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This invited special issue of Early Education and Development presents research related to the Early Development Instrument (EDI; Janus & Offord, 2007), a community tool to assess children's school readiness at a population level. In this editorial introduction, we first sketch out recent trends in school readiness research that call for a contextual and whole-child assessment of school readiness. Then we provide an overview of the EDI, including a discussion of its purpose and development, as well as its large-scale international use as a community tool to monitor children's developmental outcomes at population levels. Finally, we introduce the special issue's articles, all of which present research findings from ongoing community research projects that employ the EDI to assess children's school readiness. These articles are grouped into the following thematic themes: (a) individual-level validity of the EDI, (b) school and neighborhood effects and population-level validity of the EDI, and (c) program im...

Whereas the great majority of literacy research has been focused at the child level, this study examined the relationship between early literacy rates, developmental health of the population, and demographics in 23 school communities. The results showed that school-level literacy scores were related to the physical, social, and emotional maturity of the kindergarten population, as well as community demographics, including the proportion of families in each school catchment area living below the low income cutoff, the proportion of single-parent families, and the community 5-year mobility rate. Furthermore, the proportion of children at risk for literacy difficulties varied systematically by school, ranging from 0% to 44%; this risk was strongly related to developmental health and to demographics of the school community. The implications for models of early identification and corresponding intervention programs for at-risk children are discussed.

Data were analysed from the Organization for Economic Cooperation and Development (OECD) Program for International Student Assessment (PISA) to examine whether the relationship between parental unemployment status and child reading literacy is modified by the level of unemployment protection provided by the nation. The sample consisted of 61,946 children, nested in 3,918 schools among 17 market economies. The results of multi-level analyses indicated that, after controlling for a range of individual, family and school covariates, children with unemployed fathers in all countries had significantly lower reading literacy scores than those of employed fathers (β = −8.84, SE = 2.01). The contextual effect of unemployment protection was not significant after accounting for fathers’ employment status (β = −18.63, SE = 16.26). However, there was a significant negative interaction between unemployment protection and fathers’ unemployment, yielding the unexpected suggestion that, in countries with higher levels of unemployment protection, children with unemployed fathers fare worse, both in relation to children with unemployed fathers in lower protection countries, and in comparison with children with employed fathers (β = −26.96, SE = 8.08). Possible explanations are advanced for this result, including the potential for a ‘discouraged child effect’ arising from the potential association between unemployment protection and higher local unemployment rates (though unemployment rates at the national level were not significant).

Summary The influence of adversity over long periods of the life-span on adult cortisol metabolism is not established. We assess whether morning cortisol levels are associated with socio-economic position (SEP) from birth to mid-adulthood, and if so, whether the association is due primarily to SEP in childhood, adulthood or both. Data are from 6335 participants in the 1958 British birth cohort, with salivary cortisol samples collected at 45 yr. Two saliva samples were obtained on the same day: 45 min post-waking (t1) and 3 h later (t2). Median t1 and t2 cortisol values were 18.80 and 7.10 nmol/l for men; 19.60 and 6.60 nmol/l for women. Three outcomes were constructed: (1) extreme t1 cortisol (top and bottom 5%), (2) area-under-curve (AUC), and (3) abnormal t1–t2 pattern. All three outcomes were associated with lifetime SEP but the relative contribution of childhood and adulthood SEP varied by outcome measure. Our results suggest that the impact of less advantaged SEP over a lifetime would lead to an approximate doubling of the proportion of extreme post-waking cortisol levels for both sexes; an 8% and 10% increase, respectively for females and males in AUC, and an increased risk of having an abnormal cortisol pattern of 60% and 91%. SEP differences were independent of time of waking and sample collection, and in most instances, remained after adjustment for smoking and body mas index (BMI). Thus, our study provides evidence for effects of chronic adversity on cortisol in mid-adult life.

Background: Using a large cohort of western Canadian sawmill workers (n=28,794), the association between psychosocial work conditions and attempted and completed suicide was investigated. Methods: Records of attempted and completed suicide were accessed through a provincial hospital discharge registry to identify cases that were then matched using a nested case control method. Psychosocial work conditions were estimated by expert raters using the demand—control model. Univariate and multivariate conditional logistic regression was used to estimate the association between work conditions and suicide. Results: In multivariate models, controlling for sociodemographic (marital status, ethnicity) and occupational confounders (job mobility and duration), low psychological demand was associated with increased odds for completed suicide, and low social support was associated with increased odds for attempted suicides. Conclusions: This study indicates that workers with poor psychosocial working conditions may be at increased risk of both attempted and completed suicide.

A growing body of literature has examined the effects of neighbourhood characteristics on child health and well-being and the mechanisms through which such effects may operate. Research investigating neighbourhood effects on children is based on the notion that individuals and families who live in a neighbourhood collectively create a social context that influences the developing child. In this paper we investigate the relationship between individual and neighbourhood socioeconomic characteristics and kindergarten children's readiness to learn in Vancouver, Canada ( n = 3736), using multilevel modeling techniques and 1996 census data for Vancouver neighbourhoods ( n = 68). Findings suggest that although family-level characteristics carry the most weight in shaping children's readiness to learn, neighbourhood-level factors are independently associated with early developmental outcomes, particularly physical health and well-being, language and cognitive development, and communications skills and general knowledge. The strongest neighbourhood characteristics associated with readiness to learn were median income and the percentage of single-parent families. Also important were the percentage of the population who had not moved in the previous five years and the percentage of the population whose mother tongue was non-English. The latter neighbourhood characteristic was an especially strong predictor of communication skills and general knowledge. The findings suggest that neighbourhood-based policies to improve physical health and well-being, language and cognitive development, and communications skills may also meet with some success.

