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Objective: To provide insights into complexities of seeking access to state and federal crossjurisdictional data for linkage with the Australian Childhood Immunisation Register (ACIR). We provide recommendations for improving access and receipt of linked datasets involving Australian Government-administered data. Methods: We describe requirements for linking eleven federal and state data sources to establish a national linked dataset for safety evaluation of vaccines. The required data linkage methodology for integrating cross-jurisdictional data sources is also described. Results: Extensive negotiation was required with 18 different agencies for 21 separate authorisations and 12 ethics approvals. Three variations of the 'best practice' linkage model were implemented. Australian Government approval requests spanned nearly four years from initial request for data, with a further year before ACIR data transfer to the linkage agency. Conclusions: Integration of immunisation registers with other data collections is achievable in Australia but infeasible for routine and rapid identification of vaccine safety concerns. Lengthy authorisation requirements, convoluted disparate application processes and inconsistencies in data supplied all contribute to delayed data availability. Implications for public health: Delayed data access for safety surveillance prevents timely epidemiological reviews. Poor responsiveness to safety concerns may erode public confidence, compromising effectiveness of vaccination programs through reduced participation. Refereed/Peer-reviewed

Objective To determine whether differences in combination DTaP vaccine types at 2, 4 and 6 months of age were associated with mortality (all-cause or non-specific), within 30 days of vaccination. Design Observational nationwide cohort study. Setting Linked population data from the Australian Childhood Immunisation Register and National Death Index. Participants Australian infants administered a combination trivalent, quadrivalent or hexavalent DTaP vaccine (DTaP types) between January 1999 and December 2010 at 2, 4 and 6 months as part of the primary vaccination series. The study population included 2.9, 2.6, & 2.3 million children in the 2, 4 and 6 month vaccine cohorts, respectively. Main outcome measures Infants were evaluated for the primary outcome of all-cause mortality within 30 days. A secondary outcome was non-specific mortality (unknown cause of death) within 30 days of vaccination. Non-specific mortality was defined as underlying or other cause of death codes, R95 ‘Sudden infant death syndrome’, R96 ‘Other sudden death, cause unknown’, R98 ‘Unattended death’, R99 ‘Other ill-defined and unspecified cause of mortality’ or where no cause of death was recorded. Results The rate of 30 day all-cause mortality was low and declined from 127.4 to 59.3 deaths per 100,000 person-years between 2 and 6 month cohorts. When compared with trivalent DTaP vaccines, no elevated risk in all-cause or non-specific mortality was seen with any quadrivalent or hexavalent DTaP vaccines, for any cohort. Conclusion Use of routine DTaP combination vaccines with differing disease antigens administered during the first six months of life is not associated with infant mortality.

Objective: The objective of this study was to assess the prevalence and sociodemographic characteristics of cesarean section in Ethiopia. Methods: We used data collected for Ethiopia Demographic and Health Surveys (DHS) conducted in 2000, 2005, 2011, and 2016. A two-stage, stratified, clustered random sampling design was used to gather information from women who gave birth within the 5-year period before each of the surveys. We analyzed the data to identify sociodemographic characteristics associated with cesarean section using log-Poisson regression models. Results: The national cesarean section rate increased from 0.7% in 2000 to 1.9% in 2016, with increases across seven of the eleven administrative regions of Ethiopia. Addis Ababa had the highest cesarean section rate (21.4%) in 2016 and the greatest increase since 2000. In the adjusted analysis, women who gave birth in private health facility had a 78.0% higher risk of cesarean section (adjusted prevalence ratio (aPR) (95% CI) 1.78 (1.22, 2.58)) compared with women who gave birth in public health facility. Having four or more births was associated with a lower risk of cesarean section compared with first births (aPR (95% CI) 0.36 (0.16, 0.79)). Conclusions: The Ethiopian national cesarean section rate is about 2%, but the rate varies widely among administrative regions, suggesting unequal access. Cesarean sections were highest among urban mothers, first births, births to women with higher education, and births to women from the richest quintile of household wealth. Refereed/Peer-reviewed

Background There is evidence that parents from more socioeconomically disadvantaged backgrounds engage in fewer verbal interactions with their child than more advantaged parents. This leads to the so-called, ‘30 million-word gap’. This study aims to investigate the number of words children hear and the number of vocalizations children produce in their first year of life and examines whether these aspects of the early language home environment differ by maternal education. Methods Mothers were recruited into a five-year prospective cohort study and categorized into either high or low maternal education groups. Data was derived from the first two waves of the study, when the children were six and twelve months old. At both waves, children were involved in day-long audio recordings using the Language Environment Analysis software that provided automatic counts of adult words spoken to the child, child vocalizations and conversational turns. Descriptive results are presented by maternal education groups. Results There was large variation within each maternal education group, with the number of adult words spoken to the child ranging from 2958 to 39,583 at six months and 4389 to 45,849 at twelve months. There were no meaningful differences between adult words, child vocalizations or conversational turns across maternal education groups at either wave of data collection. Conclusions These results show that a word gap related to maternal education is not apparent up to twelve months of age. The large variability among both maternal education groups suggests that universal interventions that encourage all parents to talk more to their child may be more appropriate than interventions targeted towards disadvantaged families during the first year of life.

ObjectivesTo quantify emergency department (ED) presentations by individuals within vulnerable populations compared with other adults and the extent to which these are potentially preventable.DesignPeriod prevalence study from 2005-2006 to 2010–2011.SettingPerson-linked, ED administrative records for public hospitals in South Australia.ParticipantsAdults aged 20 or more in South Australia’s metropolitan area presenting to ED and categorised as Refugee and Asylum Seeker Countries of birth (RASC); Aboriginal; those aged 75 years or more; or All others.Main outcome measuresUnadjusted rates of ambulatory care sensitive condition (ACSC), general practitioner (GP)–type presentations and associated direct ED costs among mutually exclusive groups of individuals.ResultsDisparity between RASC and All others was greatest for GP-type presentations (423.7 and 240.1 persons per 1000 population, respectively) with excess costs of $A106 573 (95% CI $A98 775 to $A114 371) per 1000 population. Aboriginal had highest acute ACSC presenter rates (125.8 against 51.6 per 1000 population) with twice the risk of multiple presentations and $A108 701 (95% CI $A374 to $A123 029) per 1000 excess costs. Those aged 75 or more had highest chronic ACSC presenter rates (119.7vs21.1 per 1000), threefold risk of further presentations (incidence rate ratio 3.20, 95% CI 3.14 to 3.26) and excess cost of $A385 (95% CI $A178 160 to $A184 609) per 1000 population.ConclusionsVulnerable groups had excess ED presentations for a range of issues potentially better addressed through primary and community healthcare. The observed differences suggest inequities in the uptake of effective primary and community care and represent a source of excess cost to the public hospital system.

