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Background: Ethnic differences in post-stroke outcomes have been largely attributed to biological and socioeconomic characteristics resulting in differential risk factor profiles and stroke subtypes, but evidence is mixed. Aims: This study assessed ethnic differences in stroke outcome and service access in New Zealand (NZ) and explored underlying causes in addition to traditional risk factors. Methods: This national cohort study used routinely collected health and social data to compare post-stroke outcomes between NZ Europeans, Māori, Pacific Peoples, and Asians, adjusting for differences in baseline characteristics, socioeconomic deprivation, and stroke characteristics. First and principal stroke public hospital admissions during November 2017 to October 2018 were included (N = 6879). Post-stroke unfavorable outcome was defined as being dead, changing residence, or becoming unemployed. Results: In total, 5394 NZ Europeans, 762 Māori, 369 Pacific Peoples, and 354 Asians experienced a stroke during the study period. Median age was 65 years for Māori and Pacific Peoples, and 71 and 79 years for Asians and NZ Europeans, respectively. Compared with NZ Europeans, Māori were more likely to have an unfavorable outcome at all three time-points (odds ratio (OR) = 1.6 (95% confidence interval (CI) = 1.3–1.9); 1.4 (1.2–1.7); 1.4 (1.2–1.7), respectively). Māori had increased odds of death at all time-points (1.7 (1.3–2.1); 1.5 (1.2–1.9); 1.7 (1.3–2.1)), change in residence at 3 and 6 months (1.6 (1.3–2.1); 1.3 (1.1–1.7)), and unemployment at 6 and 12 months (1.5 (1.1–2.1); 1.5 (1.1–2.1)). There was evidence of differences in post-stroke secondary prevention medication by ethnicity. Conclusion: We found ethnic disparities in care and outcomes following stroke which were independent of traditional risk factors, suggesting they may be attributable to stroke service delivery rather than patient factors.

Introduction: Stroke care provision differs between urban and provincial hospitals predominantly due to economy of scale, which is correlated with resources available and degree of specialisation. We assessed the impact of urban versus non-urban hospital location on stroke outcomes. Methods: REGIONS Care is a New Zealand (NZ) nationwide prospective observational study that included consecutively admitted stroke patients involving all NZ stroke hospitals between 1 May and 31 October 2018. Patients were followed-up at 3, 6, and 12 months. The primary outcome was favourable modified Rankin Score of 0-2. Results were adjusted for age, stroke severity, pre-morbid level of independence and other potential confounders using multivariate logistic regression. Results: Of the 2,379 patients (mean age (SD), 75 (13.7)), 1,963 (82.6%) had ischaemic strokes and 291 (12.3%) haemorrhagic strokes. The odds of achieving a favourable outcome at 3 and 6 months was significantly lower for patients treated in non-urban compared to urban hospitals: aOR 0.72 (95%CI:0.56-0.93; p=0.012) and aOR 0.71 (95%CI:0.52-0.96; p=0.028), respectively. At 12-months this difference was less pronounced (aOR 0.77, 95%CI:0.57-1.04; p=0.089). Similarly, death was significantly more likely at 3 and 6 months, and borderline statistically significant at 12 months: aOR 1.64, 95%CI:1.30-2.29, p=0.001; 1.54, 95%CI:1.12-2.11, p=0.008; and 1.36, 95%CI:0.99-1.87, p=0.06, respectively. Stroke recurrence was similar between urban and non-urban settings at 3 and 6 months, but more likely in the non-urban setting at 12 months (aOR 1.94, 95%CI:1.14-3.29, p=0.014. In the non-urban setting, eligible patients were less likely to receive reperfusion therapy (aOR 0.5, 95%CI:0.28-0.91, p=0.023); acute stroke unit care was less consistently accessed (aOR 0.58, 95%CI:0.48-0.70, p Conclusion: This first comprehensive prospective NZ nationwide stroke study showed significant differences in stroke outcomes and access to key acute stroke interventions between urban and non-urban hospitals. This inequity requires urgent intervention from health system funders and providers.

Background: Non-urban hospitals often operate under greater resource constraints and less specialisation due to reduced economy of scale. We assessed whether access to stroke rehabilitation services is affected by hospital geographic location. In addition, we assessed the impact of specific rehabilitation interventions on patient outcomes. Methods: REGIONS Care is a New Zealand (NZ) nationwide prospective observational study with up to one-year follow-up exploring ethnic and geographic inequities in stroke care access and outcome. For this analysis, we compared rehabilitation outcomes and service access in urban versus non-urban hospital settings. The main outcome was favorable modified Rankin Scale of 0-2 at 3, 6, and 12 months. Outcomes were adjusted for age, stroke severity, pre-morbid function, and other potential confounders using multivariate logistic regression. Results: This cohort included 2379 patients with a confirmed diagnosis of stroke who were admitted to a NZ hospital between 1 May 2018 and 31 October 2018. There was no significant difference between geographic locations in access to inpatient services (OR=1.00; p=0.99) or reaching inpatient rehabilitation within seven days of admission (OR=1.16; p=0.32). Patients in non-urban areas had poorer access to intensive inpatient therapy (OR=0.54; p Conclusions: Patients admitted to non-urban hospital experience better IDT goal setting, but poorer access to community rehabilitation services and less intensive physical therapy during inpatient rehabilitation. Reduced therapy intensity resulted in a lower rate of functional independence at 3 months. These results will drive service improvements in the stroke rehabilitation space.