This paper uses a comparative case study of Canada and the USA to argue that, in order to fully understand the associations between population health and the socioeconomic environment we must begin to place importance on the dynamic aspect of these factors--examining them as they evolve over time. In particular, for institutional and policy shifts that often unfold over decades, population health must attend to these big, slow moving processes by adopting a historical perspective to the knowledge base. We compare Canada and the USA on basic health outcomes and a range of determinants of health for which routine data have been collected for all or most of the period between 1950 and the present. During the analysis that follows, we are able to establish that, at the level of society (i) greater economic well being and spending on health care does not yield better health outcomes, that (ii) public provision and income redistribution trump economic success where population health is concerned, and (iii) that the gradual development of public provision represents the buildup of social infrastructure that has long-lasting effects on health status. Our case study shows what can be gleaned from a comparative perspective and a long-term view. The long view allows us to detect the gradual divergence in health status between these two societies and to trace potential institutional causes that would otherwise go unnoticed. The perspective introduced here, and in particular the comparison of Canada and the USA, provides strong support for the use of cross-national comparative work, and a historical perspective on the investigation of societies that successfully support population health.

To establish whether effects of birth weight and socioeconomic position on cognition are explained or modified by home or learning environments.Prospective birth cohort (n = 13,980) with math tests at 7, 11, and 16 years of age and qualifications by 33 years of age.For 1 kg increase in birth weight, 7-year math Z score increased 0.23 (0.19 adjusted for parental interest in child's progress) and adult qualifications increased 0.22 (on a 5-point scale). Maternal reading benefited math less among lower than higher birth weights (p.05). The birth weight effect remained unchanged 7 to 16 years of age. For each increment in social class (4 categories; IVV to III), 7-year math increased 0.19 (0.12 adjusted for parental interest). Benefits of mother's reading and father's interest were greatest in classes IVV (interaction p.05). The difference in Z scores between classes III to IVV was 0.57 at 7 years; 1.12 at 16 years of age. Estimates were little affected by home and school factors. Adult qualifications increased 0.40 per unit social class (0.33 adjusted for parental interest). Maternal interest reduced the chances of those from unskilled manual origins gaining few qualifications (p.05). Similarly, interactions were seen for maternal reading and paternal interest.Influences in the home partly underlie associations between social background and cognition, but they do little to explain a birth weight/cognition association.

Exposure to noise is highly prevalent in the workplace, and an etiologic association with cardiovascular disease has been hypothesized. Although there is evidence of hypertension among noise-exposed workers, evidence of heart disease has been less conclusive.We identified a cohort of 27,464 blue-collar workers from 14 lumber mills in British Columbia who worked at least 1 year between 1950 and 1995 and who were followed up over the same period. Cumulative noise exposure was quantitatively assessed. Vital status was ascertained from the Canadian Mortality Database. We estimated standardized mortality ratios using the general population as referents, and we estimated relative risks using an internal low-exposure group as controls. To examine acute effects of noise, we assessed relative risks during subjects' working years in lumber mills. Because of the possibility of exposure misclassification as a result of hearing-protector use, we investigated a subgroup that had been employed before widespread use of protectors.During the follow-up period, 2510 circulatory disease deaths occurred. Relative risks for acute myocardial infarction mortality were elevated in the full cohort, with a stronger association in the subgroup without hearing protection. There was an exposure-response trend, with a relative risk in the highest exposed group of 1.5 (95% confidence interval=1.1-2.2). The highest relative risks (2.0-4.0) were observed during subjects' working years. Smoking did not appear to confound these associations.Chronic exposure to noise levels typical of many workplaces was associated with excess risk for acute myocardial infarction death. Given the very high prevalence of excess noise exposure at work, this association deserves further attention.

This longitudinal study examined the relationship between schooling, literacy development, and socioeconomic context, as reflected by a composite measure of socioeconomic status (SES). Reading, spelling, and phonological abilities were assessed from kindergarten to grade three in Canadian children in a school district with intensive literacy activities. In kindergarten, there were significant associations between SES and all the abilities assessed but these associations declined systematically to non‐significant levels by grade three. Risk and prevalence of reading failure also decreased with more schooling. The results suggest that the attenuation of the association between SES and literacy‐related skills, and the progressive reduction of the risk for reading failure, were positive outcomes associated with the literacy school program, especially in the early grades.

Background: The objectives of this study were to compare the predictive validity of the demand - control and effort - reward imbalance models using objective measures of physician utilization. Methods: Self-reports for psychosocial work conditions were obtained in interviews with 1,028 workers using the demand - control and effort - reward imbalance models. Physician utilization outcomes were obtained through linkage to the British Columbia Linked Health Database. Outcomes were any visit to a physician for mental health reasons and 30 or more physician visits for any reason. The predictive validity of both models was compared in a longitudinal study using logistic regression. Results: Neither job strain nor effort - reward imbalance predicted either outcome. However, low esteem reward and low status control increased the risk for 30 or more physician visits by, respectively, approximately 60% and 30%. Conclusions: In a sample of middle-aged blue-collar current and ex-sawmill workers in Western Canada, followed prospectively, after controlling for sociodemographic and workplace confounders, and reducing the potential for adverse health selection into high-stress jobs, low esteem reward and low status control were associated with a significantly greater risk for 30 or more physician visits for any reason.

The conditions that prevent highly competent children from fully developing their learning potential rarely have been addressed. The authors investigated the relationship between neighborhood socioeconomic characteristics, class composition, and changes in the proportion of highly competent children in kindergarten and in Grades 4 and 7. The authors used cross-sectional data from 78 Vancouver, British Columbia, schools to conduct a series of multipleregression analyses. Results show that the proportion of highly competent kindergarten children was correlated weakly with neighborhood socioeconomic status. In contrast, in Grades 4 and 7, the proportion of highly competent kindergarten children was correlated strongly with neighborhood socioeconomic factors. In addition, the proportion of children at risk was strongly and increasingly correlated with the proportion of highly competent children in kindergarten and in Grades 4 and 7.