ObjectiveTo examine the impact of caesarean section on breastfeeding indicators—early initiation of breastfeeding, exclusive breastfeeding under 6 months and children ever breastfed (at least once)—in sub-Saharan Africa.DesignSecondary analysis of Demographic and Health Surveys (DHS).SettingThirty-three low-income and middle-income countries with a survey conducted between 2010 and 2017/2018.ParticipantsWomen aged 15–49 years with a singleton live last birth during the 2 years preceding the survey.Main outcome measuresWe analysed the DHS data to examine the impact of caesarean section on breastfeeding indicators using the modified Poisson regression models for each country adjusted for potential confounders. For each breastfeeding indicator, the within-country adjusted prevalence ratios (aPR) were pooled in random-effects meta-analysis.ResultsThe within-country analyses showed, compared with vaginal birth, caesarean section was associated with aPR for early initiation of breastfeeding that ranged from 0.24 (95% CI 0.17 to 0.33) in Tanzania to 0.89 (95% CI 0.78 to 1.00) in South Africa. The aPR for exclusive breastfeeding under 6 months ranged from 0.58 (95% CI 0.34 to 0.98) in Angola to 1.93 (95% CI 0.46 to 8.10) in Cote d'Ivoire, while the aPR for children ever breastfed ranged from 0.91 (95% CI 0.82 to 1.02) in Gabon to 1.02 (95% CI 0.99 to 1.04) in Gambia. The meta-analysis showed caesarean section was associated with a 46% lower prevalence of early initiation of breastfeeding (pooled aPR, 0.54 (95% CI 0.48 to 0.60)). However, meta-analysis indicated little association with exclusive breastfeeding under 6 months (pooled aPR, 0.94 (95% CI 0.88 to 1.01)) and children ever breastfed (pooled aPR, 0.98 (95% CI 0.98 to 0.99)) among caesarean versus vaginally born children.ConclusionsCaesarean section had a negative influence on early initiation of breastfeeding but showed little difference in exclusive breastfeeding under 6 months and children ever breastfed in sub-Saharan Africa.

Whereas the influence of pregnancy diet and milk feeding on children’s health and development is well characterized, the role of early food intake and eating behaviors is largely unexplored. This study aimed to determine whether the degree of adherence to complementary feeding guidelines was associated with dietary, obesity, cardiovascular, and cognitive outcomes at 7–8 y of age. Data were analyzed from the Avon Longitudinal Study of Parents and Children using parent-completed dietary questionnaires at 6 mo of age to calculate a Complementary Feeding Utility Index score. Regression analysis was used to explore associations between the index score and dietary patterns derived via principal component analysis (n = 4326), body-mass index (BMI) (n = 4801), waist circumference (n = 4798), blood pressure (n = 4685), and lipids (n = 3232) measured at age 7 y; and intelligence quotient (IQ) measured at age 8 y (n = 4429) after adjustment for covariates. The index score was negatively associated with a “processed” dietary pattern [β = −0.16 (95% CI: −0.20, −0.13); P < 0.001] but positively associated with a “health conscious” dietary pattern [β = 0.18 (95% CI: 0.14, 0.21); P < 0.001]. A higher index score was also positively associated with total, verbal, and performance IQ scores at 8 y of age [β = 1.92 (95%CI: 1.38, 2.47); P < 0.001 for total IQ). The index score was weakly associated with waist circumference [β = −0.15 (95%CI: −0.31, −0.002); P = 0.046] and diastolic blood pressure [β = −0.24 (95%CI: −0.47, −0.01); P = 0.043] at 7 y of age but was not associated with BMI or other cardiovascular risk factors. These findings suggest that adherence to current complementary feeding guidelines may have implications for some, but not all, health and development outcomes in childhood Refereed/Peer-reviewed

Objective: To examine trends in reports of child maltreatment to the Northern Territory Department of Children and Families among Aboriginal and non-Aboriginal children. Design, setting and subjects: A historical cohort study using administrative data collections of notifications and substantiated cases of maltreatment among children aged from 0 to 17 years. Main outcome measures: Annual rates of notification and substantiation of different types of child maltreatment. Results: From 1999 to 2010, the overall annual rates of notification for maltreatment of Aboriginal children showed an average increase of 21% (incidence rate ratio [IRR], 1.21; 95% CI, 1.19–1.24). The greatest increases were in notifications for neglect and emotional abuse. There were parallel increases in rates of substantiated cases of maltreatment. Among non-Aboriginal children, the overall annual rates of notification also increased (IRR, 1.10; 95% CI, 1.07–1.14); however, changes in annual rates of substantiated cases for all types of maltreatment were not statistically significant. Conclusion: There have been considerable increases in both notifications and substantiated cases of child maltreatment, most prominently among Aboriginal children. It is possible that the observed increases reflect increasing incidence of maltreatment; however, they are also consistent with a mix of increased surveillance, improved service access, changes in policy and a shift in public attitudes. Refereed/Peer-reviewed

Dietary patterns are a useful summary measure of diet. Few studies have examined the nutrient profiles underpinning the dietary patterns of young children. The study aim is to determine whether dietary patterns at 6 and 15 months of age are associated with nutrient intakes at 8 and 18 months, respectively. Participants were children from the Avon Longitudinal Study of Parents and Children who had complete dietary pattern and nutrient intake data (n = 725 at 6–8 months, n = 535 at 15–18 months). The association between tertiles of dietary pattern scores and nutrient intake was examined using a non-parametric test for trend. Scores on the home-made traditional pattern (6–8 months) were positively associated with median energy intake. Each dietary pattern had different associations with energy-adjusted intakes of macro- and micro-nutrients. At both times, the discretionary pattern was positively and the ready-prepared baby foods pattern was negatively associated with sodium intake. At 6–8 months, calcium and iron intakes decreased across scores on the home-made traditional and breastfeeding patterns, but increased across the ready-prepared baby food patterns. These findings highlight that dietary patterns in infants and toddlers vary in their underlying energy and nutrient composition.

Diet supplies the nutrients needed for the development of neural tissues that occurs over the first 2 years of life. Our aim was to examine associations between dietary patterns at 6, 15 and 24 months and intelligence quotient (IQ) scores at 8 years. Participants were enrolled in an observational birth cohort (ALSPAC study, n = 7,097). Dietary data was collected by questionnaire and patterns were extracted at each time using principal component analysis. IQ was measured using the Wechsler Intelligence Scale for Children at 8 years. Associations between dietary patterns and IQ were examined in regression analyses adjusted for potential confounding and by propensity score matching, with data imputation for missing values. At all ages, higher scores on a Discretionary pattern (characterized by biscuits, chocolate, sweets, soda, crisps) were associated with 1–2 point lower IQ. A Breastfeeding pattern at 6 months and Homemade contemporary patterns at 15 and 24 months (herbs, legumes, cheese, raw fruit and vegetables) were associated with 1-to-2 point higher IQ. A Home-made traditional pattern (meat, cooked vegetables, desserts) at 6 months was positively associated with higher IQ scores, but there was no association with similar patterns at 15 or 24 months. Negative associations were found with patterns characterized by Ready-prepared baby foods at 6 and 15 months and positive associations with a Ready-to-eat foods pattern at 24 months. Propensity score analyses were consistent with regression analyses. This study suggests that dietary patterns from 6 to 24 months may have a small but persistent effect on IQ at 8 years. Refereed/Peer-reviewed

The complementary feeding period is an important stage of child development. The study aim was to develop an index reflecting the degree of adherence to complementary feeding guidelines, evaluate its convergent validity, and explore associations with socio-demographic factors and dietary pattern scores in childhood. Data were analyzed from the Avon Longitudinal Study of Parents and Children (n = 6065) using parent-completed dietary questionnaires at 6 mo of age, socio-demographic information, and dietary patterns derived by principal component analysis at age 3 y. The Complementary Feeding Utility Index (CFUI) consists of 14 components: breastfeeding duration, feeding to appetite, timing of introduction to solids, exposure to iron-rich cereals, fruit and vegetable intake, exposure to high-fat/-salt/-sugar foods including sugary drinks, food texture, and meal/snack frequency. Regression analyses were undertaken to investigate associations between index scores, socio-demographic factors, food and nutrient intakes, and dietary pattern scores at age 3 y. Milk and food intake at 6 mo and nutrient intake at 8 mo of age varied across quintiles of index score in largely the expected directions. Associations were found among index score, maternal age, education, social class, maternal smoking history, and prepregnancy BMI. After adjustment for socio-demographic factors, the index score was associated with "processed" [β = -0.234 (95% CI = -0.260, -0.209)] and "healthy" [β = 0.185 (95% CI = 0.155, 0.215)] dietary pattern scores at age 3 y. The CFUI is able to discriminate across food intake, nutrient intake, and socio-demographic factors and is associated with later dietary patterns. Refereed/Peer-reviewed