ObjectiveIschaemic heart disease (IHD) is a leading cause of death in Western countries. The aim of this study was to examine the associations between occupational exposure to loud noise, long working hours, shift work, and sedentary work and IHD.MethodsThis data linkage study included all New Zealanders employed and aged 20–64 years at the time of the 2013 census, followed up for incident IHD between 2013 and 2018 based on hospitalisation, prescription and death records. Occupation and number of working hours were obtained from the census, and exposure to sedentary work, loud noise and night shift work was assessed using New Zealand job exposure matrices. HRs were calculated for males and females using Cox regression adjusted for age, socioeconomic status, smoking and ethnicity.ResultsFrom the 8 11 470 males and 7 83 207 females employed at the time of the census, 15 012 male (1.9%) and 5595 female IHD cases (0.7%) were identified. For males, there was a modestly higher risk of IHD for the highest category (>90 dBA) of noise exposure (HR 1.19; 95% CI 1.07 to 1.33), while for females exposure prevalence was too low to calculate an HR. Night shift work was associated with IHD for males (HR 1.10; 95% CI 1.05 to 1.14) and females (HR 1.25; 95% CI 1.17 to 1.34). The population attributable fractions for night shift work were 1.8% and 4.6%, respectively. No clear associations with working long hours and sedentary work were observed.ConclusionsThis study suggests that occupational exposures to high levels of noise and night shift work might be associated with IHD risk.

IntroductionIschaemic Heart Disease (IHD) is a leading cause of death in Western countries. Common occupational exposures such as loud noise, long working hours, and sedentary work have been associated with increased IHD risks, but inconsistently. Objectives and ApproachThis study examines associations between incident IHD and exposure to long working hours, sedentary work, and loud noise. Individual-level microdata from Statistics New Zealand Integrated Data Infrastructure (IDI) were extracted for adults (age 20-64 years) with occupation recorded on the 2013 Census. The number of working hours was extracted from the Census, and exposure to sedentary work and loud noise was assessed through job exposure matrices (JEMs). IHD events (from 2013 to end of 2018) were identified using hospitalisations, prescriptions and deaths. Hazard ratios (HRs) were calculated using cox regression adjusted for age, socioeconomic status, and smoking. Results were stratified by sex and ethnicity. ResultsA total of 20,610 IHD cases were identified from 1,594,680 individuals employed at time of Census. Both short (90% of the time compared to 90dBA) compared to no exposure (

Background/Introduction Occupation is a poorly characterised risk factor for cardiovascular disease (CVD), with females and minority populations particularly under-represented in research. There is also a lack of longitudinal studies using detailed health data that does not rely on self-reports. Purpose This study aimed to address these gaps by assessing the association between a range of occupational groups and ischaemic heart disease (IHD) in New Zealand (NZ), through linkage of population-based occupational surveys to routinely collected health data. Half of the study population were females and 40% were indigenous Māori (who comprise 15% of the total 4.8 million NZ population), which enabled sex and ethnicity-specific aspects of the relationship between occupation and IHD to be assessed. Methods Two probability-based sample surveys of the NZ adult population (New Zealand Workforce Survey (NZWS); 2004–2006; n=3003) and of the Māori population (NZWS Māori; 2009–2010; n=2107), for which detailed occupational histories and lifestyle factors were collected, were linked with routinely collected health data available through Statistics NZ. Cox regression was used to calculate hazard ratios (HR) for “ever-worked” in any one of nine major occupational groups, with “never worked” in that occupational group defined as the reference group. Analyses were controlled for age, deprivation and smoking, and stratified by sex and ethnicity. Results The strongest associations were found for “plant/machine operators and assemblers” and “elementary workers”, particularly among female Māori (HR 2.19, 95% CI 1.16–4.13 and HR 2.03, 1.07–3.82 respectively). In contrast, inverse associations with IHD across all groups were observed for “technicians and associate professionals”, which was significant for NZWS males (HR 0.52, 0.32–0.84). There were some sex and ethnic differences, particularly for “clerks”, where a positive association was found for NZWS males (HR 1.81, 1.19–2.74), whilst an inverse association was observed for Māori females (HR 0.42, 0.22–0.82). Duration analyses (≤2 years, 2–10 years and 10+ years) showed significant dose-response trends for “clerks” in NZWS males, and “plant/machine operators and assemblers” and “elementary workers” in Māori females. Further adjustments for other potential confounders such diabetes mellitus, hypertension and high cholesterol did not affect the results. Conclusion Associations between occupation and IHD differed significantly across occupational groups and between sexes and ethnicities, even within the same occupational groups. This suggests that results may not be generalised across these groups and occupational interventions to reduce IHD risk may therefore need different approaches depending on the population and specific groups of interest. Funding Acknowledgement Type of funding source: Other. Main funding source(s): Health Research Council (HRC) of New Zealand