Many diseases that emerge in adult life have their origins much earlier in the life course. Influences on adult health status occur through latent, pathway and cumulative effects of experiences earlier in life. Latency refers to relationships between an exposure at one point in the life course and a health outcome years or decades later, irrespective of intervening experience. Cumulative refers to multiple exposures over the life course, whose effects on health combine. Pathways are dependent sequences in which an exposure at one stage of the life course influences the probability of other exposures later in the life course, which are the proximate causes of disease expression. The emergence of socioeconomic differences in health status across the life course may be understood as an outcome of the interplay between the developing human, who has particular prospects and vulnerabilities at each point in the life course, and the latent, pathway, and cumulative influences found in their daily living conditions in society. Without consideration of both childhood and adult life experiences, policies designed to improve health status will tend to overlook root causes. Health policies should be based on an understanding that problems emerging today may be related to life experiences years and decades earlier.

This paper reports the results of a comparative analysis of the psychosocial impacts of municipal solid waste disposal facilities (both landfills and incinerators) in six communities in the provinces of Ontario and British Columbia, Canada. Telephone surveys were administered to random samples of residents living around each facility between 1990 and 1995 (total n=1203). The results of logistic regression analyses show that type of facility was the strongest predictor of residents' awareness, concern, and actions taken in response to site concerns. Essentially, residents living in close proximity to a landfill had a higher probability of reporting awareness, concern or actions than residents living around an incinerator site. There was little evidence of differences in reactions between Ontario and British Columbia (BC) residents, despite variations in provincial policies on waste disposal. The effects of other predictors, with the exception of involvement in the local community, were not consistent, supp...

Background: Although expenditures on health care are continually increasing and often said to be unsustainable, few studies have examined these trends at the level of services delivered to individual patients. We analyzed trends in the various components that contributed to changes in overall expenditures for physician services in British Columbia from 1985/86 to 1996/97. Methods: We obtained data on all fee-for-service payments to physicians in each study year using the British Columbia Linked Health Data set and analyzed these at the level of individual patients. We disaggregated overall billing levels by year into the following components: number of physicians seen by each patient, number of visits per physician, number of services rendered on each visit and average price of those services. We removed the effect of inflation on fees by adjusting to those in 1988. We used direct age-standardization to isolate and measure the effect of demographic changes. We used the Consumer Price Index to determine the effects of inflation. Results: Total payments to fee-for-service physicians in British Columbia rose 86.3% over the study period. The increase was entirely accounted for by the combined effects of population growth (28.9%), aging (2.1%) and general inflation (41.4%). Service use per capita rose 10.5%; this increase was offset by a decline of 9.4% in inflation-adjusted fees. The average cost of age-adjusted per-capita services rendered by general or family practitioners (GP/FPs) increased very little (3.3%) over the 11-year period, compared with a nearly one-third (31.8%) increase for medical specialists. Although there was a dramatic increase in the number of GP/FPs seen on average by each patient (32.9%), this increase was offset by the combination of decreases in the number of visits per physician (–14.9%), the number of services provided per visit (–8.0%) and the “real cost” of each service provided (–3.5%). Visits to medical specialists increased by about 20% over the study period in all age groups. However, for each person 65 years of age or over receiving any services, the average fee-adjusted expenditures increased 24.8%, almost 4 times the rate of increase for people younger than 65. The use of surgical services grew 26.5% for seniors while declining –2.0% for people under age 65. Interpretation: These findings suggest a form of “homeostasis” in aggregate-level service use and cost. The supposed inflationary effects of population aging and increasing “abuse of the system” by patients were not found.

Associations of gaseous air pollutants (including carbon monoxide, sulfur dioxide, nitrogen dioxide, and ozone) with asthma hospitalization, stratified by sex and socioeconomic status, were examined among children 6-12 years of age in Vancouver, British Columbia, Canada, between 1987 and 1998. Relative risks for an exposure increment corresponding to the interquartile range for each gaseous air pollutant were estimated for asthma hospitalization after adjustment for weather conditions, including daily maximum and minimum temperatures as well as average relative humidity. Similar results were obtained by using locally weighted smoothing functions (LOESS) with default convergence criteria and by using natural cubic splines with a more stringent setting. Exposures to nitrogen dioxide were found to be significantly and positively associated with asthma hospitalization for males in the low socioeconomic group but not in the high socioeconomic group. For females, this same pattern of association was observed for exposures to sulfur dioxide. No significantly positive associations were found between carbon monoxide and ozone and asthma hospitalization in either low or high socioeconomic groups.

We evaluated the relationship between daily levels of particulate and gaseous phase pollutants and mortality within a dynamic cohort of approximately 550,000 individuals whose vital status was ascertained between 1986 and 1999. Time-series methods were applied to evaluate whether there were differential pollutant effects on daily aggregated numbers of deaths in the cohort that was stratified into quintiles of income as defined by the 1991 and 1996 Canadian censuses. The percent change in all-cause, cardiovascular, respiratory, and cancer daily mortality was calculated in relation to short-term changes in levels of a number of particulate (PM(2.5), PM(10-2.5), total suspended particle co-efficient of haze PM(10), SO(4)) and gaseous (O(3), CO, SO(2), NO(2)) pollutants. The estimated effects of air pollution on mortality were adjusted for day of week effects, and several meteorologic variables including temperature, change in barometric pressure, and relative humidity. Several gaseous pollutants were associated with an increased risk of mortality. Specifically for an increase equivalent to the difference between the 90th and 10th percentiles, the estimated percent change in daily mortality based on the 3-day average of NO(2), and SO(2) was 4.0% and 1.3%, respectively. The corresponding changes in mortality associated with SO(2) were much higher when analyses were restricted to death from respiratory disease. Specifically, a difference between the 90th and 10th percentiles was associated with a 5.6% (95% CI= -0.7% to 12.3%). The daily mean coarse fraction (PM(10-2.5)) was associated with increased cardiovascular mortality (estimated change=5.9%, 95% CI=1.1-10.8%). PM(2.5) was not found to be an important predictor of mortality. For NO(2), CO, and SO(2), there was some suggestion of increased risk of all-cause and cardiovascular mortality at lower levels of socioeconomic status. However, these results should be interpreted cautiously due to the small number of deaths observed within each stratum of socioeconomic status.