Objective: Identify preventable pre-pregnancy risk factors that may affect the prevalence of miscarriage among a cohort of Australian Indigenous women. Methods: Data from 1,009 Indigenous women of childbearing age who participated in a 1999-2000 health screening program in far-north Queensland were linked to Queensland hospitalisation data. Women who attended hospital after their health check (censor date: March 2008) for a pregnancy-related condition were identified. Characteristics associated with becoming pregnant and subsequent miscarriage were analysed using generalised linear models. Results: After adjusting for age and ethnicity, women who became pregnant were more likely to be smokers and to have low red cell folate at baseline. The risk of miscarriage increased with age. Women who reported risky drinking or had elevated gamma-glutamyl transferase were also at higher risk. After further adjustment for risky drinking, the presence of chlamydia or gonorrhoea before pregnancy was associated with miscarriage. The presence of both infections at baseline compared with women who had no infection, again after further adjustment for risky drinking, was strongly associated with miscarriage; these women had more than a four-fold increase in risk (PR: 4.57 [2.21-9.46]). Elevated body mass index, high blood pressure and smoking were not statistically significantly associated with risk of miscarriage. Conclusions and implications: A high prevalence of pre-pregnancy sexually transmitted infections and high rates of risky drinking are associated with miscarriage among young Indigenous women in rural and remote communities in north Queensland. Refereed/Peer-reviewed

Background— Childhood blood pressure is largely uninfluenced by medical treatment and behavioral changes associated with hypertension diagnosis. Examining secular trends in childhood blood pressure and its contributing factors will help us better understand population-level determinants of blood pressure and hypertension. Methods and Results— Data were from 4 waves of the Korean National Health and Nutrition Examination Survey between 1998 and 2008, including a total of 5909 boys and girls 10 to 19 years of age. Over the past 10 years, age- and height-adjusted mean systolic blood pressure decreased substantially from 115.6 to 106.9 mm Hg (by 8.7 mm Hg) among boys and from 111.8 to 101.8 mm Hg (by 10.0 mm Hg) among girls. Associated childhood hypertension and prehypertension/hypertension prevalences decreased by 52% to 86%. These remarkable decreases were found among all age and socioeconomic groups and were not explained by secular changes in childhood obesity (body mass index and waist circumferences), health behaviors (cigarette smoking and physical activity), nutritional factors (sodium, potassium, total energy, protein, and fat intake), psychological factors (perceived stress and sleep duration), and sociodemographic factors (annual household income and family size). Conclusions— We observed important population declines in blood pressure in Korea over a 10-year period in children 10 to 19 years of age, but the likely causes for these secular trends remain to be determined.

This study examined the predictive ability of mother’s age, antenatal depression, education, financial difficulties, partner status, and smoking for a range of poor maternal and offspring outcomes assessed up to 61 months postnatally. Outcomes obtained from the Avon Longitudinal Study of Parents and Children (ALSPAC) were maternal postnatal depression at 8 weeks (n = 10,070), never breastfeeding (n = 7,976), feelings of poor attachment (n = 8,253) and hostility (n = 8,159) at 47 months, and not in employment, education or training (NEET, n = 8,265) at 61 months. Only a small proportion of women with each outcome were aged less than 20 years when they were pregnant. At least half of the women experiencing these outcomes, and up to 74.7% of women with postnatal depression, could be identified if they had at least one of the predictors measured during pregnancy (age

This article reviews the historical declines in cardiovascular mortality and provides an overview of the contribution of social and economic factors to disease change. We document the magnitude of declines in cardiovascular diseases and the major role of changes in conventional risk factors, and we review the contributions of social determinants to changes in disease rates. We conclude by arguing that understanding patterns and trends of social inequalities in cardiovascular disease and its risk factors requires consideration of the specific intersections of health and social exposures acting across the life course in different settings, in both time and place.

Refereed/Peer-reviewed

Background: Individuals living in deprived neighbourhoods have poor health outcomes, including human immunodeficiency virus (HIV) infection mortality. We assessed the association between individual and neighbourhood characteristics, and HIV testing across Canada. Methods: We used logistic regression modelling to evaluate this association in 2219 men and 2815 women, aged 18-54 years, in Canada, using data from the National Population Health Survey (1996/7),. Socio-economic characteristics and presence of a sexually transmitted infection (STI) were the individual level characteristics. Small area of residence was classified according to categories of material and social deprivation; these were the ’neighbourhood’ variables in the model. Results: Ethnic minority women were less likely to report an HIV test than white women (OR 0.44, 95% CI: 0.23 to 0.86). Women without a regular doctor were significantly less likely to report ever having had an HIV test (OR 0.57, 95% CI: 0.35 to 0.93). Adjusting for individual level characteristics, we found that men and women living in the most materially deprived neighbourhoods were slightly less likely to report HIV testing than those living in the least deprived neighbourhoods (Men - OR 0.61, 95% CI: 0.34 to 1.08; Women - OR 0.62, 95% CI: 0.38 to 1.00). Discussion: Thus, living in poor neighbourhoods was associated with poor uptake of an HIV test. These economic disparities should be taken in account while designing future prevention strategies. Ethnic minority women were less likely to go for HIV testing and culturally appropriate messages may be required for prevention in ethnic minorities.

OBJECTIVES. The purpose of this work was to examine whether the positive association between birth weight and childhood cognitive ability is seen within siblings from the same family, as well as between nonsiblings, and to determine whether these associations vary with age. METHODS. We compared the association of birth weight with cognitive ability measured at ages 5 to 6, 7 to 9, and 11 to 12 years among a total of 5402 children from different families with that among 2236 to 3083 sibships from the National Longitudinal Study of Youth 1979-Children. RESULTS. In the whole cohort, there were positive associations between birth weight and cognitive ability at all ages, with the association increasing with age from a 0.81-point increase at ages 5 to 6 years to 1.30 and 1.44 points at ages 7 to 9 and 11 to 12 years, respectively, per 1 SD of gestational age- and gender-adjusted birth weight z score. With adjustment for covariates, there was marked attenuation of these associations. Mean differences were 0.28 points in children aged 5 to 6 years, 0.67 points in those aged 7 to 9 years, and 0.52 points in those aged 11 to 12 years after adjusting for child's gender, race or ethnicity, year of birth, and age at test; maternal age, height, parity, education, smoking during pregnancy, and cognitive ability; and household income. Our family-based analyses that separated within- and between-family effects found that the between-family associations were much stronger than the within-family associations. However, adjustment for potential confounders attenuated the between-family associations, and there was no evidence for a difference in association comparing the between- and within-family associations. CONCLUSIONS. In these data, the positive association between birth weight and childhood cognitive ability at ages 5 to 12 years is explained largely by family characteristics rather than a specific intrauterine effect.