Introduction: osteoporotic fractures represent a major public health burden. The risk of fragility fractures in late adulthood is strongly impacted by peak bone mass acquisition by the third decade. Weight-bearing sporting activity may be beneficial to peak bone mass accrual, but previous studies have focused on elite sporting activity and have used dual energy X-ray absorptiometry as a measure of bone density. The authors performed a narrative systematic review of individual sports (performed non-competitively or at local level) and calcaneal quantitative ultrasound (cQUS) bone measures in young people.Methods: multiple databases were systematically searched up until the 31st of March 2019. The authors included studies of participants' mean age (11–35 years), reporting any level of recreational sporting activity and cQUS measures as well as excluding elite/professional sporting physical activity. Studies (title and abstract) were screened independently by two reviewers, and a third reviewer resolved any discrepancies. STROBE guidelines were used to check the reporting of observational studies. The Newcastle–Ottawa Scale was used to assess the risk of bias of the studies included in the review. The systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO).Results: a search yielded 29,512 articles that considered relationships between bone density assessed by any technique and sporting activity. Duplicate and out of scope abstracts were removed. This left 424 papers that were screened by two reviewers; of these, six met the inclusion criteria, including assessment by cQUS. The authors identified papers where sports were considered, included soccer (football), swimming, cycling, gymnastics, dancing, badminton, basketball, fencing, wrestling, and judokas. Although study heterogeneity prohibited meta-analysis, all six included studies reported significant benefits of weight-bearing non-elite sports on cQUS outcomes.Conclusion: our study found beneficial effects of non-elite sports participation on cQUS in adolescence and young adulthood, although further work is now indicated.

Aims: Alcoholism is known to be associated with increased risk of fracture. This study aimed to study bone turnover following alcohol detoxification and to investigate lifestyle factors for low bone density that might coexist with alcohol dependency, which might be amenable to modification. Method: Pre-menopausal female participants were recruited from an alcohol-use dependency unit to a cross-sectional study. A lifestyle questionnaire, including alcohol history, smoking, physical activity, dietary calcium intake, falls, and fracture history was completed. Quantitative heel ultrasonography was performed and broadband ultrasound attenuation (BUA), speed of sound (SOS), t score, and z score were recorded. Blood was taken for bone-turnover markers at baseline and day 5 following admission for alcohol withdrawal.Results: The mean age (SD) of alcohol dependent participants was 41.6 (8.3) years, with participants reporting high levels of current cigarette smoking, physical inactivity, and falls. BUA, SOS, t scores, and z scores were lower than the age-matched reference range in alcohol-dependent participants. Levels of type 1 procollagen (P1NP) increased significantly after five days (p < .001). Conclusions: Alcohol-dependent, pre-menopausal individuals have multiple risk factors for fracture, beyond alcohol excess. These should be addressed and targeted as modification may reduce fracture risk, especially given the apparent recovery of bone turnover on the withdrawal of alcohol.

BackgroundHealth inequities between indigenous and non-indigenous people are well documented. However, the contribution of differential exposure to risk factors in the occupational environment remains unclear. This study assessed differences in the prevalence of self-reported exposure to disease risk factors, including dust and chemicals, physical factors and organisational factors, between Māori and non-Māori workers in New Zealand.MethodsPotential participants were sampled from the New Zealand electoral rolls and invited to take part in a telephone interview, which included questions about current workplace exposures. Logistic regression, accounting for differences in age, socioeconomic status and occupational distribution between Māori and non-Māori, was used to assess differences in exposures.ResultsIn total, 2344 Māori and 2710 non-Māori participants were included in the analyses. Māori had greater exposure to occupational risk factors than non-Māori. For dust and chemical exposures, the main differences related to Māori working in occupations where these exposures are more common. However, even within the same job, Māori were more likely to be exposed to physical factors such as heavy lifting and loud noise, and organisational factors such as carrying out repetitive tasks and working to tight deadlines compared with non-Māori.ConclusionsThis is one of the first studies internationally to compare occupational risk factors between indigenous and non-indigenous people. These findings suggest that the contribution of the occupational environment to health inequities between Māori and non-Māori has been underestimated and that work tasks may be unequally distributed according to ethnicity.

Objective: to investigate the barriers that prevent or delay people seeking a sexually transmitted infection (STI) test.Methods: qualitative in-depth interviews were conducted with 24 university students, who are a group prone to behaviours putting them at risk of STIs, to understand the factors that had prevented or delayed them from going for an STI test in the past. Resulting data were thematically analysed employing a qualitative content analysis method, and a final set of themes identified.Results: there were three main types of barrier to STI testing. These were: personal (underestimating risk, perceiving STIs as not serious, fear of invasive procedure, self-consciousness in genital examination and being too busy); structural (financial cost of test and clinician attributes and attitude); and social (concern of being stigmatised).Conclusions and implications for public health: these data will help health providers and policy-makers provide services that minimise barriers and develop effective strategies for improving STI testing rates. The results of this study suggest a holistic approach to encouraging testing is required, which includes addressing personal beliefs, working with healthcare providers to minimise structural barriers and developing initiatives to change social views about STIs.

Background While many Aotearoa/New Zealanders are receiving excellent palliative care the Pacific populations have limited access to available hospice and palliative care services. Little research has been conducted to identify barriers unique to Pacific populations accessing these services. The purpose of this study was to explore key stakeholders’ perspectives on the determinants of low access among Pacific populations to these services. Methods Forty-five semi-structured interviews were conducted face-to-face with hospice patients and their families, hospice/health providers and key informants from the Auckland and Wellington region of Aotearoa/New Zealand. The interviews were recorded and transcribed verbatim and a thematic analysis was carried out by identifying, coding and categorising patterns in the data. Identified themes were then discussed further to determine the relevance of the data grouped by theme. Results Five interrelated themes affecting access emerged: perception of hospice (often negative) through lack of accurate information, but changing; families’ role to look after their own and sick elderly; hospice experiences; continuity of care in the community and the need for information and communication. Conclusion Hospice and associated palliative care services are under-utilised and commonly misunderstood among Pacific populations in Aotearoa/New Zealand. There is active support following appropriate information received, hence the need for community education and culturally appropriate hospice and palliative services. Inadequate inter-professional communication contributes to polypharmacy and inefficiency in continuity of care across all levels. The Pacific individual is one component of a collective that is critical in major decisions in end-of-life and life changing situations. The findings may guide policies and further research to improve Hospice and Palliative services in Aotearoa/New Zealand.