The articles in this special issue present an in-depth look at different theoretical, methodological, and empirical aspects of a comprehensive validation research program for a population-level measure of children’s developmental status and wellbeing. The measure that is at the centre of this special issue is the Early Development Instrument (EDI; Janus and Offord 2007; Guhn et al. 2007). The EDI is currently being used at a population-level in numerous Canadian cities and provinces, and as a national indicator of children’s wellbeing in Australia. The EDI is a measure that kindergarten teachers use to rate developmental outcomes of each child in their class on five domains: (1) physical health and wellbeing, (2) social competence, (3) emotional maturity, (4) language and cognitive development, and (5) communication skills and general knowledge. The primary purpose of the EDI is to provide communities with developmental information on all of the children in the community, at the developmentally important transition to grade school—and to thus provide communities with information they can use to discuss and inform practices, decisions, and policies that aim to foster the developmental wellbeing of children during the early years (cf. Janus and Offord 2007; Nosbush 2006; Guhn and Goelman, this issue). The special issue will appeal to a broad audience of practitioners, researchers, and policy makers interested in (1) research on children’s developmental health and wellbeing, (2) the construct of school readiness, and (3) validation of large-scale measurement initiatives. The articles address multiple cutting-edge questions and challenges pertaining to a comprehensive, rigorous program of validation research for a measure that, in a general sense, may be considered a social indicator of children’s wellbeing at school entry. The articles may, of course, be of particular interest for those who use data from the EDI in

Background Childhood abuse is associated with increased adult disease risk, suggesting that processes acting over the long-term, such as epigenetic regulation of gene activity, may be involved. DNA methylation is a critical mechanism in epigenetic regulation. We aimed to establish whether childhood abuse was associated with adult DNA methylation profiles. Methods In 40 males from the 1958 British Birth Cohort we compared genome-wide promoter DNA methylation in blood taken at 45y for those with, versus those without, childhood abuse (n = 12 vs 28). We analysed the promoter methylation of over 20,000 genes and 489 microRNAs, using MeDIP (methylated DNA immunoprecipitation) in triplicate. Results We found 997 differentially methylated gene promoters (311 hypermethylated and 686 hypomethylated) in association with childhood abuse and these promoters were enriched for genes involved in key cell signaling pathways related to transcriptional regulation and development. Using bisulfite-pyrosequencing, abuse-associated methylation (MeDIP) at the metalloproteinase gene, PM20D1, was validated and then replicated in an additional 27 males. Abuse-associated methylation was observed in 39 microRNAs; in 6 of these, the hypermethylated state was consistent with the hypomethylation of their downstream gene targets. Although distributed across the genome, the differentially methylated promoters associated with child abuse clustered in genome regions of at least one megabase. The observations for child abuse showed little overlap with methylation patterns associated with socioeconomic position. Conclusions Our observed genome-wide methylation profiles in adult DNA associated with childhood abuse justify the further exploration of epigenetic regulation as a mediating mechanism for long-term health outcomes.

Background Understanding the mediating role of health care in mitigating social, economic and occupational role disability is a complex task. Results No single method of research will be successful in addressing all elements of this NORA research priority area. In this paper, we argue that research methods are needed which have the following components: (1) the detailed measurement of therapeutic intervention and the impacts of this intervention on clinical and functional health status using study designs which rule out competing explanations, (2) a longitudinal follow-up component which measures social, economic, and occupational role function following the conclusion of therapy, and (3) a commitment to execute studies across multiple settings to observe the variations in health care and in ,social and occupational role function that arise as a result of differences in labor market factors and employer and government policies. Conclusions More comprehensive portraits of the longitudinal trajectory of individual workers, social, economic and occupational role function following an occupational injury or illness will have ,significance for a large number of policy sectors.

The “Tiger” economies of Southeast Asia provide examples of developing nations where economic growth and increasing income equality are compatible and, when occurring together, are associated with superior health trends over time. The degree of income inequality in the Asian Tigers declined during the period of rapid economic growth. Traditionally, economists have viewed economic growth and relative parity in income distribution as incompatible, or trade-offs. This poses a public policy dilemma, since a reasonable propensity to increase a nation's overall economic well-being would mean forsaking measures that increase income parity. The Asian Tigers, however, have shown that this need not be viewed as a trade-off. Economic growth and a simultaneous increase in income equality are possible and, with respect to health outcomes, desirable. The authors propose a variety of mechanisms through which income inequality can enhance economic growth, and discuss policies in education, agricultural land reform, and housing that influence the simultaneous attainment of income equality and economic growth.

Objectives This study tested the reliability and validity of industry- and mill-level expert methods for measuring psychosocial work conditions in British Columbia sawmills using the demand-control model. Methods In the industry-level method 4 sawmill job evaluators estimated psychosocial work conditions at a generic sawmill. In the mill-level method panels of experienced sawmill workers estimated psychosocial work conditions at 3 sawmills. Scores for psychosocial work conditions were developed using both expert methods and applied to job titles in a sawmill worker database containing self-reported health status and heart disease. The interrater reliability and the concurrent and predictive validity of the expert rater methods were assessed. Results The interrater reliability and concurrent reliability were higher for the mill-level method than for the industry-level method. For all the psychosocial variables the reliability for the mill-level method was greater than 0.90. The predictive validity results were inconclusive. Conclusions The greater reliability and concurrent validity of the mill-level method indicates that panels of experienced workers should be considered as potential experts in future studies measuring psychosocial work conditions.

Background A union/management system of job evaluation has been in place in the British Columbia (BC) sawmill industry since the late 1960s. This system uses an instrument, very similar to the job content questionnaire (JCQ) to evaluate psychosocial work conditions for sawmill jobs. Methods Four experienced evaluators, one from the union and three from industry, independently estimated psychosocial work conditions for 54 current job titles in a “typical” coastal sawmill using a shortened, 18-question version of the JCQ questionnaire. Results Inter-rater reliability was acceptable for control but not for co-worker social support, physical demand, or psychological demand. Reliability was least for psychological demand. Conclusions Experienced job evaluators in the sawmill industry were able to reliably estimate only the control dimension of the JCQ. The observed lowest reliability for psychological job demand may be due to the imprecise construct definition in the domain of the JCQ instrument. Am. J. Ind. Med. 39:397–401, 2001. © 2001 Wiley-Liss, Inc.

