<0.01): caregiving predicted CVD onset for white (HR=2.37, 95% CI 1.43 to 3.92) but not for non-white (HR=0.28, 95% CI 0.06 to 1.28). Conclusions Spousal caregiving independently predicted risk of CVD in a large sample of US adults. There was significant evidence that the effect for long-term care givers differs for non-whites and white. [ABSTRACT FROM AUTHOR]

Background The Baby-Friendly Hospital Initiative (BFHI) has been implemented by WHO and Unicef with a view to protect, promote and support breast feeding. This paper aims to assess the influence of the BFHI on breastfeeding indicators in Brazil, using data from the 2nd Survey of Breastfeeding Prevalence, conducted in 2008. Methods Data on 64 municipalities were analysed: a total of 65 936 infants under the age of 1 year who were covered by the 2008 immunisation campaign. The outcomes of interest were breast feeding in the first hour of life in infants under 1 year of age; exclusive breast feeding on the first day after hospital discharge in infants under 4 months of age; exclusive breast feeding in infants under 2, 3 and 6 months of age; and pacifier use in infants under 6 months of age. The influence of birth in baby-friendly hospitals (BFHs) on these end points was analysed by means of Poisson regression with robust variance for complex samples. Findings Infants born in BFHs were 9% more likely to be breast fed in the first hour of life and 6% more likely to be breast fed on the first day at home. Exclusive breast feeding was 13%, 8% and 6% more likely in infants under the ages of 2, 3 and 6 months, respectively, born in BFHs. Birth in a BFH also correlated with significant less pacifier use. Conclusions The BFHI has had an impact on several indicators of breast feeding. The authors hope the results of this study will make policy makers and health professionals aware of the importance and potential of this strategy. [ABSTRACT FROM AUTHOR]

Objective To determine the effectiveness and impact of the Dutch childhood hepatitis B virus (HBV) vaccination policy targeted at children with at least one parent born in a HBV endemic country. Methods The Dutch vaccination registration database was used to determine vaccine coverage for HBV and DTP-IPV-Hib in the target population. HBV notifications were used to estimate the impact. The HBV incidence was determined in children aged 0-4 years and born after (2003-7) and before (1990-2002) the introduction of the HBV vaccination programme. Results HBV vaccine coverage in the target population was 89.6% (96 186/107 338) in the period 2003-5. There were 37 notified acute infections in the pre-vaccination birth cohort 1990-2002 (incidence 2.9/106 person-years), compared with one in the post-vaccination birth cohort 2003-7 (incidence 0.3/106 person-years). The incidence rate ratio for the 2003-7 birth cohort compared with the 1990-2002 birth cohort was 0.12 (95% CI 0.02 to 0.87; p=0.04). Conclusions This paper shows that the incidence of HBV notifications in children born after the introduction of targeted childhood HBV vaccinations is lower compared with the incidence in children born before the start of this vaccination programme. Although this is consistent with a good HBV vaccine coverage, the interpretation is hampered by a change in case definition for notification in 1999. The results are of importance to policy makers in both The Netherlands and other countries that have a targeted HBV vaccination programme. [ABSTRACT FROM AUTHOR]

Background Confounding of mediator–outcome associations resulting in collider biases causes systematic error when estimating direct and indirect effects. However, until recently little attention has been given to the impact of misclassification bias. Objective To quantify the impact of non-differential and independent misclassification of a dichotomous exposure and a dichotomous mediator on three target parameters: the total effect of exposure on outcome; the direct effect (by conditioning on the mediator); and the indirect effect (identified by the percentage reduction in the excess OR on adjusting for the mediator). Methods Simulations were conducted for varying strength of associations between exposure, mediator and outcome, varying ratios of exposed to unexposed and mediator present to mediator absent, and varying sensitivity and specificity of exposure and mediator classification.Results ORs before (total effect) and after adjustment (direct effect) for the mediator are both biased towards the null by non-differential misclassification of the exposure, but the percentage reduction in the excess OR is little affected by misclassification of exposure. Conversely, misclassification of the mediator rapidly biases the percentage reduction of the excess OR (indirect effect) downwards.Conclusions If the research objective is to quantify the proportion of the total association that is due to mediation (ie, indirect effect), then minimising nondifferential misclassification bias of the mediator is more important than that for the exposure. Misclassification bias is an important source of error when estimating direct and indirect effects. [ABSTRACT FROM AUTHOR]

Objectives Alcohol use in Russia has a number of relatively distinct features which have been shown to be strongly associated with mortality. The aim of this paper is to investigate how specific aspects of Russian drinking behaviour and its consequences are related to scores obtained from the internationally recognised AUDIT instrument for detecting alcohol problems. Design Population-based age-stratified cross sectional survey. Setting Izhevsk, Russia. Participants 925 men aged 25–59 years. Main outcome measure Men and proxy respondents completed an interview including questions on alcohol consumption and socio-economic and demographic variables. These included questions on six drinking behaviours and their consequences. These were: going on zapoi (a period of continuous drunkenness of two or more days); drinking non- beverage alcohol; frequency of excessive drunkenness; frequency of hangover; drinking before noon and frequency of sleeping in clothes at night because of drunkenness. The men also completed a Self Completed Questionnaire containing questions constituting the alcohol use disorders identification test (AUDIT). Results There was a strong association with AUDIT score and hazardous drinking (one or more episodes of zapoi in the past year or drinking non beverage alcohol or twice a week or more occurrence of excessive drunkenness, hangover or going to sleep at night clothed because of drunkenness) using both proxy and self report of drinking behaviours (self-report OR 5.25 95% CI 2.86 to to 9.65). The association was stronger when proxy report was used (proxy-report OR 6.66 95% CI 4.00 to to 11.07). The same pattern was seen for all the drinking behaviours individually. Confirmatory factor analysis supported a two factor structure for the AUDIT measuring alcohol consumption and alcohol related problems. Hazardous drinking behaviour specific to Russia was more strongly associated with AUDIT questions relating to alcohol related problems than to questions measuring consumption. Conclusions The drinking behaviours used in this paper are unconventional measures of hazardous drinking. The strong association with AUDIT shows that both self and in particular proxy report of distinctive directly observable drinking behaviours provide useful data on alcohol consumption and abuse in Russian men. [ABSTRACT FROM PUBLISHER]

Background: Studies have shown associations between higher income and better health, but income has not been studied in relation to neck pain. The aims of this cohort study were to assess the sex-specific role of disposable income for onset and prognosis of neck pain in the general population and if economic stress influences such potential associations. Methods: Two subcohorts were identified in the Stockholm Public Health Cohort with data from 2002. Cohort I (risk cohort) included persons without neck pain (n=8348). Cohort II (prognostic cohort) included persons with occasional neck pain during the previous 6 months (n=10 523). Both cohorts were assessed for long duration troublesome neck pain (LDNP) in 2007. Individual income was defined as aggregated annual family income in 2002 with each family member assigned a weighted consumption share, based on salary, pensions and social benefits. LDNP in 2007 was defined as having had troublesome neck pain lasting for three or more consecutive months the previous 5 years. Association between income and LDNP, considering potential confounding, was investigated by multivariable logistic regression. Economic stress was tested as effect modifier between income and LDNP. Results: In both cohorts, associations were found between lower income and a higher risk for LDNP. The results were similar between the sexes. Economic stress modified the associations in both cohorts. Conclusions: Low income may be a risk as well as prognostic factor for developing LDNP. Furthermore, the results indicate that economic stress may be an underlying factor to consider when studying associations between income and neck pain. [ABSTRACT FROM AUTHOR]