Sleep duration may be associated with risk of osteoporosis, with suggestions that too little or indeed too much sleep may be detrimental to bone health. In this study, we considered whether perceived sleep quality is also associated with bone health in older adults. We explored this association in a cohort of 443 older community-dwelling UK adults. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI); poor sleep quality was defined as > 5 on this score system. Bone density, shape and microarchitecture were assessed using dual energy X-ray absorptiometry (DXA), peripheral quantitative computed tomography (pQCT) and high-resolution pQCT (HRpQCT). Thirty-seven percent of men and 43% of women had a PSQI score greater than 5, indicative of poor perceived sleep. We found that quality of sleep was associated with altered bone microarchitecture. In men, poor sleep quality was associated with lower radial trabecular (4% slice, p p = 0.02) bone mineral density, as well as decreased tibial cortical density (p p p p p p p p

ObjectivesAlthough cardiovascular disease (CVD) risk has been shown to differ between occupations, few studies have specifically evaluated the distribution of known CVD risk factors across occupational groups. This study assessed CVD risk factors in a range of occupational groups in New Zealand, stratified by sex and ethnicity.MethodsTwo probability-based sample surveys of the general New Zealand adult population (2004–2006; n = 3003) and of the indigenous people of New Zealand (Māori; 2009–2010; n = 2107), for which occupational histories and lifestyle factors were collected, were linked with routinely collected health data. Smoking, body mass index, deprivation, diabetes, high blood pressure, and high cholesterol were dichotomized and compared between occupational groups using age-adjusted logistic regression.ResultsThe prevalence of all known CVD risk factors was greater in the Māori survey than the general population survey, and in males compared with females. In general for men and women in both surveys ‘Plant and machine operators and assemblers’ and ‘Elementary workers’ were more likely to experience traditional CVD risk factors, while ‘Professionals’ were less likely to experience these risk factors. ‘Clerks’ were more likely to have high blood pressure and male ‘Agricultural and fishery workers’ in the general survey were less likely to have high cholesterol, but this was not observed in the Māori survey. Male Māori ‘Trades workers’ were less likely to have high cholesterol and were less obese, while for the general population survey, this was not observed.ConclusionsThis study showed differences in the distribution of known CVD risk factors across occupational groups, as well as between ethnic groups and males and females.

Background Human papillomavirus (HPV) is a common sexually transmitted infection implicated in 5% of cancers worldwide including most cervical cancer cases. In the UK, the HPV vaccine has been offered routinely to girls aged 11-13 since 2008 while cervical screening is offered to women aged 25-64. HPV testing will soon replace cytology as the primary screening method. This research evaluates what healthcare professionals (HCPs) across the UK know about HPV. Methods A total of 643 UK-based HCPs from primary and secondary care took part in an anonymous cross-sectional survey between March and April 2018. The survey measured general HPV knowledge; HPV triage and test of cure knowledge; HPV vaccine knowledge; attitudes to the HPV vaccine and self-perceived adequacy of knowledge. Results Participants had a generally good understanding of HPV and the vaccination but there were gaps in detailed knowledge of the National Health Service HPV testing processes. There were some gaps in knowledge about the health sequelae of HPV for males. Years since HPV training was associated with triage and test of cure and vaccine knowledge scores. Furthermore, nurses and doctors in colposcopy clinics had much greater odds of having higher knowledge across all domains than other roles. In total, 76.2% of participants felt adequately informed about HPV and 35.6% made suggestions for improvements in training, many of which requested additional frequency and topics. Conclusion Our results suggest that additional training is needed to ensure HCPs are equipped to deal with the changing landscape of HPV screening and vaccination in the UK.

Reactive arthritis (ReA) is an inflammatory spondyloarthritis occurring after infection at a distant site. Chlamydia trachomatis is proposed to be the most common cause of ReA, yet the incidence of sexually acquired ReA (SARA) has not been well established. We therefore carried out a systematic literature review to collate and critically evaluate the published evidence regarding the incidence of SARA. MEDLINE and EMBASE databases were searched using free-text and MeSH terms relating to infection and ReA. The title and abstract of articles returned were screened independently by two reviewers and potentially relevant articles assessed in full. Data was extracted from relevant articles and a risk of bias assessment carried out using a validated tool. Heterogeneity of study methodology and results precluded meta-analysis. The search yielded a total of 11,680 articles, and a further 17 were identified from review articles. After screening, 55 papers were assessed in full, from which 3 met the relevant inclusion criteria for the review. The studies reported an incidence of SARA of 3.0-8.1 % and were found to be of low to moderate quality. More studies are required to address the lack of data regarding the incidence of SARA. Specific and sensitive classification criteria must be developed in order for consistent classification and valid conclusions to be drawn. In clinical practice, it is recommended clinicians discuss the possibility of ReA developing at the time of STI diagnosis and to encourage patients to return if they experience any relevant symptoms.