Illness increases with age. All else being equal, an older population has greater needs for health care. This logic has led to dire predictions of skyrocketing costs “apocalyptic demography”. Yet numerous studies have shown that aging effects are relatively small, and all else is not equal. Cost projections rest on specific assumptions about trends in age-specific morbidity and health care use that are far from self-evident. Sharply contrasting assumptions, for example, are made by Fries, who foresees a “of morbidity” and falling needs. Long-term trends in health care use in British Columbia show minimal effects of population aging, but major effects, up and down, from changes in age-specific use patterns. Why then is the demographic apocalypse story so persistent, despite numerous contrary studies? It serves identifiable economic interests.

The book Why Are Some People Healthy and Others Not? The Determinants of Health of Populations represented a milestone in our evolving understanding of the determinants of population health. Building on Marc Lalonde's earlier A New Perspective on the Health of Canadians, it created a theoretical framework that could incorporate emerging evidence from a wide range of disciplines. Central to its authors' approach was the observation of heterogeneity, of the systematic differences in health observed when populations are partitioned on characteristics such as income, education, geographic region, etc. The universal observation of a social gradient, of a strong correlation between socio-economic class and health, led to a focus on how the social environment might influence health. Social position strongly influences both the stresses to which individuals are subject, and the resources available to cope with them. Furthermore, healthy and unhealthy responses to stress become "embedded", learned or conditioned both behaviourally and biologically, thus influencing health over the whole life course. The book's impact has been remarkable, not merely in academic citations but through its authors' subsequent work and strategic positions in Canadian health research organizations. The concept of "Population Health" has become part of our shared intellectual heritage.

Rapidly expanding economies, such as the post-war Tiger Economies, are associated with increasing health and rapidly contracting economies, such as Central and Eastern Europe in the early 1990s, are associated with declining health. In Central and Eastern Europe health decline in association with economic contraction has been mediated by changes in income distribution and, also, by health-determining aspects of civil society. The nations of Central and Eastern Europe are an example of swift economic and political transformation occurring concurrently with economic decline; with increasing disparity in income distributions; and with high levels of distrust in civil institutions. Concurrent with these declines was a marked reduction in health status, described here in terms of life expectancy. Conversely, the nations of Southeast Asia experienced rapid economic growth and increasing life expectancies. Though data are scarce, the experience of the Tiger Economies appears to be one of economic growth; a virtuous cycle of increased investment in education and housing; and increasing parity in income distribution based upon a relatively equitable distribution of returns on education.

In the early 1980s, the sawmill sector in British Columbia (BC), Canada experienced economic recession which was followed by industrial restructuring in many mills. This is an investigation of the relationship between unemployment, which occurred in the recession and the new psychosocial and physical work conditions in restructured workplaces using a cohort of approximately 29,000 sawmill workers in 14 BC sawmills. The purpose of this investigation is to describe the changes in the cohort's job structure and labour demography in order to best frame future health studies on the effects of unemployment and restructuring. Downsizing reduced the number of workers by 60% and the number of job titles by 25%. The youngest workers were downsized and job titles with the least control and most demand were eliminated by restructuring. Although psychosocial conditions of work (assessed using 'expert' raters) improved after restructuring, these better work conditions were available to fewer workers. Four main lessons ...

Objectives This paper investigates changes in the psychosocial and physical work conditions of the sawmill industry in British Columbia, Canada, over the past 35 years. Methods Shifts in work conditions were examined within the context of historical changes in sawmill labor demography and job taxonomy as the industry was both downsized and restructured, largely in response to an economic recession in the early 1980s. Results and conclusions Downsizing eliminated approximately 60% of the work force and 1/4 of sawmill job titles. Although all the job categories in restructured sawmills showed increased levels of control, the gradient in control across job categories was steeper in 1997 than in 1965; this change may have important health implications particularly for the unskilled workers in the restructured mills.

Senile cataract may be a marker of generalized tissue aging. We examined this hypothesis using population-based linked health data. We hypothesized that any such association would diminish with increased use of cataract surgery. Mortality rates of those 50-95 years of age undergoing cataract surgery in British Columbia during either 1985 or 1989 were compared with the provincial population of comparable age who did not undergo cataract surgery during the study period. The 1985 cohort included 8,262 patients undergoing surgery and a comparison population of 804,303, and the 1989 cohort included 11,952 patients and a comparison population of 839,393. Using Cox regression, for the 1985 cohort, the hazard ratios for dying during follow-up were 3.2 for males 50-54.9 years of age [95% confidence limits (CL) = 2.0, 5.0] and 3.3 for females (95% CL = 1.9, 5.7). Hazard ratios for older age groups decreased with age. We also fit an additive risk model that produced excess mortalities that were less age dependent. In the 1985 analysis, these ranged from +7.1 per 1,000 (95% CL = +0.44, +13.76) to +20.3 (95% CL = +13.24, +27.36) for males and -17.5 (95% CL = -28.28, -6.72) to +2.0 (95% CL = -2.12, +6.12) for females. Findings for the 1989 analyses were similar, indicating that the association between cataracts and generalized aging remained constant despite a large increase in the use of cataract surgery.