Background: Previous studies, all of <20 years of followup, have suggested an association between lung function and the risk of fatal stroke. This study investigates the stability of this association in a cohort followed for 4 decades. Methods: The Bergen Clinical Blood Pressure Survey was conducted in Norway in 1964--1971. The risk of fatal stroke associated with forced expiratory volume after one second (FEV1) was estimated with Cox proportional hazards regression, making progressive adjustment for potential confounders. Results: Of 5617 (84%) participants with recorded baseline FEV1, 462 died from stroke over 152 786 subsequent person-years of follow-up according to mortality statistics of 2005; mean (SD) follow-up was 27 (12) years. An association between baseline FEV1 (L) and fatal stroke was observed; HR=1.38 (95% CI 1.11 to 1.71) and HR=1.62 (95% CI 1.22 to 2.15) for men and women, respectively (adjusted for age and height). The findings were not explained by smoking, hypertension, diabetes, atherosclerosis, socioeconomic status, obstructive lung disease, physical inactivity, cholesterol or body mass index and persisted in subgroups of never-smokers, subgroups without respiratory symptoms and survivors of the first 20 years of follow-up. For male survivors with a valid FEV1 at follow-up (1988--1990) (n=953), baseline FEV1 (L) indicated a possible strong and independent association to the risk of fatal stroke after adjustments for individual changes in FEV1 (ml/year) (HR 1.95 (95% CI 0.98 to 3.86)). Conclusion: There is a consistent, independent and long-lasting association between lung function and fatal stroke, probably irrespective of changes during adult life. [ABSTRACT FROM AUTHOR]

Background To examine the association between the presence of community advocacy groups (CAGs) and female sex workers' (FSWs) access to social entitlements and outcomes of police advocacy. Methods Data were used from a cross-sectional survey conducted in 2010-2011 among 1986 FSWs and 104 NGO outreach workers from five districts of Andhra Pradesh. FSWs were recruited using a probability-based sampling from 104 primary sampling units (PSUs). A PSU is a geographical area covered by one outreach worker and is expected to have an active CAG as per community mobilisation efforts. The presence of active CAGs was defined as the presence of an active committee or advocacy group in the area (PSU). Outcome indicators included acquisition of different social entitlements and measures of police response as reported by FSWs. Multivariate linear and logistic regression analyses were used to examine the associations. Results Areas with active CAGs compared with their counterparts had a significantly higher mean number of FSWs linked to ration cards (12.8 vs 6.8; p<0.01), bank accounts (9.3 vs 5.9; p=0.05) and health insurance (13.1 vs 7.0; p=0.02). A significantly higher percentage of FSWs from areas with active CAGs as compared with others reported that the police treat them more fairly now than a year before (79.7% vs 70.3%; p<0.05) and the police explained the reasons for arrest when arrested the last time (95.7% vs 87%; p<0.05). Conclusion FSWs from areas with active CAGs were more likely to access certain social entitlements and to receive a fair response from the police, highlighting the contributions of CAGs in community mobilisation. [ABSTRACT FROM AUTHOR]

Background To assess the association between female sex workers' (FSWs) degree of community collectivisation and self-efficacy, utilisation of sexually transmitted infection (STI) services from government-run health centres in Andhra Pradesh, India. Methods Cross-sectional analyses of 1986 FSWs recruited using a probability-based sampling from five districts of Andhra Pradesh during 2010-2011. Multiple logistic regression models were constructed to assess associations. The independent variables included-collective efficacy, collective agency and collective action-measured using a series of items that assessed the grouping of the community on issues that concern most sex workers. An additional independent variable included FSWs belonging to an area where there was a project partnership with government health centres to provide STI treatment services to FSWs. The outcome indicators included self-efficacy for service utilisation from government health facilities and the treatment for STIs from government health facilities at least once in the past year experience of STI symptoms. Results Of the 1986 FSWs, nearly two-fifths (39.5%) reported a high level of overall collectivisation (collective efficacy: 89%, collective agency: 50.7%; collective action: 12.7%). Sex workers with a high degree compared with low degree of overall collectivisation were significantly more likely to report high self-efficacy to use government health facilities (75.0% vs 57.3%, adjusted OR 2.5, 95% CI 2.0 to 3.1) and to use government health centres for STI treatment in past 1 year (78.1% vs 63.2%, adjusted OR 2.1, 95% CI 1.6 to 2.8), irrespective of project partnership with government centres. Conclusion The current research findings reinforce the need for stronger community mobilisation for better utilisation of government health facilities for STI and HIV prevention interventions. [ABSTRACT FROM AUTHOR]

Background: There have been few evaluations of national area-based interventions. This study evaluated the early effects of Communities for Children (CfC) on children and their families and whether the effectiveness differed for more disadvantaged families. Methods: A quasi-experimental cohort study in socioeconomically disadvantaged communities in Australia. Mothers of children aged 2--3 years participated at wave 1; 1488 children in CfC communities and 714 children in comparison communities. Outcome measures included child health and development, family functioning and parenting, and services and community. Results: After controlling for background factors, there were beneficial effects associated with CfC. At wave 3, in CfC areas children had higher receptive vocabulary (mean difference (MD) 0.25, 95% CI --0.02 to 0.51; p=0.07), parents showed less harsh parenting (MD --0.14, 95% CI --0.30 to 0.02; p=0.08) and higher parenting self-efficacy (MD 0.11, 95% CI 0.00 to 0.21; p=0.04). Fewer children living in CfC sites were living in a jobless household (OR 0.56, 95% CI 0.32 to 0.95; p=0.03) but children's physical functioning (MD --0.26, 95% CI --0.53 to 0.00; p=0.05) was worse in CfC sites. For children living in households with mothers with low education there were reduced child injuries requiring medical treatment (MD --0.61, 95% CI --0.07 to --1.13; p=0.03) and increased receptive vocabulary (MD 0.57, 95% CI 0.06 to 1.08; p=0.03). Conclusions: CfC showed some benefits for child receptive vocabulary, parenting and reducing jobless households and two adverse effects. Children living in the most disadvantaged households also benefited. [ABSTRACT FROM AUTHOR]

Background Disturbed sleep is common throughout the community and is associated with an increase in daytime sleepiness, both of which, in turn are associated with an increased risk of ischaemic vascular disease. The hypothesis that sleep disturbances are predictive of dementia, and in particular vascular dementia was tested in a large community-based cohort of older men. Methods A questionnaire on sleep disturbances was administered to 1986 men aged 55-69 years in the Caerphilly Cohort Study and 10 years later the men were examined clinically for evidence of dementia or cognitive impairment with no dementia (CIND). Findings Approximately 20% of the men reported disturbed sleep and 30% reported 'severe' daytime sleepiness. Ten years later 1225 men (75% of the surviving men in the cohort) were tested and 268 (22%) were found to be cognitively impaired with 93 (7.6%) showing clear evidence of dementia and the remaining 175 (14.3%) showing evidence of CIND. After adjustment for possible confounding, including cognitive function and the taking of sleeping tablets at baseline, sleep disturbances appeared to be predictive of dementia and CIND of vascular origin, while there was no suggestion of prediction of non-vascular cognitive impairment by sleep. Prediction of vascular dementia appeared to be particularly strong for daytime sleepiness, with an adjusted OR of 4.44 (95% CI 2.05 to 9.61). Further adjustments for psychological distress at baseline reduced the size of the relationships, but the ORs remain large, consistent with a direct positive effect of sleep disturbance on vascular dementia. Interpretation Sleep disturbances, and in particular severe daytime sleepiness, appear to be strongly predictive of vascular dementia, but have no predictive power for non vascular dementia. [ABSTRACT FROM AUTHOR]