Objective: To update a systematic review on the association between childhood socioeconomic circumstances and cause-specific mortality. Studies published since 2003 include a far greater number of deaths than was previously available justifying an update of the previous systematic review. Methods: Individual-level studies examining childhood socioeconomic circumstances and adult overall and cause-specific mortality published between 2003 and April 2007. Results and conclusions: The new studies confirmed that mortality risk for all causes was higher among those who experienced poorer socioeconomic circumstances during childhood. As already suggested in the original systematic review, not all causes of death were equally related to childhood socioeconomic circumstances. A greater proportion of new studies included women and showed that a similar pattern is valid for both genders. In addition, the new studies show that this association persists among younger birth cohorts, despite temporal general improvements in childhood conditions across successive birth cohorts. The difficulties of establishing a particular life-course model were highlighted.

The authors provide an overview of methods for summarizing social disparities in health using the example of lung cancer. They apply four measures of relative disparity and three measures of absolute disparity to trends in US lung cancer incidence by area-socioeconomic position and race-ethnicity from 1992 to 2004. Among females, measures of absolute and relative disparity suggested that area-socioeconomic and race-ethnic disparities increased over these 12 years but differed widely with respect to the magnitude of the change. Among males, the authors found substantial disagreement among summary measures of relative disparity with respect to the magnitude and the direction of change in disparities. Among area-socioeconomic groups, the index of disparity increased by 47% and the relative concentration index decreased by 116%, while for race-ethnicity the index of disparity increased by 36% and the Theil index increased by 13%. The choice of a summary measure of disparity may affect the interpretation of changes in health disparities. Important issues to consider are the reference point from which differences are measured, whether to measure disparity on the absolute or relative scale, and whether to weight disparity measures by population size. A suite of indicators is needed to provide a clear picture of health disparity change.

The reasons for social inequality in breast cancer survival are far from established. Our study aims to study the importance of a range of socioeconomic factors and comorbid disorders on survival after breast cancer surgery in Denmark where the health care system is tax-funded and uniform. All 25,897 Danish women who underwent protocol-based treatment for breast cancer in 1983-1999 were identified in a clinical database and information on socioeconomic variables and both somatic and psychiatric comorbid disorders was obtained from population-based registries. We used Cox proportional hazards models to estimate the association between socioeconomic position and overall survival and further to analyse breast cancer specific deaths in a competing risk set-up regarding all other causes of death as competing risks. The adjusted hazard ratio (HR) for death was reduced in women with higher education (HR, 0.91; 95% confidence interval (CI), 0.85-0.98), with higher income (HR, 0.93; 95% CI, 0.87-0.98) and with larger dwellings (HR, 0.90; 95% CI, 0.85-0.96 for women living in houses larger than 150 m(2)). Presence of comorbid disorders increased the HR. An interaction between income and comorbid disorders resulting in a 15% lower survival 10 year after primary surgery in poor women with low-risk breast cancer having comorbid conditions ( approximately 65%) compared to rich women with similar breast cancer prognosis and comorbid conditions ( approximately 80%) suggests that part of the explanation for the social inequality in survival after breast cancer surgery in Denmark lies in the access to and/or compliance with management of comorbid conditions in poorer women. (c) 2007 Wiley-Liss, Inc.

The authors investigated the association between socioeconomic position and stage of breast cancer at the time of diagnosis in a nationwide Danish study. All 28 765 women with a primary invasive breast cancer diagnosed between 1983 and 1999 were identified in a nationwide clinical database and information on socioeconomic variables was obtained from Statistics Denmark. The risk of being diagnosed with a high-risk breast cancer, that is size >20 mm, lymph-node positive, ductal histology/high histologic grade and hormone receptor negative, was analysed by multivariate logistic regression. The adjusted odds ratio (OR) for high-risk breast cancer was reduced with longer education with a 12% reduced risk (95% confidence interval (CI), 0.80,0.96) in women with higher education and increased with reduced disposable income (low income group: OR, 1.22; 95% CI, 1.10,1.34). There was an urban–rural gradient, with higher risk among rural women (OR 1.10; 95 % CI, 1.02, 1.18) and lower risk among women in the capital suburbs (OR, 0.85; 95% CI, 0.78, 0.93) and capital area (OR, 0.93; 95% CI, 0.84–1.02). These factors were significant only for postmenopausal women, although similar patterns were observed among the premenopausal women, suggesting a subgroup of aggressive premenopausal breast cancers less influenced by socioeconomic factors.

We investigated the contribution of the large-scale immigration of White Europeans into the US between 1850 and 1930 to the timing and extent of the epidemic pattern of heart disease between 1900 and 1980. The analyses are based on data collected through the United States Federal Census from 1850 to the present. The hardcopy historical record confirms that census reports themselves and related monographs were concerned from 1850 with excessive mortality from heart disease of immigrants, particularly of Northern European origin and initially at least, their first-generation native-born children. Our analysis of the electronic database indicates a strong relationship between the percentage of US population foreign born and native born of foreign parentage and age adjusted mortality from heart disease. We identified a lag of 50 years giving the maximum linear correlation coefficient for men (r(2) = 0.92), and for women a shorter lag of 38 years and an earlier decline in Coronary Heart Disease (CHD) rates (r(2) = 0.96). Both the rise and fall of the CHD epidemic over an 80-year period correspond closely to the rise and fall of the foreign population in previous years. For the foreign born only, age adjusted negative binomial general estimated equation (GEE) models calculate the relative risk of dying of heart disease per 10% increase in proportion foreign born. There is an independent influence for men until 1930 and for women throughout the period from 1910 onwards. We conclude there is an impact of immigration on the pattern of the epidemic, mediated through a combination of factors, such as accumulated life-course susceptibility, deprived socio-economic conditions upon arrival, and the enthusiastic uptake of behaviours related to the classic risk factors of smoking, high saturated fat and salt diet. Our analysis provides a more contextualised understanding of the scale and timing of the epidemic of CHD in the US.

Background Childhood socioeconomic circumstances have been shown to contribute to adult mortality. The purpose of this study was to compare the association between objective historical records and recalled questionnaire-based information on childhood socioeconomic position (SEP) with regard to cardiovascular and all-cause mortality. Methods We examined the association between a socially disadvantaged childhood and all-cause mortality, cardiovascular disease (CVD) mortality, coronary heart disease (CHD) mortality, and acute coronary events among male participants in the Kuopio Ischemic Heart Disease (KIHD) Risk Factor Study, a population-based cohort study in eastern Finland with follow-up until 2002. The historical data on childhood factors were collected from school health records (n = 698), mainly from the 1930s to the 1950s. Recall data on socioeconomic conditions in childhood were obtained from the baseline examinations of the KIHD cohort (n = 2,682) in 1984-89. Results According to original school health records the men who were socially disadvantaged in childhood had a 1.41-fold (95% confidence interval 1.01-1.97) age-adjusted and examination-year-adjusted risk of all-cause death, a 1.32-fold (0.83-2.11) risk of CVD death, a 1.48-fold (0.85-2.57) risk of CHD death, and a 1.50-fold (1.02-2.20) risk of acute coronary events. After adjustment for biological and behavioural risk factors and for the SEP in adulthood the association was attenuated in all-cause death but did not change in CVD death, CHD death, and acute coronary events. On the contrary, the questionnaire-based recalled childhood data on childhood SEP showed no associations with mortality or acute coronary events. Conclusions With regard to adult mortality, the use of historical records concerning hygiene and living conditions collected in childhood may either provide more accurate measures of early-life socioeconomic conditions or capture more relevant aspects of childhood socioeconomic disadvantage than retrospective recall data.