This report presents the process and summative evaluation results from a community-based diabetes prevention and control project implemented in response to the increasing prevalence and impact of non-insulin-dependent diabetes mellitus (NIDDM) in the Canadian Aboriginal population. The 24-month project targeted the registered Indian population in British Columbia's rural Okanagan region. A participatory approach was used to plan strategies by which diabetes could be addressed in ways acceptable and meaningful to the intervention community. The strategies emphasised a combination of changing behaviours and changing environments. The project was quasi-experimental. A single intervention community was matched to two comparison communities. Workers in the intervention community conducted interviews of individuals with or at risk for diabetes during a seven-month pre-intervention phase (n = 59). Qualitative analyses were conducted to yield strategies for intervention. Implementation began in the eighth month of the project. Trend measurements of diabetes risk factors were obtained for 'high-risk' cohorts (persons with or at familial risk for NIDDM) (n = 105). Cohorts were tracked over a 16-month intervention phase, with measurements at baseline, the midpoint and completion of the study. Cross-sectional population surveys of diabetes risk factors were conducted at baseline and the end of the intervention phase (n = 295). Surveys of community systems were conducted three times. The project yielded few changes in quantifiable outcomes. Activation of the intervention community was insufficient to enable individual and collective change through dissemination of quality interventions for diabetes prevention and control. Theory and previous research were not sufficiently integrated with information from pre-intervention interviews. Interacting with these limitations were the short planning and intervention phases, just 8 and 16 months, respectively. The level of penetration of the interventions mounted was too limited to be effective. Attention to process is warranted and to the feasibility of achieving effects within 24 months.

Russia has the lowest life expectancy among industrialised countries, but little is known about other health outcomes and determinants of health in the Russian population. Here we report a cross-sectional study in a national sample of the Russian population of social and psychosocial determinants of two self-reported health indicators: self-rated health (shown to predict mortality in prospective studies) and physical functioning (validated against more objective health measures). A multi-stage sample of the Russian population aged 18 years and more was interviewed (n=1599, response rate 66%). The questionnaire included political attitudes, social and economic circumstances, psychosocial factors, smoking, alcohol consumption, self-rated health and physical functioning (from the SF36 instrument). Scores of perceived control over life and over one's health were calculated from 6 and 3 questions, respectively. Data were analysed in logistic regression for two dichotomised outcomes: poor self-rated health (worse than average) and low physical functioning (less than 60% of maximum). Overall, 25% of subjects rated their health as worse than average; this is substantially more than in western countries. Perceived control over life was strongly related to both outcomes; age- and sex-adjusted OR for 1 standard deviation increase in control were 0.60 (95% CI 0.52-0.69) for poor self-rated health and 0.67 (0.57-0.81) for low physical functioning. Adjustment for a battery of other factors reduced these estimates only slightly. Associations between control over one's health and both outcomes were also significant, but weaker and attenuated in multivariate models. Material deprivation was also strongly related to both outcomes. Education was inversely related to self-rated health, and unmarried men reported poor physical functioning substantially more often. Subjects not approving the economic changes reported poorer health but this association was removed by adjustment for socioeconomic factors and control. Subjects who could not rely on informal social structures when in problems reported worse health; this effect largely persisted in multivariate analyses. These results are consistent with the hypothesis that poor health status in Russia is related to dysfunction of social structures, socioeconomic deprivation, and lack of perceived control. The absence of informal social networks, vital for maintaining general welfare, seems to affect adversely self-rated health. Deprivation and low perceived control may be important mediators between the broad social environment and health in populations undergoing transition and can provide a useful framework for many biological and behavioural factors. Prospective studies are needed to address the issue of temporality and reporting bias, the major problems in interpreting these findings.

As the availability of both health utilization and outcome information becomes increasingly important to health care researchers and policy makers, the ability to link person-specific health data becomes a critical objective. The integration of population-based administrative health databases has been realized in British Columbia by constructing an historical file of all persons registered with the health care system, and by probabilistically linking various program files to this 'coordinating' file. The linkages have achieved a high rate of success in matching service events to person-specific registration records. This success has allowed research projects to be proposed which would otherwise not have been feasible, and has initiated the development of policies and procedures regarding research access to linked data. These policies and procedures include a framework for addressing the ethical issues surrounding data linkage. With continued attention to confidentiality issues, these linked data present a valuable resource for health services research and planning.

The complex relationship between life course and social/economic-psychosocial conditions in a given society has a powerful determining effect on human health. The socioeconomic gradient emerges from a complex mixture of psychosocial and material influences operating at various levels of social aggregation and, also, a series of biological responses whose character and significance vary over the life course. Biological embedding and the “latency” and “pathways” model incorporate the notion of a critical period in development; the pathways model emphasizes the cumulative effect of life events and the ongoing importance of social/economic-psychosocial conditions throughout the life cycle. The models, although conceptually complementary, result in ideological conflict and lend themselves to different policy directions.

This paper presents a novel approach to establishing environmental health priorities for a large society, based upon the concept of principal environmental exposure pathways (PEEPs). Principal environmental exposure pathways extend the concept of a causal pathway backward from health outcome to exposure, then to the industrial, transportation, commercial, or living conditions that gave rise to the pollution of interest. In the Philippines, where the method was developed and used, five PEEPs were identified: an urban air-pollution pathway; a community water-supply pathway; an urban solid-waste pathway; a rural "point-source" pathway; and a pathway whereby fertilizers and pesticides affect food, worker health, and rural water supplies. Characterizing the PEEPs involved pinpointing the populations at risk necessary to estimate the burden of morbidity and mortality related to each as well as identifying the health outcomes that were experienced by those exposed along each pathway or that they could be expected to experience; determining where adequate health-outcome information was available or absent; where exposure sources were or were not adequately identified; where there were significant gaps in agency responsibilities; where new data flows were needed; and where things could have been improved by improving inter-agency cooperation. The most important success of the PEEP method was to reduce the "problem of everything" in a complex country of 65 million people to a small and manageable number of priority environmental exposures.

Occupational cohort studies conducted to study cancer incidence and mortality require extensive data gathering about workers’ job histories, exposures, and health outcomes. Although this process is expensive, the database created can be looked upon as a resource for broad investigations of the relationship between work and health. This paper presents the example of a retrospective cohort study which began in the traditional way, examining the link between a specific pesticide exposure and mortality and cancer incidence. The cohort register has since been used to investigate whether infertility, adverse reproductive outcomes, and childhood cancers might be associated with this exposure. It is also being used as the basis for studying other sawmill exposures including noise and wood dust, as well as socioeconomic factors including job strain, job mobility, unemployment, and retraining. This approach allows both the efficient use of occupational cohorts as well as providing the opportunity for investigators to develop a more comprehensive perspective on the determinants of the health status of workers and their families.