Background In non-randomised evaluations of public-health interventions, statistical methods to control confounding will usually be required. We review approaches to the control of confounding and discuss issues in drawing causal inference from these studies. Methods Non-systematic review of literature and mathematical data-simulation. Results Standard stratification and regression techniques will often be appropriate, but propensity scores may be useful where many confounders need to be controlled, and data are limited. All these techniques require that key putative confounders are measured accurately. Instrumental variables offer, in theory, a solution to the problem of unknown or unmeasured confounders, but identifying an instrument which meets the required conditions will often be challenging. Obtaining measurements of the outcome variable in both intervention and control groups before the intervention is introduced allows balance to be assessed, and these data may be used to help control confounding. However, imbalance in outcome measures at baseline poses challenges for the analysis and interpretation of the evaluation, highlighting the value of adopting a design strategy that maximises the likelihood of achieving balance. Finally, when it is not possible to have any concurrent control group, making multiple measures of outcome pre- and postintervention can enable the estimation of intervention effects with appropriate statistical models. Conclusion For non-randomised designs, careful statistical analysis can help reduce bias by confounding in estimating intervention effects. However, investigators must report their methods thoroughly and be conscious and critical of the assumptions they must make whenever they adopt these designs. [ABSTRACT FROM AUTHOR]

Background and Objectives In the US, Hispanic mothers have rates of infant mortality and low birthweight that are comparable to non-Hispanic White mothers despite being more likely to live in socio-economically deprived areas. This well known phenomenon is termed the Hispanic paradox. Recent research suggests that this phenomenon may be partly explained by the areas in which Hispanic people live. Hispanic mothers living in counties with a high proportion of Hispanic people (Hispanic density) have lower rates of infant mortality and smoking during pregnancy. In this paper, we investigate whether or not Hispanic density is associated with better birth outcomes for mothers of other ethnicities. Design Multilevel analysis of the US Linked Birth and Infant Death Dataset 2000 and US census data at county level. Setting USA. Participants 2 274 247 White and 581 151 Black non-Hispanic mothers of singleton births. Main outcome measures Infant mortality, low birthweight, preterm delivery and maternal smoking during pregnancy. Results Living in counties with a higher percentage of Hispanic residents was associated with reduced risk of all outcomes for non-Hispanic White and Black mothers and infants in analyses adjusting for individual and area level socio-demographic characteristics. The reduction in odds was greatest for maternal smoking during pregnancy. White mothers living in counties where more than half the residents were Hispanic had their odds of smoking during pregnancy reduced by approximately 80% (OR 0.19 95% CI 0.11 to 0.33), relative to comparable mothers living at Hispanic densities of 0 to 1%. Similar reductions in risk of maternal smoking during pregnancy were found for Black mothers (OR 0.14 95% CI 0.14 to 0.51). Infant mortality was reduced by approximately a third for both Black and White mothers living in counties with a high proportion of Hispanic residents. In addition, higher Hispanic density was associated with modest but significant reductions in the risks of preterm delivery and low birthweight. Conclusions Living in Hispanic communities appears to have health benefits for those of non-Hispanic origin. [ABSTRACT FROM PUBLISHER]

Background Despite considerable improvements in the overall health of the UK population, the gap between the richest and poorest groups in society continues to widen. Health trainers are a new workforce introduced in the 2004 “Choosing Health” White Paper to address these inequalities by targeting individuals from the poorest groups and supporting them to make healthy lifestyle choices. The largely grass-roots development of health trainers has resulted in a diversity of local service models that lack sound theoretical or empirical basis. However, the role provides an opportunity to enhance our understanding of the needs of typically “hard-to-reach” communities and develop tailored behaviour change interventions. Objectives To conduct an in-depth exploratory study of the ways in which contrasting health trainer models influence behaviour change. Design Qualitative longitudinal study, involving serial interviews conducted over a 12-month period. The interviews have been audio-recorded, transcribed verbatim and analysed using the constant comparative method associated with grounded theory. Setting and Participants 26 clients, 13 health trainers and 5 managers theoretically sampled from 3 local health trainer services in the North East of England. Results The health trainer services are characterised by diversity in terms of the main target groups, modes of client engagement and degree of emphasis on individual behaviour change. This has implications for the extent to which they are integrated (or not) into local public health systems, and also for the experiences of staff and service users. An emerging theme is the perception that these services are more flexible and holistic than similar lifestyle interventions, and that they address multiple priorities for clients. The importance of delivering interventions in appropriate settings was emphasised, particularly where clients have limited or negative experience of accessing other forms of support. The fact that health trainers tend to be members of the local community was often perceived to act as a facilitator of clients' ongoing engagement with the service. Conclusions These preliminary findings highlight the potential role for health trainers in engaging with individuals from disadvantaged areas and attempting to facilitate their access into the health care system. Health Trainers are being embedded as an integral part of regional and local work on tackling health inequalities, as well as addressing a cross-government agenda. The findings of this study will be used to inform the development and evaluation of the role, as well as generating new evidence to assist practitioners in overcoming the barriers to successfully working with local communities. [ABSTRACT FROM PUBLISHER]

Background Travellers are a distinct minority grouping, characterised by a nomadic tradition and shared cultural traditions, who experience poor health and social disadvantage. Objective To explore in-depth a series of important issues related to the social determinants of health with members of the Irish Traveller community. Setting This paper presents data from 26 focus groups conducted with the Traveller community in the Republic of Ireland (ROI) and Northern Ireland (NI). The data presented are a sub-study of the All-Ireland Traveller Health Study. The focus groups incorporated a geographical spread, a gendered and age-related perspective and compared and contrasted the findings across ROI and NI. Methodology Participatory methodology ensured that the Traveller community was consulted throughout the research progress and ingress was achieved. The focus groups were recruited via the Traveller Health Network. Peer researchers were co-trained by Pavee Point, the Traveller stakeholder organisation and by university research staff to act as co-facilitators and mediators. Focus groups were transcribed and thematically analysed using grounded theory and the constant comparison method and were validated by inter-raters. Results The analysis produced rich data which reached saturation. Key thematic issues arose from the data. These non-comprehensively included rapid historical changes in the economic, cultural and policy arenas have impacted on the traditional lived experience of Travellers; nomadism has decreased whilst accommodation problems have increased marginalisation and isolation; a recognised sense of loss of Traveller culture, sense of identity and self esteem but a resilience and determination to seek new forms of meaning; new cultural conditions impacting directly on the quality of life and health chances influencing social and institutional opportunities and barriers; High rates of discrimination perceived in NI and ROI; Irish Traveller community is not a homogenous community; major concerns regarding the increase in drug culture in ROI, although less marked in NI; education as a continuing source of concern during the educational process and beyond; new mass communication technology embraced by some (younger/literate) Travellers as an important source of information, exchange and sociability. Conclusion The findings echo and reinforce previous evidence but also highlight novel issues. Based on their own account, Travellers continue to face multiple health challenges that impact directly upon their physical and mental health. It is a time of flux and disembodying mechanisms in the broader culture that can generate both positive and negative developments. Travellers have interpreted these experiences as “pushing against a hill”. [ABSTRACT FROM PUBLISHER]

The article focuses on the stability of suicide rates in Greece, Europe even though the economic slowdown. It examines the suicide mortality rate which has increased by 11.7 percent between year 2007-2010 and suicide mortality trends. It also states that Gross Domestic Product (GDP) of Greek economy has been decreased by 6.8 percent during that period of time. It proposes that suicide mortality rate for men aged below 65 years has increased by 20 percent in the same period.