Background Stroke systems of care differ between larger urban and smaller rural settings and it is unclear to what extent this may impact on patient outcomes. Ethnicity influences stroke risk factors and care delivery as well as patient outcomes in nonstroke settings. Little is known about the impact of ethnicity on poststroke care, especially in Māori and Pacific populations. Objective Our goal is to describe the protocol for the Reducing Ethnic and Geographic Inequities to Optimise New Zealand Stroke Care (REGIONS Care) study. Methods This large, nationwide observational study assesses the impact of rurality and ethnicity on best practice stroke care access and outcomes involving all 28 New Zealand hospitals caring for stroke patients, by capturing every stroke patient admitted to hospital during the 2017-2018 study period. In addition, it explores current access barriers through consumer focus groups and consumer, carer, clinician, manager, and policy-maker surveys. It also assesses the economic impact of care provided at different types of hospitals and to patients of different ethnicities and explores the cost-efficacy of individual interventions and care bundles. Finally, it compares manual data collection to routine health administrative data and explores the feasibility of developing outcome models using only administrative data and the cost-efficacy of using additional manually collected registry data. Regarding sample size estimates, in Part 1, Study A, 2400 participants are needed to identify a 10% difference between up to four geographic subgroups at 90% power with an α value of .05 and 10% to 20% loss to follow-up. In Part 1, Study B, a sample of 7645 participants was expected to include an estimated 850 Māori and 419 Pacific patients and to provide over 90% and over 80% power, respectively. Regarding Part 2, 50% of the patient or carer surveys, 40 provider surveys, and 10 focus groups were needed to achieve saturation of themes. The main outcome is the modified Rankin Scale (mRS) score at 3 months. Secondary outcomes include mRS scores; EQ-5D-3L (5-dimension, 3-level EuroQol questionnaire) scores; stroke recurrence; vascular events; death; readmission at 3, 6, and 12 months; cost of care; and themes around access barriers. Results The study is underway, with national and institutional ethics approvals in place. A total of 2379 patients have been recruited for Part 1, Study A; 6837 patients have been recruited for Part 1, Study B; 10 focus groups have been conducted and 70 surveys have been completed in Part 2. Data collection has essentially been completed, including follow-up assessment; however, primary and secondary analyses, data linkage, data validation, and health economics analysis are still underway. Conclusions The methods of this study may provide the basis for future epidemiological studies that will guide care improvements in other countries and populations. International Registered Report Identifier (IRRID) DERR1-10.2196/25374

Untreated sexually transmitted infections (STIs) can lead to serious health complications and may be transmitted to uninfected individuals. Therefore, the early detection and subsequent management of STIs is crucial to control efforts. Time to presentation for STI symptoms and risk of transmission in this period has not been assessed in New Zealand to date.All new clients presenting to an urban sexual health clinic (SHC) were invited to complete a questionnaire, which included demographic information, sexual health history, and details about the clinic visit.Of 331 people approached, 243 (73.4%) agreed to complete the questionnaire. Four incomplete questionnaires were excluded, leaving 239 participants (47.3% female and 52.7% male, 43.8% under the age of 25). The most common reason for seeking healthcare was experiencing symptoms (39.4%) and 41.7% of people with symptoms waited more than seven days to seek healthcare. Around a third (30.6%) of people with symptoms had sex after they first thought they may need to seek healthcare. Infrequent condom use was reported more often by people who had sex with existing partners (84.6%) than by people who had sex with new partners (10.0%).This is the first study to quantify healthcare-seeking behaviour for STI in New Zealand. Delayed healthcare-seeking (defined as waiting more than seven days) was common and almost a third of people reported engaging in sex while symptomatic. Enabling prompt healthcare-seeking is crucial to minimise transmission risk. Structural barriers such as the financial cost of STI tests must be removed and education around symptom recognition and healthcare system navigation should be provided.

BackgroundHuman papillomavirus (HPV) is a common sexually transmitted infection that is implicated in 99.7% of cervical cancers and several other cancers that affect both men and women. Despite the role that HPV plays in an estimated 5% of all cancers and the evolving role of HPV vaccination and testing in protecting the public against these cancers, preliminary research in New Zealand health care professionals suggest knowledge about HPV may not be sufficient.MethodsA total of 230 practice nurses, smear takers and other clinical and laboratory staff who attended a range of training events completed a cross-sectional survey between April 2016 and July 2017. The survey explored four broad areas: demographics and level of experience, HPV knowledge (general HPV knowledge, HPV triage and test of cure (TOC) knowledge and HPV vaccine knowledge), attitudes towards the HPV vaccine and self-perceived adequacy of HPV knowledge.ResultsThe mean score on the general HPV knowledge questions was 13.2 out of 15, with only 25.2% of respondents scoring 100%. In response to an additional question, 14.0% thought (or were unsure) that HPV causes HIV/AIDS. The mean score on the HPV Triage and TOC knowledge questions was 7.4 out of 10, with only 9.1% scoring 100%. The mean score on the HPV vaccine knowledge questions was 6.0 out of 7 and 44.3% scored 100%. Only 62.6% of respondents agreed or strongly agreed that they were adequately informed about HPV, although 71.8% agreed or strongly agreed that they could confidently answer HPV-related questions asked by patients. Multivariate analyses revealed that knowledge in each domain predicted confidence in responding to patient questions. Furthermore, the number of years since training predicted both HPV knowledge and Triage and TOC knowledge.DiscussionAlthough overall level of knowledge was adequate, there were significant gaps in knowledge, particularly about the role of HPV testing in the New Zealand National Cervical Screening Programme. More education is required to ensure that misinformation and stigma do not inadvertently result from interactions between health practitioners and the public.