It has been hypothesized that senile cataract may serve as a marker for generalised tissue aging, since structural changes occurring in the proteins of the lens during cataract formation are similar to those which occur elsewhere as part of the aging process. An earlier analysis we carried out to test this hypothesis revealed a strong age-dependent relationship between undergoing cataract surgery and subsequent mortality. Relative risks for dying over 9 yr of follow-up were particularly increased for individuals who had developed cataract requiring operation between the ages of 50-65. This finding prompted us to test the hypothesis that younger patients undergoing surgery for cataract (those in which surgery was undertaken at 50-65 yr of age) would tend disproportionately to be resident in areas of generally lower socioeconomic status. A population-based linked health data resource containing data on all hospital separations in the province of British Columbia was used to examine this hypothesis. Linkage to Canadian census data was used to assign a socioeconomic decile to the area of residence for all individuals in British Columbia who either did, or did not, undergo cataract surgery over a 3 yr period, and were aged 50-95. Relative to those who resided in the highest socioeconomic areas, odds ratios for undergoing cataract surgery between 50 and 65 yr of age were significantly greater than 1 for the four lowest socioeconomic deciles. This association was observed despite a conservative bias in our setting that favoured those of higher socioeconomic status tending to receive earlier treatment. The results of this ecologic study prompt consideration of whether factors which have the dual attributes of being correlates of socioeconomic status and implicated in the development of cataract may play a role in mediating the processes involved in the well known association of socioeconomic status and mortality.

We examined the effect of decision latitude and work demand on risk of myocardial infarction in a former Soviet Bloc country and analyzed whether these factors contributed to the educational gradient in myocardial infarction in this population. We conducted a case-control study among full-time working men in the general population of five districts of the Czech Republic. Cases were 179 men 25-64 years of age with a first nonfatal myocardial infarction diagnosed in selected districts over a 1-year period, and controls were 784 men in the same age group randomly selected from the population register. We used logistic regression to estimate the odds of developing myocardial infarction in relation to self-reported work demand and decision latitude at work and the contribution of these factors as well as standard risk factors to socioeconomic differences in the risk of myocardial infarction. Cases reported lower decision latitude and lower work demand than controls. Age-adjusted odds ratios for the highest vs lowest quartiles of decision latitude and work demand were 0.43 (95% confidence interval = 0.25-0.75) and 0.54 (95% confidence interval = 0.31-0.93), respectively. Further adjustment for coronary risk factors and education did not change these estimates. Decision latitude accounted for part of the association between education and myocardial infarction, and decision latitude and risk factors jointly explained virtually all of it. The association between decision latitude at work and myocardial infarction found in our study is consistent with research in western populations and may partly explain the socioeconomic gradient in myocardial infarction.

The purpose of this study was to determine whether exposure to chlorophenate fungicides and their dioxin contaminants is associated with male infertility among sawmill workers. The study was conducted using fertility data compiled from 26,487 sawmill workers in 14 British Columbian sawmills. Our analysis was restricted to workers who had been employed for at least 1 continuous year between 1950 and 1985 and to live-births born at least 1 year after the initiation of employment in the period 1955-1988. We assessed fertility trends by internal comparison using Mantel-Haenszel rate ratios and by calculating standardized fertility ratios using an external and an internal reference population. We identified 19,684 births in the study period. Initially, both external and internal analyses showed that sawmill workers from mills using chlorophenates had lower fertility than workers employed in mills not using chlorophenates. After controlling for time since first hire, however, we found no inverse relation between cumulative exposure to chlorophenate fungicides and fertility. Based on the results of our study, there is little evidence for a reduction in fertility among chlorophenate-exposed sawmill workers in British Columbia. The analyses indicate the importance of time since hire as a potentially strong confounder in this type of investigation.

Objectives: The purposes of this study were to measure household food security and to determine its association with potential predictor variables related to household and community environments, as well as the relationship between household food insecurity and preschool children’s nutritional status. Methods: In this cross-sectional study, household food security was measured in a convenience sample of households (n=142) with children aged 2–5 years in Vancouver in March 2004. We assessed the association between environmental predictors and household food security status, adjusted for household income. Indicators of children’s nutrition were compared between categories of household food security. Results: Household food insecurity was associated with indicators of suboptimal health status in preschoolers. After controlling for household income, parents with less access to food of reasonable quality, fewer kitchen appliances and a lower rating of their cooking skills had greater odds of experiencing household food insecurity. Implications: Our study results support the need to test interventions involving collaborative efforts among government, social planners and public health practitioners to remove barriers to food security for families. Multiple measures, including opportunities to gain practical food skills and household resources that enable convenient preparation of nutrient-dense foods, could be examined. Our findings suggest the need for improved selection and quality at existing small stores and an increase in the number of food outlets in low-income neighbourhoods.

Health care utilization by the elderly has increased during recent times. However, a number of investigators have indicated that this increase has had less to do with increasing numbers of elders than with increasing age-specific utilization rates for a variety of health services. 1985 and 1993 health data for British Columbia were used to examine changes in outpatient surgical utilization among the general population and changes in cataract surgical utilization among the elderly. Utilization increases in the older persons exceeded what would be expected on the basis of population increase. Furthermore, cataract surgery alone accounted for more than 29 percent of the entire utilization increase observed for outpatient surgery. Despite this increase, the average age at cataract surgery has not changed—seniors of all ages are much more likely to receive cataract surgery now than a decade ago. The authors' findings suggest that a part of this observed increase is due to operating on individuals at preoperative levels of better visual function.