Systematic reviews of meta-analysis can provide helpful insights in several aspects of meta-analysis: quality of published meta-analyses, statistical methods, publication bias and its determinants, and on the causes of heterogeneity. However, they present limitations, mostly derived from the current statistical procedures applied to detect some facts, such as publication bias and heterogeneity. [ABSTRACT FROM AUTHOR]

Background Few studies have addressed how political and economic contexts shape the effects of health services and environment, such that a politically and economically unstable society, despite having sufficient health professionals and facilities, finds it difficult to transfer health resources into actual population health performance. We examined whether political and economic characteristics moderate the effects of health services on infant mortality rates (IMR) in less-developed countries. Methods This study used a longitudinal ecological study design and focused on 46 less-developed countries during the 30-year period from 1980 to 2009. Data were derived from World Development Indicators, the United Nations Commodity Trade Statistics Database and the Polity IV project. Lagged dependent variable panel regression models were used to increase the causal inferences. Random intercept models were used to accommodate the possible problem of a serial correlation of errors because of the repeated measurements. Results After controlling for baseline IMR and other socioeconomic variables, our study showed that democracy had a direct effect on IMR, and a moderating effect on the relationship between health services and IMR. The effects of health services on IMR were stronger for countries with a lower level of democracy than for countries with a higher level of democracy in the 10-year models. Compared with other trade-rated characteristics, democracy is a more robust predictor of long-term IMR in less-developed countries. Conclusions Our study provides additional evidence that democracy has direct effects on IMR and further showed that democracy can modify the effects of health services on IMR. [ABSTRACT FROM AUTHOR]

Background Western observational studies show moderate alcohol use, compared with never use, positively associated with health. Moderate users differ systematically from others, making these observations vulnerable to confounding. Observations from other contexts may help distinguish whether these associations are confounded. To assess whether southern Chinese would provide a more suitable setting to examine the association of moderate alcohol use with health, we compared never alcohol users with moderate alcohol users and occasional users in this setting. Methods We used age-adjusted multinomial regression to assess sex-stratified associations of alcohol use (never, occasional (<1 occasion/week), moderate (≤140 g ethanol/week for women and ≤210 g for men)) with health attributes and indicators in the Guangzhou Biobank Cohort Study (2003-2008) (n=26 361). Results Among men, moderate alcohol users, when compared with never users, had slightly lower socioeconomic position and unhealthier lifestyle. Conversely, occasional alcohol users, when compared with never users, had higher socioeconomic position and healthier lifestyle. Among women, when compared with never users, both occasional and moderate users had higher socioeconomic position and healthier lifestyle. However, all alcohol users for both sexes, when compared with never users, were more likely to be ever smokers and to be exposed to secondhand smoke. Conclusions Observations in alcohol epidemiology may be affected by confounding due to contextually specific systematic differences. Results from a particular setting should not be interpreted as causal unless they are verified in different populations and, preferably, in nonobservational studies. [ABSTRACT FROM AUTHOR]

Background Cognitive ability is negatively associated with functional somatic symptoms (FSS) in childhood. Lower childhood cognitive ability might also predict FSS and functional somatic syndromes in adulthood. However, it is unknown whether this association would be modified by subjective and objective measures of parental academic expectations. Methods 14 068 participants from the 1958 British birth cohort, whose cognitive ability was assessed at 11 years. Outcomes were somatic symptoms at 23, 33 and 42 years. Self-reported irritable bowel syndrome (IBS), chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) and operationally defined CFS-like illness were measured at 42 years. Results Lower cognitive ability at age 11 years was associated with somatic symptoms at ages 23, 33 and 42 years. Adjusting for sex, childhood internalising problems, previous somatic symptoms and concurrent psychological symptoms, childhood cognitive ability remained negatively associated with somatic symptoms at age 23 years (β =-0.060, 95% CI-.0.081 to -0.039, p<0.01), 33 years (β = -0.031, 95% CI -0.050 to -0.011, p<0.01), but not with somatic symptoms at 42 years. Overall, we found no clear association between lower childhood cognitive ability and CFS/ME, CFS-like illness and IBS. Associations between cognitive ability and somatic symptoms at 23 years were moderated by low parental social class, but not by subjective indicators of parental academic expectations. Conclusions Lower childhood cognitive ability predicted somatic symptoms, but not CFS/ME, CFS-like illness and IBS in adulthood. While earlier research indicated an important role for high parental academic expectations in the development of early-life FSS, these expectations do not seem relevant for somatic symptoms or functional somatic syndromes in later adulthood. [ABSTRACT FROM AUTHOR]

Background As most obese adults were not overweight as children, the prediction of adult obesity from childhood body size alone is limited. We constructed a two-way, multifactor risk assessment framework for predicting adult obesity during childhood using the Foresight Obesity System Map and tested it against longitudinal data from the 1958 National Child Development Study. Methods The framework divided study participants according to two categories of risk: 'conditioning factors' (past/fixed events and conditions) and 'intervention factors' (present and modifiable). At the age of 11 years, conditioning factors were 'low/high birth weight' and 'absence of breastfeeding', and intervention factors were 'low childhood activity level' and 'having at least one obese parent'. From a composite score of all four variables, study participants were assigned to one of the four risk groups: low risk, past 'conditioning' risk only, present 'intervention' risk only and high combined risk. ORs and relative risks for the development of future overweight/obesity at ages 23, 33 and 42 years were calculated for each risk group. Results Those identified in the highest risk category at the age of 11 were around twice as likely to become overweight (body mass index (BMI)≥25 kg/m2) by the age of 23 years, and obese (BMI≥30 kg/m2) by ages 33 and 42 years, in comparison to their low-risk peers (total sample, N=11 752). Increased prevalence of future obesity was also observed for high-risk children who were not already overweight at the age of 11 (filtered sample, N=9549). Conclusions This framework identifies a greater proportion of the population that is at risk for future obesity than does childhood weight assessment alone. [ABSTRACT FROM AUTHOR]

Background Many efforts have been undertaken to improve access to healthcare services in low-income settings; nevertheless, underutilisation persists. Women's lack of empowerment may be a central reason for underutilisation, but empirical literature establishing this relationship is sparse. Methods We conducted a cross-sectional study using data from the 2007 Liberia Demographic and Health Survey. Our sample included all non-pregnant women who were currently married or living with a partner (N=3925 unweighted). We used multivariate logistic regression to assess the associations between constructs derived from the Theory of Gender and Power (TGP) and healthcare utilisation. Results Two-thirds of women (65.6%) had been to a healthcare facility for herself or her children in the past 12 months. Constructs from the three major theoretical structures were associated with healthcare utilisation. Women with no education, compared with women with some education, were less likely to have been to a healthcare facility (OR=0.76; 95% CI 0.62 to 0.93) as were women who had experienced sexual abuse (OR=0.65; 95% CI 0.45 to 0.95) and women who were married (OR=0.69, 95% CI 0.54 to 0.88). Women in higher wealth quintiles, compared with women in the next lower wealth quintile, and women with more decision-making power had greater odds of having been to a healthcare facility (OR=1.22; 95% CI 1.10 to 1.36 and OR=1.10; 95% CI 1.01 to 1.20; respectively). Conclusions Strong associations exist between healthcare utilisation and empowerment among women in Liberia, and gender imbalances are prevalent. This fundamental issue likely needs to be addressed before large-scale improvement in health service utilisation can be expected. [ABSTRACT FROM AUTHOR]