BACKGROUND Our objective was to investigate the contribution of childhood and adult socioeconomic position (SEP) to adult obesity and smoking behaviour, in particular to establish the role of childhood circumstances across different studies in Europe and the US. METHODS Seven population-based surveys in six Western countries (Britain, Denmark, Finland, Netherlands, Sweden, US) were examined, with participants aged 30-50 yr and born between 1910 and 1960. Adult smoking was analysed using three outcomes (ever, current, or ex-) and adult obesity was defined as body mass index (kg/m(2)) > or =30. RESULTS A strong effect of adult social position was observed for smoking outcomes and obesity. For example, manual SEP in adulthood increased the risk of ever smoking (adjusted odds ratio (OR) 1.47-2.00 for men; 0.94-1.81 for women), and obesity (adjusted OR 1.06-2.24 for men, 1.21-3.26 for women). In most studies, childhood position was not associated with ever-smoking. For current smoking, manual childhood position was associated among women (adjusted OR 1.09-1.54), but no consistent pattern was seen for men. For ex-smoking, manual childhood origins lowered the chance of quitting among women (adjusted OR 0.64-0.81) except in the US (OR = 1.17); among men this association was seen in fewer studies (adjusted OR 0.74-1.09). For obesity, manual origins increased the risk for women (adjusted OR 0.96-2.50); effects were weaker among men but mostly in the same direction (adjusted OR 0.79-1.42). CONCLUSIONS As expected, adult SEP was an important influence on smoking behaviour and obesity. In addition, factors related to disadvantaged social origins appeared to increase the risk of obesity and reduce the probability of quitting smoking in adulthood, particularly in women.

There is convincing evidence that exposures acting across the life course influence adult health outcomes (1–3). Lifecourse epidemiology examines a range of potential processes through which exposures acting at different stages of life can, singly or in combination, influence disease risk (table 1) (4). In the critical period model, an exposure acting at a specific time has long-lasting effects on the structure or function of the body. The fetal origins hypothesis, in its original formulation, took this approach (5). Other examples of processes where outcomes appear to depend upon the time window during which an exposure acts are limb development (in relation to maternal thalidomide use); infection with hepatitis B and risk of adulthood liver cancer (with very early postnatal infection being most implicated); and environmental lead exposure, which results in serious neurodevelopmental deficits only if occurring in infancy and childhood (3). However, the influence of exposures acting during critical periods of susceptibility may be modified by later life exposures. This is the case for the associations of birth weight with coronary heart disease, high blood pressure, and insulin resistance, where associations are stronger (or only evident) among those who become obese during adolescence or adulthood (6–8).

An ideological climate has persisted in Korea that has discouraged public discussion of social inequalities. Thus studies on inequalities in mortality remain undeveloped. This study is to examine age- and cause-specific socioeconomic mortality differentials for both men and women representative of the Korean population.Using Korea's 1995 Census and 1995-2000 Death Certificate data, age-, sex-, and education-specific mortality rates were measured, after which education-specific rate ratios, and relative indices of inequality were calculated.Graded educational differentials in mortality were observed among both sexes with higher mortality rates related to lower educational attainment in most causes of death. However, positive associations were identified between education levels and mortality rates with respect to ischaemic heart disease among older males and breast cancer among older females. The magnitude of educational inequality in mortality was not constant across causes and in some cases differed by sex.The changing relation between educational attainment and mortality rates from ischaemic heart disease and breast cancer likely reflects changes in the social distribution of risk factors that emerged in the process of Korea's rapid economic development. Studies on specific exposures over the life course influencing the occurrence of and survival after specific diseases would help provide a more complete understanding of patterns and trends in socioeconomic mortality differentials in Korea.

Study objectives: To identify and quantify a hypothesised collective effect of the neighbourhood on individual use of anxiolytic-hypnotic drugs (AHD). To analyse the general impact of neighbourhood social participation on use of AHD, adjusting for individual characteristics. Design: Cross sectional analysis performed by multilevel logistic regression with women at the first level and neighbourhoods at the second level. Setting: Malmö (250 000 inhabitants), Sweden. Participants:15 456 women aged 45 to 73, residing in 95 neighbourhoods in Malmö, who took part in the Malmö diet and cancer study (1991–1996). Main results: The prevalence of AHD use was 5.5% in the study sample. Overall, 1.7% of the total individual differences in the propensity for using AHD were explained by the neighbourhood level. This percentage, however, differed between different individuals. Low level of social participation in the neighbourhood was associated with higher probability of AHD use (OR = 3.10 (95% CI 1.51 to 6.41)), independently of individual age, low social participation, low educational level, and living alone. This association was reduced (OR = 2.01 (95% CI 0.97 to 4.14)) after the additional accounting for individual disability pension, low self rated health, stress, and medication for somatic disorders. Conclusions: The neighbourhood level of social participation seems to affect individual use of AHD, possibly through individual characteristics. However, neighbourhood boundaries play a minor part in understanding individual AHD use in the city of Malmö.

Objective Self-esteem is considered to be importantly associated with both psychosocial states such as depression as well as physical health. There are no population-based studies that examine the association between self-esteem and mortality. The objective of this study was to assess whether low self-esteem was prospectively associated with increased risk of death in a population-based sample of Finnish men. Methods A sample of 2682 male residents of Kuopio, Finland were interviewed and followed prospectively as part of the Kuopio Ischemic Heart Disease Risk Factor Study (KIHD). Characteristics of the KIHD sample at baseline included self-esteem, measured by the Rosenberg ten-item scale, socioeconomic factors, behavioral risk factors, other psychosocial characteristics, and prevalent diseases. Mortality was ascertained through linkage to the Finnish national death registry. We assessed the relationship between self-esteem and all-cause mortality using Cox proportional hazards models. Results Low self-esteem was associated with a two-fold [hazard ratio (HR) = 2.0, 95% confidence interval (CI) = 1.3–3.2] increase in age-adjusted mortality. This relationship was partially explained by behavioral and socioeconomic factors, and prevalent diseases, and fully explained by other psychosocial characteristics (hopelessness, depression, cynical hostility, and sullenness). When adjusted for hopelessness alone there was no increased risk associated with low self-esteem (HR = 1.3, 95% CI = 0.8–2.2). Conclusions This study found no association between self-esteem and all-cause mortality after adjustment for other psychosocial characteristics, primarily hopelessness. Our understanding of the observed relationships between some psychosocial factors and mortality may be improved by simultaneous measurement of multiple psychosocial domains, thus diminishing the potential for residual confounding.

While early childhood development interventions (ECDIs) have the potential to bring about wide-ranging societal benefits in both the short and the long term (Bennett and Tayler, 2006; Engle et al., 2007; Heckman and Masterov, 2004), less is known about the potential for center based ECDIs to improve the health of children and adults. Many governments have invested in nutrition and health services as part of a range of comprehensive services in ECDIs (Currie and Thomas, 1995; Goodson et al., 2000; Kropp et al., 2001), with an expectation that they will improve child health outcomes. The focus of most of the evidence of health effects of ECDIs is on the short-term increased risk of infectious diseases and injury (Ball et al., 2002; Lu et al., 2004; Rivara et al., 1989) from center-based children’s services, or a small range of health outcomes examined in infant home visiting programs (Elkan et al., 2000; Gomby, 1999). The health benefits associated with ECDIs are potentially broader in scope than infectious diseases and injury and may extend beyond the preschool years. In addition to the provision of health services, ECDIs that improve educational and social outcomes, lessening the impacts of social disadvantage, may reduce the shorter- and longer-term health differences known to be associated with growing up in poorer social conditions (Galobardes, Lynch, and Davey Smith, 2004).