The growing recognition of sarcopenia, the age-related loss of skeletal muscle mass and function, has highlighted the need to understand more about its etiology. Declines in muscle mass and strength are expected aspects of aging, but there is significant variability between individuals in rates of loss. Although some of these differences can be explained by fixed factors, such as sex, much of the remaining variation is unexplained. This has led to increasing interest in the influence of adult lifestyle, particularly in the effects of modifiable factors such as physical activity and diet, and in identifying intervention opportunities both to prevent and manage sarcopenia. A number of trials have examined the separate effects of increased exercise or dietary supplementation on muscle mass and physical performance of older adults, but less is known about the extent to which benefits of exercise training could be enhanced when these interventions are combined. In a comprehensive review of the literature, we consider 17 studies of older adults (≥65 years) in which combined nutrition and exercise interventions were used to increase muscle strength and/or mass, and achieve improvements in physical performance. The studies were diverse in terms of the participants included (nutritional status, degree of physical frailty), supplementation strategies (differences in nutrients, doses), exercise training (type, frequency), as well as design (duration, setting). The main message is that enhanced benefits of exercise training, when combined with dietary supplementation, have been shown in some trials – indicating potential for future interventions, but that existing evidence is inconsistent. Further studies are needed, particularly of exercise training combined with dietary strategies that increase intakes of a range of nutrients, as well as bioactive non-nutrients, to provide the evidence on which public health and clinical recommendations can be based.

Overseas clinics specialising in management of transgender people have noted a marked increase in the numbers of people requesting therapy in the last few years. No data has been presented for New Zealand. We therefore reviewed the number of transgender people seen in the Wellington Endocrine Service to assess if the pattern was similar and assess any potential problems for service delivery.Using hospital records, we reviewed the new appointments of people who were referred for advice on gender reassignment and seen in the Wellington Endocrine Service from 1990 to 2016.In total, 438 people who identified as transgender attended the clinic at least once in this period. There has been a progressive increase in number of people identifying as transgender presenting to the clinic, particularly since 2010. In addition to increasing overall numbers, there has been in particular increase in referrals for people under age 30, as well as an increasing proportion of people requesting female-to-male (FtM) therapy so that it is now approaching the number of people requesting male-to-female therapy (MtF).The pattern observed is comparable to changes reported overseas. These changes have practical consequences for the delivery of both secondary and primary level healthcare, requiring an increased focus on clinical coordination between the relevant medical services and their links to the primary services sector.

We report a pilot study of bone health of alcohol dependent women. Women admitted to an alcohol-withdrawal unit (cases) and a convenience sample of controls (nursing staff) were recruited and asked to complete a lifestyle questionnaire before undergoing heel ultrasound measurements. Fasting blood samples were obtained on the day of admission (day 1) and at 5 days. Bone turnover markers (P1NP and CTX) and vitamin D levels were measured in a subset of the alcohol dependent population. Cases were less physically active than controls. Alcoholic women had lower heel ultrasound derived Stiffness Index scores (mean 85.2 (17.6)) compared with controls (mean 95.5 (18.7)) (p=0.07). P1NP rose significantly over the detoxification programme (day 1: 28.35 � g/l (12.25); day 5: 34.19 � g/l (13.16), p=0.003) but CTX change was not significant. Lifestyle factors associated with poor bone health are prevalent in female alcoholics. Significant increase in bone formation was observed 5 days after alcohol withdrawal.

BackgroundAssociations between ischaemic heart disease (IHD) and occupation are poorly understood. We linked two previously conducted New Zealand workforce surveys with routinely collected health data to assess occupational risk factors of IHD in New Zealand.MethodsTwo probability-based sample surveys of the general New Zealand adult population (2004–2006; n=3003) and of the New Zealand indigenous peoples (M&_x0101;ori; 2009–2010; n=2107), for which occupational history was collected, were linked with health data up to the end of 2017 using Statistics New Zealand individual-level microdata. Incident IHD events were identified using hospitalisations, prescriptions and deaths. The odds ratios associated with ever being employed in occupational groups were estimated by logistic regression adjusting for age, smoking and socio-economic status separately for males and females in each cohort.ResultsA total of 282 IHD cases were identified in both surveys. Statistically significant elevated IHD risks were observed for male clerks in the general survey (OR=1.60, 95%CI=1.02–2.49) and agriculture and fishery male workers in the M&_x0101;ori survey (OR=1.70, 95%CI=1.02–2.82). Among females, the odds ratios for agriculture and fishery workers were 1.69 (95%CI=0.81–3.51) and 1.49 (95%CI=0.81–2.75) in the general survey and the M&_x0101;ori survey, respectively. A statistically significant increased risk was observed for female plant and machine operators and assemblers in the M&_x0101;ori survey (OR=1.87, 95%CI=1.05–3.31). In the general survey, male plant and machine operators and assemblers had an odds ratio of 1.26 (95%CI=0.81–1.95). We also identified borderline increased odds ratios for trades workers among males in the general survey (OR=1.39, 95%CI=0.92–2.12, p-value=0.12) and among females in the M&_x0101;ori survey (OR=2.26, 95%CI=0.98–5.21, p-value=0.06).ConclusionThis study identified associations between several occupational groups and IHD in the New Zealand population. Further analyses will be conducted to assess specific occupational exposures associated with IHD risk.