Background Childhood and adulthood socio-economic position (SEP) is associated with cardiovascular disease in later life, but associations with hypertensive disorders in pregnancy are not well established. Objective The aim of this study was to investigate the association of childhood and adulthood SEP with hypertensive disorders in pregnancy (chronic hypertension, gestational hypertension and preeclampsia/ eclampsia). Method Study participants were Swedish women (n=9507) from generation 3 of the Uppsala Birth Cohort Multigenerational Study (UBCoS Multigen) who delivered a live singleton offspring between 1982 and 2008. Social and health data were obtained from routine Swedish registers. Associations of own education (adulthood SEP), and parental education and social class (childhood SEP) with hypertensive disorders were studied using logistic regression with adjustments for age, calendar period, parity, smoking and body mass index. Results Low own education was associated with chronic hypertension, but not with gestational hypertension or pre-eclampsia/eclampsia. Increased risk of chronic hypertension was seen in women whose mothers had medium education compared with women whose mothers had high education (OR 2.18, 95% CI 1.03 to 4.62). Women from a manual social class during childhood had twice the risk of chronic hypertension compared with those from non-manual backgrounds (OR 2.19, 95% CI 1.28 to 3.75). Childhood SEP was not associated with gestational hypertension or preeclampsia/ eclampsia. Conclusions Childhood and adulthood SEP was associated with chronic hypertension in pregnancy. In contrast, no association with childhood or adulthood SEP was seen for gestational hypertension or pre-eclampsia/ eclampsia. [ABSTRACT FROM AUTHOR]

Background: Little is known about the neighbourhood characteristics of workplaces, the extent to which they are independently and synergistically correlated with residential environments, and their impact on health. Methods: This study investigated cross-sectional relationships between home and workplace neighbourhood environments with body mass index (BMI) in 1503 working participants of the Multi-Ethnic Study of Atherosclerosis with mean age 59.6 (SD=7.4). Neighbourhood features were socioeconomic status (SES), social environment (aesthetic quality, safety and social cohesion) and physical environment (walking environment, recreational facilities and food stores) derived from census data, locational data on businesses and survey data. Paired t tests and correlations compared environments overall and by distance between locations. Cross-classified multilevel models estimated associations with BMI. Results: Home neighbourhoods had more favourable social environments while workplaces had more favourable SES and physical environments. Workplace and home measures were correlated (0.39-0.70), and differences between home and workplaces were larger as distance increased. Associations between BMI and neighbourhood SES and recreational facilities were stronger for home environment (p?0.05) but did not significantly differ for healthy food, safety or social cohesion. Healthy food availability at home and work appeared to act synergistically (interaction p=0.01). Conclusions: Consideration of workplace environment may enhance our understanding of how place affects BMI. [ABSTRACT FROM AUTHOR]

Background: Various human and animal studies suggest that peak alcohol exposure during a binge episode, rather than total alcohol exposure, may determine fetal development. Research about the impact of binge drinking on birth outcomes is sparse and inconclusive. Data from the Born in Bradford cohort study were used to explore the impact of binge drinking on birth outcomes. Methods: Interview-administered questionnaire data about the lifestyle and social characteristics of 10 851 pregnancies were linked to maternity and birth data. The impact of self-reported binge drinking (5 units: 40 g of pure alcohol) on two birth outcomes (small for gestational age (SGA) and preterm birth (<37 weeks)) was assessed using multivariate logistic regression models, while adjusting for confounders. Results: The percentage of women classified as binge drinkers fell from 24.5% before pregnancy to 9% during the first trimester and 3.1% during the second trimester. There was a significant association between SGA birth and binge drinking (all categories combined; OR 1.68, 95% CI 1.15 to 2.47, p=0.01). No association was observed between moderate drinking and either birth outcome, or between binge drinking and preterm birth. Conclusions: Binge drinking during the second trimester of pregnancy was associated with an increased risk of SGA birth. No association was found between any level of alcohol consumption and premature birth. This work supports previous research showing no association between SGA and low-alcohol exposure but adds to evidence of a dose-response relationship with significant risks observed at binge drinking levels. [ABSTRACT FROM AUTHOR]

Background: To assess the effectiveness of text-messages in reducing the proportion of non-attendance in a youth clinic of a University Hospital. Methods: Patients who registered for an appointment and provided a mobile phone number were randomly selected to receive or not a text-message reminder before the planned appointment. A 10% reduction in the proportion of missed appointments was considered clinically and economically useful and the study was powered accordingly. Results: The proportion of missed appointments was 16.4% (95% CI 13.1% to 19.8%) in the text-message group (N 462) and 20.0% (95% CI 16.6% to 23.4%) in the control group (N 529), showing no significant effect of the intervention (p=0.346). Conclusions: In our primary care youth clinic, text-message reminders are not effective in reducing the proportion of missed appointments. This may in part be due to the fact that most patients are referred by a professional or by their parents and do not initiate appointments themselves. [ABSTRACT FROM AUTHOR]

Background Neighbourhood characteristics may contribute to differences in physical inactivity. Purpose To evaluate whether the availability of sports facilities helps explain the differences in physical inactivity according to the economic context of the neighbourhood. Methods 6607 participants representative of the population aged 16–74 years, resident in Madrid (Spain) in 2005, were analysed. Using ORs calculated by multilevel logistic regression, the association between per capita income of the neighbourhood of residence and physical inactivity was estimated, after adjusting for age, population density, individual socioeconomic characteristics and the availability of green spaces. The analysis was repeated after further adjustment for the availability of sports facilities to determine if this reduced the magnitude of the association. Results Residents in the neighbourhoods with the lowest per capita income had the highest OR for the prevalence of physical inactivity. In participants aged 16–49 years, after adjusting for the availability of sports facilities, the magnitude of the OR in the poorest neighbourhoods with respect to the richest neighbourhoods increased in men (from 2.22 to 2.35) and declined by 13% in women (from 2.13 to 1.98). In contrast, in the population aged 50–74 years, this adjustment reduced the magnitude of the OR by 21% in men (from 2.00 to 1.80) and by 53% in women (from 2.03 to 1.48). Conclusions The poorest neighbourhoods show the highest prevalence of physical inactivity. The availability of sports facilities explains an important part of this excess prevalence in participants aged 50–74 years, but not in younger individuals. [ABSTRACT FROM AUTHOR]