This paper presents the development of the Complementary Feeding Utility Index (CFUI), a composite index aimed to measure adherence to infant feeding guidelines. Through an axiomatic characterization this paper shows the advantages in using the CFUI are the following: it avoids the use of arbitrary cut-offs, and by converting observed diet preferences into utilities, summing the score is meaningful. In addition, as the CFUI is designed to be scored continuously, it allows the transition from intake of beneficial foods (in low quantities) and intake of detrimental foods (in high quantities) to be more subtle. The paper first describes the rationale being the development of the CFUI and then elaborates on the methodology used to develop the CFUI, including the process of selecting the components. The methodology is applied to data collected from the Avon Longitudinal Study of Parents and Children to show the advantages of the CFUI over traditional diet index approaches. Unlike traditional approaches, the distribution of the CFUI does not peak towards mean value but distributes evenly towards the tails of the distribution.

Purpose: This study aims to measure the impact of HRT use at the time of screening on rates of screen-detected invasive breast cancer (IBC) and ductal carcinoma in situ (DCIS), interval cancers and investigative procedures, within a well-established population-based mammography screening program. Methods: Using South Australian BreastScreen data from 1998 to 2009 pertaining to 819,722 screening episodes, Poisson regression models were undertaken to estimate the incidence risk ratios (IRR) for various screening outcomes at both the first and subsequent screening rounds, among women who had been using HRT in the 6 months prior to screening compared with those who had not. Results: Current HRT use was associated with increased risk of recall for assessment, biopsy procedures, and breast cancer diagnosis among BreastScreen participants. Risk of screen-detected breast cancer was increased at subsequent screening rounds (IRR = 1.30, 95 % confidence interval 1.18-1.34), but not at women's first screening round (1.05, 0.88-1.25). This increased risk applied to IBC (1.35, 1.27-1.45), but not to DCIS (1.04, 0.89-1.23). Interval cancer risk was elevated among HRT users following both the first screen (1.77, 1.33-2.37) and subsequent screening episodes (1.92, 1.72-2.15). Conclusions: Increased risks of recall, biopsy rates, screen-detected, and interval cancers among HRT users have important implications for population-based breast cancer screening programs. Our findings support the concept that HRT use may increase the growth of preexisting cancers. Lack of effect on DCIS could imply different etiology or time frames for DCIS and IBC development or increased transition from preinvasive to invasive disease due to HRT use. Refereed/Peer-reviewed

OBJECTIVE: We aimed to examine the ability of mother's age, and other factors measured during pregnancy (education, financial difficulties, partner status, smoking, and depression), to predict child development outcomes up to age 5 years. METHODS: Data were obtained from the Avon Longitudinal Study of Parents and Children (ALSPAC). Poor child development was defined as scoring in the worst 10% of a parent-reported ALSPAC developmental scale (ADS) at 18 months (n = 7546), the Strengths and Difficulties Questionnaire (SDQ) at 47 months (n = 8328), or teacher-reported School Entry Assessment (SEA) scores at 4 to 5 years (n = 7345). RESULTS: Only a small proportion of children with poor development had mothers aged younger than 20 years at their birth (3.3%, 6.4%, and 9.2%, for the ADS, SDQ, and SEA, respectively). A greater proportion with each measure of poor development would be identified (48.9%, 63.6%, and 74.4%, respectively) if all 6 predictors were used and a woman had at least 1 of these. Model discrimination was poor using maternal age only (area under the receiver operator characteristic curve ∼0.5 for all 3 outcomes). This improved when all 6 predictors were included in the model (ADS: 0.56; SDQ: 0.66; SEA: 0.67). Calibration also improved with the model including all 6 predictors. CONCLUSIONS: Even if programs targeted at teen-aged mothers are successful in improving child development, they will have little impact on population levels of poor child development if young maternal age is the sole or main means of identifying eligibility for the program.

Objective : To assess the effect of South Australian Kindergarten Union participation on adult cardiovascular behavioural risk factors. Methods : Using a retrospective cohort design, this study examined the effect of attendance at a Kindergarten Union preschool from 1940 to 1972 on behavioural risk factors for cardiovascular disease in adults 34-67 years. Dichotomous outcomes were analysed using a generalised linear model (Poisson distribution) with robust variance estimates. Outcomes with more than two categories were analysed with a multinomial logistic model. Results : There was a beneficial effect of preschool on high physical activity relative to sedentary and on ever smoking, but a negative effect on fruit consumption. Preschool attendance was not associated with alcohol risk or vegetable consumption under traditional criteria, however the point estimate for vegetable consumption was in the beneficial direction. The point estimates from the multinomial model suggested a step-wise decreasing risk for preschool attendees to have less risk of experiencing multiple behavioural risk factors (e.g. risk of five risk factors for preschool participants compared with non-participants). Conclusions and implications: Attendance at a Kindergarten Union preschool was associated with a reduced risk of two and an indication of benefit in a third behavioural risk factor in adulthood. This study provides some evidence for the potential health benefit of interventions outside of the health sector to prevent cardiovascular diseases, which are strongly associated with lifelong social disadvantage. Refereed/Peer-reviewed

Potential upstream determinants of coronary heart disease (CHD) include life-course socioeconomic position (e.g., childhood socioeconomic circumstances, own education and occupation); however, several plausible biological mechanisms by which socioeconomic position (SEP) may influence CHD are poorly understood. Several CHD risk factors appear to be more strongly associated with SEP in women than in men; little is known as to whether any CHD risk factors may be more strongly associated with SEP in men. Objectives were to evaluate whether cumulative life-course SEP is associated with a measurement of subclinical atherosclerosis, the ankle-brachial index (ABI), in men and women. This study was a prospective analysis of 1,454 participants from the Framingham Heart Study Offspring Cohort (mean age 57 years, 53.8% women). Cumulative SEP was calculated by summing tertile scores for father's education, own education, and own occupation. ABI was dichotomized as low (1.1 to 1.4). After adjustment for age and CHD risk factors cumulative life-course SEP was associated with low ABI in men (odds ratio [OR] 2.04, 95% confidence interval [CI] 1.22 to 3.42, for low vs high cumulative SEP score) but not in women (OR 0.86, 95% CI 0.56 to 1.33). Associations with low ABI in men were substantially driven by their own education (OR 4.13, 95% CI 1.86 to 9.16, for lower vs higher than high school education). In conclusion, cumulative life-course SEP was associated with low ABI in men but not in women. Refereed/Peer-reviewed

Background The analysis describes trends in the levels and social distribution of total life expectancy and healthy life expectancy in South Australia from 1999 to 2008. Methods South Australian Burden of Disease series for the period 1999-2001 to 2006-2008 and across statistical local areas according to relative socioeconomic disadvantage were analyzed for changes in total life expectancy and healthy life expectancy by sex and area level disadvantage, with further decomposition of healthy life expectancy change by age, cause of death, and illness. Results Total life expectancy at birth increased in South Australia for both sexes (2.0 years [2.6%] among males; 1.5 years [1.8%] among females). Healthy life expectancy also increased (1.4 years [2.1%] among males; 1.2 years [1.5%] among females). Total life and healthy life expectancy gains were apparent in all socioeconomic groups, with the largest increases in areas of most and least disadvantage. While the least disadvantaged areas consistently had the best health outcomes, they also experienced the largest increase in the amount of life expectancy lived with disease and injury-related illness. Conclusions While overall gains in both total life and healthy life expectancy were apparent in South Australia, gains were greater for total life expectancy. Additionally, the proportion of expected life lived with disease and injury-related illness increased as disadvantage decreased. This expansion of morbidity occurred in both sexes and across all socio-economic groups. This analysis outlines the continuing improvements to population health outcomes within South Australia. It also highlights the challenge of reducing population morbidity so that gains to healthy life match those of total life expectancy.