BackgroundDifferences in cardiovascular disease (CVD) risk between occupations have been observed, but what specific risk factors underlie these patterns remains unclear. This study assessed how established CVD risk factors differ across occupational groups in New Zealand, and whether patterns differ by gender and ethnicity.MethodsTwo probability-based sample surveys of the general New Zealand adult population (2004–2006; n=3003) and of the indigenous peoples of New Zealand (M&_x0101;ori; 2009–2010; n=2107), for which occupational histories and lifestyle factors were collected, were linked with routinely collected health data. For males and females in each cohort, smoking, body mass index, diabetes, hypertension and high cholesterol were dichotomised and compared between occupational groups using age-adjusted logistic regression. In addition, two way tables and chi-squared tests were used to compare the distribution of risk factors between white and blue-collar workers.ResultsThe prevalence of ever smoking was greater in blue-collar compared to white-collar workers of both cohorts, i.e. general population male (56%; 47%), general population female (62%; 47%), M&_x0101;ori male (68%; 55%) and M&_x0101;ori female (84%; 64%). For diabetes and high cholesterol, differences were statistically significant only for general population females (11%; 6% and 26%; 16% respectively). Hypertension prevalence was higher in blue versus white-collar workers for general population females (36%; 29%), M&_x0101;ori males (43%; 36%) and M&_x0101;ori females (44%; 37%), but not for general population males (35%; 34%). Results by occupational group revealed the same patterns with some noteworthy exceptions. In both cohorts, clerks had an increased risk of hypertension, particularly among males. Male agricultural workers in the general population cohort had a reduced risk of hypertension, diabetes and high cholesterol, but this pattern was not observed for females or among M&_x0101;ori.ConclusionThis study showed differences in profiles of known CVD risk factors across occupations, with some notable ethnic and gender differences.

Introduction: sarcopenia is associated with adverse health outcomes. The aim of this study was to describe the prevalence of sarcopenia in community-dwelling older people in the UK using the European Working Group on Sarcopenia in Older People (EWGSOP) consensus definition.Methods:we applied the EWGSOP definition to 103 community-dwelling men participating in the Hertfordshire Sarcopenia Study (HSS) using both the lowest third of dual-energy X-ray absorptiometry (DXA) lean mass (LM) and the lowest third of skin-fold-based fat-free mass (FFM) as markers of low muscle mass. We also used the FFM approach among 765 male and 1,022 female participants in the Hertfordshire Cohort Study (HCS). Body size, physical performance and self-reported health were compared in participants with and without sarcopenia.Results: the prevalence of sarcopenia in HSS men (mean age 73 years) was 6.8% and 7.8% when using the lowest third of DXA LM and FFM, respectively. DXA LM and FFM were highly correlated (0.91, P < 0.001). The prevalence of sarcopenia among the HCS men and women (mean age 67 years) was 4.6% and 7.9%, respectively. HSS and HCS participants with sarcopenia were shorter, weighed less and had worse physical performance. HCS men and women with sarcopenia had poorer self-reported general health and physical functioning scores.Conclusions: this is one of the first studies to describe the prevalence of sarcopenia in UK community-dwelling older people. The EWGSOP consensus definition was of practical use for sarcopenia case finding. The next step is to use this consensus definition in other ageing cohorts and among older people in a range of health-care settings.

The FRAX(tr) algorithm uses clinical risk factors (CRF) and bone mineral density (BMD) to predict fracture risk but does not include falls history in the calculation. Using results from the Hertfordshire Cohort Study, we examined the relative contributions of CRFs, BMD and falls history to fracture prediction. We studied 2299 participants at a baseline clinic that included completion of a health questionnaire and anthropometric data. A mean of 5.5years later (range 2.9-8.8years) subjects completed a postal questionnaire detailing fall and fracture history. In a subset of 368 men and 407 women, bone densitometry was performed using a Hologic QDR 4500 instrument. There was a significantly increased risk of fracture in men and women with a previous fracture. A one standard deviation drop in femoral neck BMD was associated with a hazards ratio (HR) of incident fracture (adjusted for CRFs) of 1.92 (1.04-3.54) and 1.77 (1.16-2.71) in men and women respectively. A history of any fall since the age of 45years resulted in an unadjusted HR of fracture of 7.31 (3.78-14.14) and 8.56 (4.85-15.13) in men and women respectively. In a ROC curve analysis, the predictive capacity progressively increased as BMD and previous falls were added into an initial model using CRFs alone. Falls history is a further independent risk factor for fracture. Falls risk should be taken into consideration when assessing whether or not to commence medication for osteoporosis and should also alert the physician to the opportunity to target falls risk directly.

Background: the European Working Group on Sarcopenia in Older People has developed a clinical definition of sarcopenia based on low muscle mass and reduced muscle function (strength or performance). Grip strength is recommended as a good simple measure of muscle strength when ‘measured in standard conditions’. However, standard conditions remain to be defined. Methods: a literature search was conducted to review articles describing the measurement of grip strength listed in Medline, Web of Science and Cochrane Library databases up to 31 December 2009. Results: there is wide variability in the choice of equipment and protocol for measuring grip strength. The Jamar hand dynamometer is the most widely used instrument with established test–retest, inter-rater and intra-rater reliability. However, there is considerable variation in how it is used and studies often provide insufficient information on the protocol followed making comparisons difficult. There is evidence that variation in approach can affect the values recorded. Furthermore, reported summary measures of grip strength vary widely including maximum or mean value, from one, two or three attempts, with either hand or the dominant hand alone. Conclusions: there is considerable variation in current methods of assessing grip strength which makes comparison between studies difficult. A standardised method would enable more consistent measurement of grip strength and better assessment of sarcopenia. Our approach is described.