Background We examined midlife dietary patterns in relation to (1) sociodemographic and health-related characteristics and (2) survival. Methods A two-step cluster analysis of a 12-item food questionnaire was used to derive dietary patterns in a cohort of 16 649 members of the Swedish Twin Registry, a prospective, population-based study of twins. The average age at baseline (1967) was 55.5 years; the follow-up for all-cause mortality extended until 2011 (26.8±12.35 years or 345 127 person-years) via death records. Results Four dietary patterns (classes) distinguishable by demographic and health characteristics emerged: Moderate Intake and Starch Diet (Class 1), Moderate Intake Diet with Low Flour-Based Foods (Class 2), Meat and Starch Diet (Class 3) and Low Meat Intake Diet (Class 4). Membership in Class 3 was associated with 7% increased risk of mortality compared with Class 2 independent of baseline age, cohort, sex and body mass index. These results were mostly explained by sociodemographic and lifestyle factors. When follow-up was restricted to those in the study for 20+ years, both Classes 1 and 3 conferred increased risk of mortality compared with Class 2, independent of covariates. Analyses conducted within twin pairs revealed similar results. Conclusions Midlife diet over-represented by meat and starch-based foods may increase the risk of mortality, whereas the diet low in starch may be beneficial. These results appear to be independent of factors shared by twins, as well as at least partially a function of social and lifestyle factors, particularly marital status and smoking. [ABSTRACT FROM AUTHOR]

Background Parent-offspring studies have shown that cardiovascular risk factors cluster within families. However, most studies have assessed the offspring cardiovascular risk factor level at a young age, and whether an association persists into the offspring’s adult life is less clear. This study linked information between parents and their adult offspring to investigate the intergenerational association of anthropometric measures, blood pressure, blood lipid levels and physical activity. Methods The study population consisted of parent and adult offspring pairs (11 931 fathers–sons, 12 563 fathers–daughters, 15 626 mothers–sons and 16 449 mothers–daughters) who participated in the second and third cross-sectional waves of the Nord-Trøndelag Health Study (HUNT 2, 1995–1997 and HUNT 3, 2006–2008). A general linear model and logistic regression were used to estimate the association between the parent and offspring risk factor levels. Results All continuously measured cardiovascular risk factors under study showed a statistically significant positive association between parents and offspring, except the waist-hip ratio. Adjusted coefficients from linear regression ranged from 0.09 (95% CI 0.07 to 0.11) for waist circumference to 0.29 (95% CI 0.27 to 0.32) for body weight. Moreover, offspring were two to three times more likely to be obese, have a high cholesterol level, or hypertension when comparing extreme categories of the corresponding parental risk factor level. Physically active parents had a lower risk of having physically inactive offspring. Conclusions The results suggested that cardiovascular risk factors track across generations and persist into the offspring’s adult life. [ABSTRACT FROM AUTHOR]

Background Earlier research has shown that residents of Dutch deprived neighbourhoods drink less alcohol than people in other areas. We aimed to assess the role of individual and neighbourhood characteristics in across-sectional, nationwide, multilevel study. Methods Individual data of 30 117 Dutch adults, living in 1722 neighbourhoods across the Netherlands, were obtained from the 2004 to 2009 national health survey (POLS). Chronic heavy alcohol consumption was measured as ≥14 drinks/week for women and ≥21 for men, and episodic heavy drinking as ≥6 drinks/day at least once a week. Neighbourhood deprivation was dichotomous; deprived districts as selected by the Dutch government versus other areas. Multilevel logistic regression models of the association between deprivation and heavy drinking were corrected for age, gender, household composition, population density and potential predictors ethnicity, socioeconomic status (education, income), neighbourhood-level social cohesion and percentage Muslims. Results The prevalence of heavy drinking was lower in deprived neighbourhoods than in the rest of the Netherlands. This association was found for both chronic and episodic heavy drinking (OR=0.58 (0.47 to 0.72)and OR=0.57 (0.45 to 0.72), respectively). Adding ethnicity to the model reduced these associations by approximately one half. Socioeconomic composition did not contribute to the relationship. The proportion of Muslims explained a small part, while social cohesion explained even less of the association. Stronger associations were observed for women and older adults than for men and younger adults. Conclusions The lower prevalence of heavy drinking occurring in deprived areas is largely explained by the ethnicity of neighbourhood residents. [ABSTRACT FROM AUTHOR]

Background Mortality increases during heat waves have been reported worldwide. The magnitude of these increases can vary within regions according to sociodemographic and urban landscape characteristics. The objectives of this study were to explore this variation and its determinants, and to identify the most heat-vulnerable areas by mapping heat vulnerability. Methods We conducted a time-stratified case-crossover analysis using daily mortality in the Barcelona metropolitan area during the warm seasons of 1999-2006. Temperature data on the date of death were assigned to each individual, which were assigned to their census tract of residence. Eight census tract-level variables on socioeconomic or built environment characteristics were obtained from the census. Residence surrounding greenness was obtained from satellite data. The relative risk (RR) of mortality after three consecutive hot days (defined as those exceeding the 95th percentile of maximum temperature) was calculated via conditional logistic regression. Effect modification was examined by including interaction terms. Results Analyses were based on 52 806 deaths. The effect of three consecutive hot days was a 30% increase in all-cause mortality (RR=1.30, 95% CI 1.24 to 1.38). Heterogeneity of this effect was observed across census tracts. The effect of heat on mortality was higher in the census tracts with a large percentage of old buildings (RR=1.21, 95% CI 1.00 to 1.46), manual workers (RR=1.25, 95% CI 0.96 to 1.64) and residents perceiving little surrounding greenness (RR=1.29, 95% CI 1.01 to 1.65). After three consecutive hot days, mortality doubled in the most heat-vulnerable census tracts. Conclusions Sociodemographic and urban landscape characteristics are associated to mortality risk during heat waves and are useful to build heat vulnerability maps. [ABSTRACT FROM AUTHOR]

Background A previous study found an association between maternal cell phone use during pregnancy and maternal-reported child behaviour problems at age 7. Together with cell phones, cordless phones represent the main exposure source of radiofrequency-electromagnetic fields to the head. Therefore, we assessed the association between maternal cell phone and cordless phone use during pregnancy and teacher-reported and maternal-reported child behaviour problems at age 5. Methods The study was embedded in the Amsterdam Born Children and their Development study, a population-based birth cohort study in Amsterdam, the Netherlands (2003–2004). Teachers and mothers reported child behaviour problems using the Strength and Difficulties Questionnaire at age 5. Maternal cell phone and cordless phone use during pregnancy was asked when children were 7 years old. Results A total of 2618 children were included. As compared to non-users, those exposed to prenatal cell phone use showed an increased but non-significant association of having teacher-reported overall behaviour problems, although without dose-response relationship with the number of calls (OR=2.12 (95% CI 0.95 to 4.74) for <1 call/day, OR=1.58 (95% CI 0.69 to 3.60) for 1–4 calls/day and OR=2.04 (95% CI 0.86 to 4.80) for ≥5 calls/day). ORs for having teacher-reported overall behaviour problems across categories of cordless phone use were below 1 or close to unity. Associations of maternal cell phone and cordless phone use with maternal-reported overall behaviour problems remained non-significant. Non-significant associations were found for the specific behaviour problem subscales. Conclusion Our results do not suggest that maternal cell phone or cordless phone use during pregnancy increases the odds of behaviour problems in their children. [ABSTRACT FROM AUTHOR]