Purpose One of the specific aims of life course epidemiology is to assess the explanatory utility of three general hypotheses, namely the critical period hypothesis, the accumulation of risk hypothesis, and the effect modification hypothesis. Methods A structured regression approach to this problem is illustrated with data from an ongoing longitudinal study of children and their families established in Adelaide in 1998−2000. A series of nested models that correspond to the alternative life course hypotheses were fit in an investigation of the effects of maternal depressive states in early childhood on internalizing child behavior at 9.5 years. Both linear and logistic regression models were considered. Results The structured regression framework showed the accumulation hypothesis was most plausible for these data. The analyses also provided some evidence of a critical period for the effect of maternal depressive status around child age 2 years on internalizing behavior at 9.5 years. Conclusions The findings of this study suggest that comparing a suite of nested models to a full model can be useful in attempting to disentangle life course processes.

This Hints & Kinks paper describes a technique enabling quantification of the contributions of determinants to socioeconomic inequality in health. This technique, differing from an analysis investigating the determinants of average health levels, has received considerable attention from health economists (van Doorslaer and Gerdtham 2003; van Doorslaer and Jones 2003; van Doorslaer et al. 2004; Wagstaff et al. 2003) but only more recently from epidemiologists as well (Harper and Lynch 2007; Lynch 2006; Hosseinpoor et al. 2006). This paper employs the relative concentration index (RCI), described in Konings et al. (2009), to summarize relative inequality across the entire socioeconomic distribution. The RCI of a continuous health outcome y results from a relative concentration curve, which graphs on the x-axis the cumulative percentage of the sample, ranked by an indicator of socioeconomic position such as education or income beginning with the poorest. The y-axis then indicates the cumulative percentage of the health outcome corresponding to each cumulative percentage of the distribution of the socioeconomic indicator. Figure 1 provides an example of a concentration curve, where the health variable is childhood malnutrition in Ghana in 2003. It shows that the level of malnutrition accumulates faster among the poor than among the better-off because the line is above the diagonal. The RCI is defined as twice the area between the concentration curve and the line of equality (the 45 diagonal from the bottom-left corner to the top-right). Details on how to compute the RCI can be found in Konings et al. (2009). If yi is linearly modeled, linking a health variable, y to a set of k health determinants, xk, this can be expressed by: yi 1⁄4 a þ X

Objective. To examine the association between socioeconomic factors and weight status across 53 countries.Methods. Data are cross-sectional and from the long version of the World Health Survey (WHS). There were 172,625 WHS participants who provided self-reported height and weight measures and sociodemographic information. The International Classification of adult weight status was used to classify participants by body mass index (BMI): (1) underweight (30.0). Multinomial regression was used in the analyses.Results. Globally, 6.7% was underweight, 25.7% overweight, and 8.9% obese. Underweight status was least (5.8%) and obesity (9.3%) most prevalent in the richest quintile. There was variability between countries, with a tendency for lower-income quintiles to be at increased risk for underweight and reduced risk for obesity.Conclusion. International policies may require flexibility in addressing cross-national differences in the socio-economic covariates of BMI status.

Background: Previous research has suggested that dehydration in infancy may lead to high blood pressure in later life because of sodium retention. The purpose of this study was to examine the effect of poor hygiene of the child, poor social and poor housing conditions at home and diarrhoea in childhood as proxies for dehydration on high blood pressure in later life. Methods: Data were from a subset of participants in the Kuopio Ischaemic Heart Disease Risk Factor Study,a population-based cohort study in eastern Finland.Information on childhood factors was collected from school health records (n¼952), from the 1930s to the1950s. Adult data were obtained from baseline examinations of the Kuopio Ischaemic Heart Disease Risk Factor Study cohort (n¼2682) in 1984e1989. Results: Men who had poor hygiene in childhood had on average 4.07 mm Hg (95% CI 0.53 to 7.61) higher systolic blood pressure than men who had good or satisfactory hygiene in childhood in the age-adjusted analysis. Reports of diarrhoea were not associated with adult blood pressure. Conclusions: The authors’ findings suggest that poor hygiene and living in poor social conditions in childhood are associated with higher systolic blood pressure in adulthood. Reported childhood diarrhoea did not explain the link between hygiene and high blood pressure in adulthood. Refereed/Peer-reviewed

Associations between life course socioeconomic position (SEP) and novel biological risk markers for coronary heart disease such as inflammatory markers are not well understood. Most studies demonstrate inverse associations of life course SEP with C-reactive protein (CRP), interleukin-6 (IL-6) and fibrinogen, however little is known about associations between life course SEP and other inflammatory markers including intercellular adhesion molecule-1 (ICAM-1), tumor necrosis factor II (TNFR2), lipoprotein phospholipase A2 (Lp-PLA2) activity, monocyte chemoattractant protein-1 (MCP-1) or P-selectin. The objectives of this analysis were to determine whether three life course SEP frameworks ("accumulation of risk", "social mobility" and "sensitive periods") are associated with the aforementioned inflammatory markers. We examined 1413 Framingham Offspring Study participants (mean age 61.2+/-8.6 years, 54% women), using multivariable regression analyses. In age- and sex-adjusted regression analyses, cumulative SEP ("accumulation of risk" SEP framework), for low vs. high SEP, was inversely associated with CRP, IL-6, ICAM-1, TNFR2, Lp-PLA2 activity, MCP-1 and fibrinogen. We found that there were few consistent trends between social mobility trajectories and most inflammatory markers. Own educational attainment was inversely associated with 7 of 8 studied inflammatory markers, while father's education, father's occupation and own occupation were inversely associated with 4, 5 and 4 inflammatory markers, respectively, in age- and sex-adjusted analyses. The strengths of association between SEP and inflammatory markers were typically substantially accounted for by CHD risk markers (smoking, body mass index, systolic blood pressure, total:HDL cholesterol ratio, fasting glucose, medications, depressive symptomatology) suggesting these may be important mechanisms that explain associations between SEP and the studied inflammatory markers.

Objectives. We assessed life expectancy increases in the past several decades in South Korea by age and specific causes of death. Methods. We applied Arriaga's decomposition method to life table data (1970–2005) and mortality statistics (1983–2005) to estimate age- and cause-specific contributions to changes in life expectancy. Results. Reductions in infant mortality made the largest age-group contribution to the life expectancy increase. Reductions in cardiovascular diseases (particularly stroke and hypertensive diseases) contributed most to longer life expectancy between 1983 and 2005 (30% in males and 28% in females). Lower rates of stomach cancer, liver disease, tuberculosis, and external-cause mortality accounted for 30% of the male and 20% of the female increase in longevity. However, higher mortality from ischemic heart disease, lung and bronchial cancer, colorectal cancer, breast cancer, diabetes, and suicide offset gains by 10% in both genders. Conclusions. Rapid increases in life expectancy in South Korea were mostly achieved by reductions in infant mortality and in diseases related to infections and blood pressure.