OBJECTIVES: This study examined the association between exposure to chlorophenates and the risk of soft tissue sarcoma; non-Hodgkin's lymphoma; Hodgkin's disease; and cancers of the lung, nose, and nasopharynx. METHODS: A retrospective cohort study was conducted of 26487 workers employed for at least 1 year between 1950 and 1985 in 11 chlorophenate-using and 3 non-using sawmills in British Columbia, Canada. Exposures by job were ascertained with interviews of senior employees. RESULTS: Probabilistic record linkage to the Canadian Mortality Data Base and the British Columbia Cancer Registry found 4710 deaths between 1950 and 1990, and 1547 incident cases of cancer between 1969 and 1989. None of the cancers of interest had elevated mortality related to chlorophenate exposure. Non-Hodgkin's lymphoma incidence (n = 65) increased with increasing chlorophenate exposure hours, yielding the following standardized incidence ratios: less than 120 hours 0.68; 120 to 1999 hours, 0.59; 2000 to 3999 hours, 1.04; 4000 to 9999 hours, 1.02; and 10000 or more hours, 1.30. CONCLUSIONS: These results are consistent with the borderline positive associations seen in other recently reported studies of chlorophenate-exposed workforces.

Evidence is presented for a pathways model linking early life factors and adult disease, which takes account of the inter-relationships between social and biological risks throughout the lifecourse. Few studies, if any, have yet recorded adequate birth to death information which could be used to quantify the effects of different factors and their timing. Hence, there is only limited understanding of the extent to which biological and social risks experienced at different life stages combine to influence adult disease. However, some of the pathways between early and later life are suggested when evidence from earlier stages of the lifecourse is linked to that from studies at older ages, in which adult disease risk factors have been established. Further support for pathway effects is provided by studies showing that health outcomes of early biological insults can depend on the subsequent social and biological environment. Thus, it is argued that adult disease will be more fully understood when account is taken of the combined effects of social and biological risk occurring at different life stages.

Clyde Hertzman's sudden and untimely death was a terrible blow to those who knew him. It was also a major loss to health research and policy in Canada and well beyond. He was an outstanding public academic, at the top of his intellectual game. Here I attempt a highly selective and personal account of how he developed the conceptual framework that he called “the whole enchilada,” of the social context influencing both biological and behavioural development from earliest infancy. From these roots spring our life trajectories, evolving social gradients of more – or less – successful experience at each life stage. The international performance of a society reflects the sum of these trajectories. Canada could do much better, but not in Harperland.

This article draws on the vast evidence that suggests, on one hand, that socioeconomic inequalities in health are present in every society in which they have been measured and, on the other hand, that the size of inequalities varies substantially across societies. We conduct a comparative case study of the United States and Canada to explore the role of neoliberalism as a force that has created inequalities in socioeconomic resources (and thus in health) in both societies and the roles of other societal forces (political, economic, and social) that have provided a buffer, thereby lessening socioeconomic inequalities or their effects on health. Our findings suggest that, from 1980 to 2008, while both the United States and Canada underwent significant neoliberal reforms, Canada showed more resilience in terms of health inequalities as a result of differences in: ( a) the degree of income inequality, itself resulting from differences in features of the labor market and tax and transfer policies, ( b) equality in the provision of social goods such as health care and education, and ( c) the extent of social cohesiveness across race/ethnic- and class-based groups. Our study suggests that further attention must be given to both causes and buffers of health inequalities.

In a recent issue of PNAS, Lam et al. (1) identified three CpG sites associated with early-life socioeconomic status (SES) in adult blood DNA. The authors observed that this small number of associated CpG sites “appears to be at odds” with the 1,252 gene promoters found in our study of 40 adult males stratified by early-life SES (2). The authors suggest that our analysis of the data inflated the statistical significance of methylation associations and wonder whether blood composition may have further inflated the results.

Objective Associations of cortisol and depression vary at different life-stages, yet population-based, prospective studies are scarce. We aimed to assess associations of morning cortisol with depressive symptoms in mid-life taking account of lifetime psychological health. Methods Participants were 5,403 men and women from the 1958 British Birth Cohort whose salivary cortisol was assessed at 45y (45min after waking (T1) and 3h later (T2)) and who completed the 5-item Mental-Health Index (MHI-5) about depressive symptoms at age 50y. Lifetime psychological health was identified from child and adult measures. Results For women, higher T2 cortisol at 45y predicted depression (MHI-5 scores ≤52) at 50y (odds ratio [OR]=1.17; 95% confidence intervals [CI] 1.05,1.30 per standard deviation increase in T2 cortisol), attenuating when adjusted for current (45y) and previous (7-42y) psychological health (OR=1.11; 95% CI 0.98, 1.24). Similarly, an association in women of flatter cortisol delta (T2-T1) with depressive symptoms at 50y weakened after adjustment for current (45y) and previous (7-42y) psychological health. For men, lower T2 cortisol at 45y predicted greater depressive symptoms at 50y and the association strengthened when adjusted for lifetime psychological health. Likewise, lower cortisol AUC predicted higher risk of depression for men after adjusting for prior psychological health (OR=0.85; CI 0.72, 1.00). Associations were largely unaltered by control for covariates. Conclusions In women, higher cortisol in late morning at 45y is prospectively associated with depressive symptoms at 50y through a link with lifetime psychological health. In men, lower cortisol predicts subsequent symptoms, independent of depressive history.

Objectives The purpose of the study was to determine whether paternal occupational exposure to dioxin-contaminated chlorophenols is associated with an increased risk of congenital anomalies or other adverse reproductive outcomes in offspring. Methods As a result of a multistep linkage, 19 675 births between 1952 and 1988 were identified as children of a cohort of 9512 fathers who had worked at least one year in British Columbia sawmills where chlorophenate wood preservatives had been used. A nested case-referent analysis was applied, using conditional logistic regression, with five referents matched per case according to year of birth and gender. Chlorophenate exposure was based on expert raters' estimations of hours of exposure applied to specific time windows prior to birth. Results The offspring of male sawmill workers were at increased risk for developing congenital anomalies of the eye, particularly congenital cataracts; elevated risks for developing anencephaly or spina bifida and congenital anomalies of genital organs were shown according to specific windows of exposure. No associations were found for low birthweight, prematurity, stillbirths, or neonatal deaths. Conclusion The study adds further support to the hypothesis of male-mediated developmental toxicity. Paternal exposure to chlorophenates was associated with the development of certain congenital anomalies in offspring.