Background Despite the rising childhood obesity rates,few studies have examined the association between access to recreational parks and facilities and obesity.Methods A cross-sectional study was performed among 42 278 US children who participated in the2007 National Survey of Children’s Health. Access to parks and recreational facilities was self-reported by parents, and body mass index was calculated from parents’ self-report of the child’s height and weight.Logistic regression was used to obtain ORs and 95%CIs. Since obesity was not a rare occurrence, an OR correction method was used to provide a more reliable estimate of the prevalence ratio (PR).Results Children with access to parks and facilities had decreased prevalence of obesity as compared to children without access (PR=0.79, 95% CI 0.69 to 0.91). After adjustment for covariates, the magnitude of the association remained unchanged; however, results were no longer statistically significant (PR=0.77, 95% CI 0.55to 1.07). Race/ethnicity was an effect modifier of the access–obesity relationship ( p<0.0001). Among Non-Hispanic White children, there was no strong association(PR=0.89, 95% CI 0.64 to 1.23). However, among Non-Hispanic Black children, those who had access to recreational parks and facilities had 0.40 times the prevalence of obesity as compared to those without access, and this result was statistically significant (95%CI 0.17 to 0.90).Conclusions This research highlights potential health disparities in childhood obesity due to limited access to recreational parks and facilities. Additional studies are needed to further investigate this association. If confirmed, providing safe, accessible parks and facilities may be one way to combat childhood obesity,particularly among minority children. [ABSTRACT FROM AUTHOR]

Background Theoretically, there may be benefit in augmenting school-based sexual health education with sexual health services, but the outcomes are poorly understood. Healthy Respect 2 (HR2) combined sex education with youth-friendly sexual health services, media campaigns and branding, and encouraged joint working between health services, local government and the voluntary sector. This study examined whether HR2: (1) improved young people’s sexual health knowledge, attitudes, behaviour and use of sexual health services and (2) reduced socioeconomic inequalities in sexual health. Methods A quasi-experiment in which the intervention and comparison areas were matched for teenage pregnancy and terminations, and schools were matched by social deprivation. 5283 pupils aged 15–16 years (2269 intervention, 3014 comparison) were recruited to cross-sectional surveys in 2007, 2008 and 2009. Results The intervention improved males’ and, to a lesser extent, females’ sexual health knowledge. Males’ intention to use condoms, and reported use of condoms, was unaffected, compared with a reduction in both among males in the comparison arm. Although females exposed to the intervention became less accepting of condoms, there was no change in their intention to use condoms and reported condom use. Pupils became more tolerant of sexual coercion in both the intervention and comparison arms. Attitudes towards same-sex relationships remained largely unaffected. More pupils in the HR2 area used sexual health services, including those from lower socioeconomic backgrounds. This aside, sexual health inequalities remained. Conclusions Combining school-based sex education and sexual health clinics has a limited impact. Interventions that address the upstream causes of poor sexual health, such as a detrimental sociocultural environment, represent promising alternatives. These should prioritise the most vulnerable young people. [ABSTRACT FROM AUTHOR]

Background Though wide disparities in wealth have been documented across racial/ethnic groups, it is largely unknown whether differences in wealth are associated with health disparities within racial/ethnic groups. Methods Data from the Survey of Consumer Finances (2004, ages 25-64) and the Health and Retirement Survey (2004, ages 50+), containing a wide range of assets and debts variables, were used to calculate net worth (a standard measure of wealth). Among non-Hispanic black, Hispanic and non-Hispanic white populations, we tested whether wealth was associated with self-reported poor/fair health status after accounting for income and education. Results Except among the younger Hispanic population, net worth was significantly associated with poor/fair health status within each racial/ethnic group in both data sets. Adding net worth attenuated the association between education and poor/fair health (in all racial/ethnic groups) and between income and poor/fair health (except among older Hispanics). Conclusions The results add to the literature indicating the importance of including measures of wealth in health research for what they may reveal about disparities not only between but also within different racial/ethnic groups. [ABSTRACT FROM AUTHOR]

Background People living in areas of multiple deprivation are more likely to smoke and less likely to quit smoking. This study examines the effect on smoking and intention to quit smoking for those who have experienced housing improvements (HI) in deprived areas of Glasgow, UK, and investigates whether such effects can be explained by improved mental health. Methods Quasi-experimental, 2-year longitudinal study, comparing residents’ smoking and intention to quit smoking for HI group (n=545) with non-HI group (n=517), adjusting for baseline (2006) sociodemographic factors and smoking status. SF-12 mental health scores were used to assess mental health, along with self-reported experience of, and General Practitioner (GP) consultations for, anxiety and depression in the last 12 months. Results There was no relationship between smoking and HI, adjusting for baseline rates (OR=0.97, 95% CI 0.57 to 1.67, p=0.918). We found an association between intention to quit and HI, which remained significant after adjusting for sociodemographics and previous intention to quit (OR 2.16, 95% CI 1.12 to 4.16, p=0.022). We found no consistent evidence that this association was attenuated by improvement in our three mental health measures. Conclusions Providing residents in disadvantaged areas with better housing may prompt them to consider quitting smoking. However, few people actually quit, indicating that residential improvements or changes to the physical environment may not be sufficient drivers of personal behavioural change. It would make sense to link health services to housing regeneration projects to support changes in health behaviours at a time when environmental change appears to make behavioural change more likely. [ABSTRACT FROM AUTHOR]

Background A reduction in sex ratio at live birth has been proposed as a sentinel health indicator that can be used to monitor the health of populations.Objective To test the hypothesis that a lower sex ratio is associated with adverse national population health using the prevalences of HIV and tuberculosis as measures of societal well-being.Methods An ecological study design using routinely collected data and adjusting for potential confounding factors.Results The mean global sex ratio was 1.05. There was marked heterogeneity in the sex ratio between different global regions (p<0.0001). Those regions with the highest prevalences of HIV infection had lower sex ratios, with the value for the highest quartile being0.022 (95% CIs CI 0.013 to 0.031) lower than the lowest quartile. Similarly, those areas with the highest quartile of tuberculosis infection had a sex ratio of 0.016(95% CI 0.004 to 0.028) lower than those in the lowest quartile. Similar results were observed in a subgroup analysis limited to countries from the African continent.Conclusions The data are consistent with the hypothesis that a reduced sex ratio at live birth is a potential sentinel health indicator of lower population health. However, these data do not demonstrate either a casual relationship or reveal any biological mechanisms that may account for these observations. [ABSTRACT FROM AUTHOR]

Background Evidence of a relationship between residential retail food environments and diet-related outcomes is inconsistent. One reason for this may be that food environments are typically defined in terms of the absolute number of particular store types in an area, whereas a measure of the relative number of healthy and unhealthy stores may be more appropriate. Methods Using cross-sectional data from the VicLANES study conducted in Melbourne, Australia, multilevel logistic regression analysis was used to estimate the independent associations between absolute measures (numbers of healthy and unhealthy stores) and a relative measure (relative density of healthy stores) of the food environment, and self-reported variety of fruit and vegetable purchasing in local households. Purchasing behaviour was measured as the odds of purchasing above the median level of fruit and vegetables. Results Compared to households in areas where healthy food stores made up no more than 10% of all healthy and unhealthy stores, households in areas with 10.1-15.0% healthy food stores and >15% healthy stores had increased odds of healthier purchasing (OR=1.48 (95% CI 1.12 to 1.96) and OR=1.45 (95% CI 1.09 to 1.91), respectively). There was less evidence of an association between absolute numbers of healthy or unhealthy stores and fruit and vegetable purchasing. Conclusions We found strong evidence of healthier fruit and vegetable purchasing in households located in areas where the proportion of food stores that were healthy was greater. Policies aimed at improving the balance between healthy and unhealthy stores within areas may therefore be effective in promoting greater consumption of fruit and vegetables. [ABSTRACT FROM AUTHOR]