Background: Studies suggest that sex differences in blood pressure (BP) are established early in life. Sex differences in BP increases that occur during adolescence may be due to differences in changes in anthropometric characteristics. Methods: Using sex-specific individual growth models, we assessed the effect of height, body mass index (BMI; kg/m2), waist circumference, and triceps and subscapular skinfold thickness on changes in systolic BP in a cohort of 1293 adolescents in Montreal, Canada. BP and anthropometry were assessed biannually (1999/2000, 2002, 2004) at mean ages 12.8, 15.2, and 17.0. Results: On average, systolic BP increased by 11.1 mm Hg in boys and 3.2 mm Hg in girls during 5 years. Changes in height explained half of the overall increase in systolic BP in boys and virtually all of the increase in systolic BP in girls. No meaningful sex differences were observed in the association of changes in BMI, waist circumference, and triceps and subscapular skinfold thickness with systolic BP change during 5 years. Increases in 1 BMI unit, 1 cm waist circumference, or 1 mm triceps or subscapular skinfold thickness were associated with increases of 0.7, 0.24, 0.3, and 0.4 mm Hg systolic BP, respectively. Conclusions: Although sex differences in mean systolic BP changes during adolescence were largely attributable to differences in gains in height, the effect of gaining weight or body fat on systolic BP change was similar in boys and girls. Refereed/Peer-reviewed

Background: Early child development interventions can set children on positive social and educational trajectories. The aim of this review was to examine the evidence for the adult health impacts of centre-based preschool interventions for preschoolers.Methods: Medline, Embase, ERIC, Psych Info, Sociological Abstracts, the Cochrane Library,C2-SPECTR and the Head Start database were searched (1980-2008), and reference lists were searched for articles missed by the electronic search. Results: The 12 eligible articles reviewed reported multi-faceted interventions and involved disadvantaged populations in all but one study. Limitations included a restricted range of health outcomes, reliance on self-report measures (11 studies), small sample sizes (nine studies with

Early childhood development interventions (ECDIs) have the potential to bring about wide ranging human capital benefits for children through to adulthood. Less is known, however, about the potential for such interventions to improve population health. The aim of this study was to examine the evidence for child health effects of centre-based preschool intervention programs for healthy 4 year olds, beyond the preschool years. Medline, Embase, ERIC, Psych Info, Sociological Abstracts, the Cochrane Library, C2-SPECTR and the Head Start database were searched using terms relating to preschool and health from 1980 to July 2008, limited to English language publications. Reference lists and the journal Child Development were hand searched for eligible articles missed by the electronic search. There were 37 eligible studies identified. The reviewed studies examined a range of interventions from centre-based preschool alone, to interventions also including parenting programs and/or health services. The study populations were mostly sampled from populations at risk of school failure (76%). Only eight of the 37 studies had a strong methodological rating, 15 were evaluated as at moderate potential risk of bias and 14 as at high potential risk of bias. The review found generally null effects of preschool interventions across a range of health outcomes, however there was some evidence for obesity reduction, greater social competence, improved mental health and crime prevention. We conclude that the great potential for early childhood interventions to improve population health across a range of health outcomes, as anticipated by policy makers worldwide, currently rests on a rather flimsy evidence base. Given the potential and the increasingly large public investment in these interventions, it is imperative that population health researchers, practitioners and policy makers worldwide collaborate to advance this research agenda.

Background: Breast cancer is the most commonly diagnosed cancer and the second leading cause of cancer death among women in the United States and varies systematically by race-ethnicity and socioeconomic status. Previous research has often focused on disparities between particular groups, but few studies have summarized disparities across multiple subgroups defined by race-ethnic and socioeconomic position. Methods: Data on breast cancer incidence, stage, mortality, and 5-year cause-specific probability of death (100 − survival) were obtained from the Surveillance, Epidemiology, and End Results program and data on mammography screening from the National Health Interview Survey from 1987 to 2005. We used four area-socioeconomic groups based on the percentage of poverty in the county of residence ( Results: From 1987 to 2004, area-socioeconomic disparities declined by 20% to 30% for incidence, stage at diagnosis, and 5-year cause-specific probability of death, and by roughly 100% for mortality, whether measured on the absolute or relative scale. In contrast, relative area-socioeconomic disparities in mammography use increased by 161%. Absolute race-ethnic disparities declined across all outcomes, with the largest reduction for mammography (56% decline). Relative race-ethnic disparities for mortality and 5-year cause-specific probability of death increased by 24% and 17%, respectively. Conclusions: Our analysis suggests progress towards race-ethnic and area-socioeconomic disparity goals for breast cancer, especially when measured on the absolute scale. However, greater progress is needed to address increasing relative socioeconomic disparities in mammography and race-ethnic disparities in mortality and 5-year cause-specific probability of death. (Cancer Epidemiol Biomarkers Prev 2009;18(1):121–31)

Objectives. We examined the association between childhood socioeconomic position and incidence of type 2 diabetes and the effects of gender and adult body mass index (BMI). Methods. We studied 5913 participants in the Alameda County Study from 1965 to 1999 who were diabetes free at baseline (1965). Cox proportional hazards models estimated diabetes risk associated with childhood socioeconomic position and combined childhood socioeconomic position–adult BMI categories in pooled and gender-stratified samples. Demographic confounders and potential pathway components (physical inactivity, smoking, alcohol consumption, hypertension, depression, health care access) were included as covariates. Results. Low childhood socioeconomic position was associated with excess diabetes risk, especially among women. Race and body composition accounted for some of this excess risk. The association between childhood socioeconomic position and diabetes incidence differed by adult BMI category in the pooled and women-only groups. Adjustment for race and behaviors attenuated the risk attributable to low childhood socioeconomic position among the obese group only. Conclusions. Childhood socioeconomic position was a robust predictor of incident diabetes, especially among women. A cumulative risk effect was observed for both childhood socioeconomic position and adult BMI, especially among women.

Background Patients living under better socioeconomic circumstances often receive more active treatments after an acute myocardial infarction (AMI) compared to less affluent patients. However, most previous studies were performed in countries with less comprehensive coverage for medical services. In this Swedish nation-wide longitudinal study we wanted to evaluate long-term survival after AMI in relation to socioeconomic position (SEP) and use of revascularization. Methods From the Swedish Myocardial Infarction Register we identified all 45 to 84-year-old patients (16,041 women and 30,366 men) alive 28 days after their first AMI during the period 1993 to 1996. We obtained detailed information on the use of revascularization, cumulative household income from the 1975 and 1990 censuses and 5-year survival after the AMI. Results Patients with the highest cumulative income (adding the values of the quartile categories of income in 1975 and 1990) underwent a revascularization procedure within one month after their first AMI two to three times as often as patients with the lowest cumulative income and had half the risk of death within five years. The socioeconomic differences in the use of revascularization procedures could not be explained by differences in co-morbidity or type of hospital at first admission. Patients who underwent revascularization showed a similar lowered mortality risk in the different income groups, while there were strong socioeconomic differences in long-term mortality among patients who did not undergo revascularization. Conclusion This nationwide Swedish study showed that patients with high income had a better long-term survival after recovery from their AMI compared to patients with low income. Furthermore, even though the use of revascularization procedures is beneficial, low SEP groups receive it less often than high SEP groups.

Background: Socioeconomic inequalities in health are ubiquitous in developed countries; however, whether these inequalities differ between women and men over time is less clear. Objective: To estimate the potentially different health effects of changes in socioeconomic position (SEP) on changes in health for working-age women and men over a 10-year period. Three main questions were addressed: (1) are there health differences between women and men over time, (2) do changes in SEP lead to health inequalities and (3) do changes in SEP impact health differently for women and men? Methods: Generalised estimating equations models were used to analyse cycles 1–5 of the Canadian National Population Health Survey for four measures of health, number of chronic conditions, self-rated health, functional health and mental distress, and three measures of SEP, income, education and employment status. Results: Health inequalities by sex/gender and by changes in SEP were present for all four outcomes in age-adjusted models; however, after controlling for time-dependent social structure, behaviour, and psychosocial factors the relationships persisted only for chronic conditions and psychological distress. There was no evidence that these effects differed, over time, between women and men. Conclusions: Men and women in this nationally representative sample of Canadians do not differentially embody changes in SEP, although both sex/gender and changes in SEP independently impact health.