Background: Major behavioural risk factors, namely obesity, alcohol consumption, smoking, lack of fruit and vegetable intake and physical inactivity negatively impact on self-reported quality of life. However, little is known about their impact on preference-based measures of health-related quality of life commonly used to inform economic evaluations. Methods: Preference-based health-related quality of life outcomes associated with major behavioural risk factors were estimated using the EuroQol EQ-5D responses of 14 117 participants, aged ≥16 years, in the 2008 Health Survey for England. Multivariable linear regression was used to model the relationship between the five risk factors and EQ-5D utility scores. In addition, logistic regression was used to model their relationship to dichotomous reports of problems for each of the five EQ-5D dimensions. Results: Only one-third of participants had a body mass index within normal range, never drank alcohol, consumed at least five portions of fruit or vegetable/day or exercised regularly, while nearly half of participants were smokers or ex-smokers. In the fully adjusted multivariable analyses, reductions in EQ-5D utility scores (95% CI) of 0.105 (0.072 to 0.137), 0.062 (0.042 to 0.082) and 0.142 (0.129 to 0.155) were estimated for a body mass index ≥40 kg/m2, heavy smoking (≥20 cigarettes/day) and physical inactivity, respectively. Hazardous alcohol consumption (men >4 and ≤8 units/ day; women >3 and ≤6 units/day) and daily fruit and vegetable intake between three and less than five portions were associated with small positive effects on EQ-5D utility scores (p<0.05). Conclusions: The high prevalence and substantial utility loss associated with obesity, smoking and physical inactivity highlight the potential impact that interventions aimed at their prevention or alleviation may have on population health. [ABSTRACT FROM AUTHOR]

Background: People with larger social networks are known to have better well-being; however, little is known about (1) the association with socio-demographic factors that may predict the size and composition of social networks and (2) whether the association with well-being is independent of pre-existing psychological health or socio-demographic factors. Methods: The authors used information collected from 3169 men and 3512 women who were born in Great Britain in 1958. First, age on leaving full-time education, partnership and employment status at age 42 were used to predict the size and composition of cohort members' social networks at age 45 using ordered logistic regression. Second, using multiple linear regression, the associations between social network size by composition (relatives and friends) and psychological well-being at age 50 were assessed, adjusting for socio-demographic factors and psychological health at age 42. Results: Not having a partner and staying in full-time education after age 16 was associated with a smaller kinship network in adults. Having a smaller friendship network at age 45 was associated with poorer psychological well-being among adults at age 50, over and above socio-demographic factors and previous psychological health. Additionally, having a smaller kinship network was associated with poorer psychological well-being among men. Conclusions: Having a well-integrated friendship network is a source of psychological well-being among middle-aged adults, while kinship networks appear to be more important for men's well-being than for women's. These relationships are independent of education, material status and prior psychological health. [ABSTRACT FROM AUTHOR]

Background: Pre-eclampsia is a common complication of pregnancy and is a major cause of fetal-maternal mortality and morbidity. Despite a number of plausible mechanisms by which air pollutants might contribute to this process, few studies have investigated the association between pre-eclampsia and traffic emissions, a major contributor to air pollution in urban areas. Objective: The authors investigated the association between traffic-related air pollution and risk of preeclampsia in a maternal population in the urban centre of Perth, Western Australia. Method: The authors estimated maternal residential exposure to a marker for traffic-related air pollution (nitrogen dioxide, NO2) during pregnancy for 23 452 births using temporally adjusted land-use regression. Logistic regression was used to investigate associations with pre-eclampsia. Results: Each IQR increase in levels of traffic-related air pollution in whole pregnancy and third trimester was associated with a 12% (1%--25%) and 30% (7%--58%) increased risk of pre-eclampsia, respectively. The largest effect sizes were observed for women aged younger than 20 years or 40 years or older, aboriginal women and women with pre-existing and gestational diabetes, for whom an IQR increase in traffic-related air pollution in whole pregnancy was associated with a 34% (5%--72%), 35% (0%--82%) and 53% (7%--219%) increase in risk of pre-eclampsia, respectively. Conclusions: Elevated exposure to traffic-related air pollution in pregnancy was associated with increased risk of pre-eclampsia. Effect sizes were highest for elevated exposures in third trimester and among younger and older women, aboriginal women and women with diabetes. [ABSTRACT FROM AUTHOR]

Background Obesity in childhood and adolescence has important health consequences, but its relation to risk of adult depression remains uncertain. Objective To examine the effect of perceived and actual obesity during childhood and adolescence on prevalence and incidence of adult depression risk. Methods Cohort study of 91 798 female registered nurses followed longitudinally for 12 years. Results As compared with lean women of the same age, women in the two highest categories of body shape at age 10 had both higher prevalence (OR=2.59, 95% CI 1.46 to 4.61) and incidence (OR=2.01, 95% CI 1.08 to 3.71) of depression. Similar results were obtained for body shape at age 20 (OR=3.43 for prevalence and OR=2.03 for incidence) and for body mass index (BMI) at age 18 (OR=2.92 for BMI ≥40 kg/m2). These associations remained significant after adjustment for multiple confounders. Conclusion These results indicate that childhoodeadolescence obesity is a strong and independent risk factor for adult depression. [ABSTRACT FROM AUTHOR]

Background This study aimed to examine prospective associations of young infants' home environments with expressive vocabulary delay and internalising and externalising problem scores independently of family socioeconomic status (SES) and national origin. Methods Prospective data from fetal life to age 3 were collected in a total of 2711 families participating in the Generation R Study, a longitudinal population-based cohort. Infants' home environments (ie, the learning environment and the physical environment) were assessed exclusively by observation in their first few months of life (mean age=3.38 months, SD=1.17). Internalising and externalising problems were measured at age 1.5 and 3; expressive vocabulary delay was assessed at age 2.5. Family socio-demographic characteristics, including SES variables and national origin, were measured during pregnancy. Results Lower quality learning environments of young infants, but not physical environments, were associated with expressive vocabulary delay and more internalising problems in toddlerhood independently of SES and national origin. Associations of SES and national origin with children's outcomes were reduced when the home environmental variables were added to the regression model. Conclusions The current findings suggest that SES and national origin are reflected, to some degree, in the quality of infants' home environments. Some of the possible interpretations of these results are discussed together with their implications for the early identification of children at risk of impaired development. [ABSTRACT FROM AUTHOR]

Background There is a strong case for early identification of factors predicting life-course-persistent conduct disorder. The authors aimed to identify factors associated with repeated parental reports of preschool conduct problems. Method Nested case-control study of Scottish children who had behavioural data reported by parents at 3, 4 and 5 years. Results 79 children had abnormal conduct scores at all three time points ('persistent conduct problems') and 434 at one or two points ('inconsistent conduct problems'). 1557 children never had abnormal scores. Compared with children with no conduct problems, children with reported problems were significantly more likely to have mothers who smoked during pregnancy. They were less likely to be living with both parents and more likely to be in poor general health, to have difficulty being understood, to have a parent who agrees that smacking is sometimes necessary and to be taken to visit other people with children rarely. The results for children with persistent and inconsistent conduct problems were similar, but associations with poverty and maternal smoking were significantly less strong in the inconsistent group. Conclusion These factors may be valuable in early identification of risk of major social difficulties. [ABSTRACT FROM AUTHOR]