OBJECTIVES: To determine patterns of supplement use in a UK community-dwelling older population, and to investigate the extent to which supplement user groups differ, in terms of their sociodemographic and lifestyle characteristics, diet and morbidity. DESIGN: Cross-sectional cohort study. SETTING: Home interview and clinic visit. PARTICIPANTS: 3217 Hertfordshire Cohort Study participants, aged 59 to 73. MEASUREMENTS: Information was obtained on the participant's social and medical history by a trained research nurse. Diet over the preceding 3 months was assessed by Food Frequency Questionnaire; compliance with 'healthy' eating recommendations was defined using individual scores for a 'prudent' dietary pattern, identified using principal components analysis. Details of all dietary supplements taken in the preceding 3 months were recorded. Individual supplements were allocated to one of 10 types based on their nutrient composition. Cluster analysis was used to define groups of supplement users. RESULTS: 45.4% of men and 57.5% of women reported taking at least one dietary supplement in the previous 3 month period. There were 5 distinct clusters of supplement users; these were common to men and women. They were labelled according to the principal supplement taken; oils, glucosamine, single vitamins, vitamins and minerals, and herbal products. These groups differed in their social class and prudent diet score, but few other characteristics. With the exception of a difference in diagnosis of diabetes among the women, there were no differences in morbidity between the supplement groups in either men or women. CONCLUSIONS: Dietary supplement use is high in this population. There are distinct patterns of supplement use, which are related to sociodemographic and lifestyle characteristics including diet, though there were few clear differences in morbidity.

The Hertfordshire Cohort Study (HCS) comprises a nationally unique study of 3225 men and women born during the period 1931–39 in the English county of Hertfordshire and still resident there in the late 1990s. The study has previously been described in detail in an IJE Cohort Profile.1 In brief, from 1911 to 1948, health visitors recorded information on birthweight and weight at 1 year on infants born in Hertfordshire. In 1998, those born between 1931 and 1939 were traced through the National Health Service Central Register and a total of 7106 men and women were identified as alive and still resident in the county. Permission to contact these men and women was obtained from their general practitioners. Between 1999 and 2004, they were invited to participate in studies examining the interactions between early life, diet, adult lifestyle and genetic factors as determinants of adult disease. A total of 3225 men and women, aged 59–73 years, were interviewed at home by a trained research nurse who obtained information on the participants' medical and social histories. Subsequently, 2997 men and women attended a clinic for further investigations. Since then, cohort-wide postal follow-up questionnaires and face to face detailed clinical studies of subgroups of the cohort have been conducted. This photoessay describes the history of the HCS across the past 100 years, from instigation of the system that provided us with the historical records that made the study possible to the modern-day high-tech measurement systems that enable us to characterize in detail the health-related outcomes of our cohort members. Photo 1 Ethel Margaret Burnside was the Chief Health Visitor and Lady Inspector of Midwives in Hertfordshire from 1906 to 1919 Photo 2 Miss Burnside set up a system whereby each birth, whether in hospital or at home, was attended by a trained midwife. Records were entered into ledgers that spanned births from 1911 to 1948 Photo 3 The details included type of milk feeding in infancy, weight at 1 year and health in childhood Photo 4 The MRC Lifecourse Epidemiology Unit sought out old records from early life to test the hypothesis that non-communicable diseases have their roots in utero. Some were found in the nick of time! Photo 5 Miss Burnside's records from almost the entire county were found, and are now housed in a purpose-built archive in Southampton. The records began in 1911, and so have reached their centenary Photo 6 Babies born between 1931 and 1939 were traced as adults, and were interviewed at home to characterize their health and well-being Photo 7 Current lifestyle was characterized in detail including assessment of diet using food frequency questionnaires and 24-h food diaries Photo 8 Study members were invited to attend local clinics, the first of which were held at Hertford County Hospital Photo 9 Grip strength was measured by dynamometer as a measure of muscle strength Photo 10 Dual-energy X-ray absorptiometry (DXA) scans were taken to characterize body composition and bone mass Photo 11 Peripheral quantitative computed tomography (pQCT) scans were also taken; this technique uses multiple cross-sectional X-rays to reconstruct a volumetric model of bone density distribution Photo 12 Follow-up studies continue, and regular public engagement events are held

Background: systematic review is a powerful research tool which aims to identify and synthesize all evidence relevant to a research question. The approach taken is much like that used in a scientific experiment, with high priority given to the transparency and reproducibility of the methods used and to handling all evidence in a consistent manner.Early career researchers may find themselves in a position where they decide to undertake a systematic review, for example it may form part or all of a PhD thesis. Those with no prior experience of systematic review may need considerable support and direction getting started with such a project. Here we set out in simple terms how to get started with a systematic review.Discussion: advice is given on matters such as developing a review protocol, searching using databases and other methods, data extraction, risk of bias assessment and data synthesis including meta-analysis. Signposts to further information and useful resources are also given.Conclusion: a well-conducted systematic review benefits the scientific field by providing a summary of existing evidence and highlighting unanswered questions. For the individual, undertaking a systematic review is also a great opportunity to improve skills in critical appraisal and in synthesising evidence.

In light of the rising number of referrals to secondary level services of people who identify as transgender, and the Human Rights Commission concerns regarding the care of this group in New Zealand, we felt it was timely to determine the availability of services for people who identify as transgender and whether there are variations in management protocols.We contacted 100 physicians involved in providing a secondary level service to care for people who identify as transgender, and asked them to complete a questionnaire about the services available in their region. This questionnaire consisted of two parts, a 'general questionnaire', which focussed on the consultants' understanding of services available locally, and a 'clinical questionnaire', which presented hypothetical clinical case histories and asked respondents to indicate how they would manage the case.Sixty-two of the physicians responded. Of these, 18 (45% of the 40 physicians that answered the question) believed they could access a psychological or psychiatric opinion in the public sector for a patient who identifies as transgender, whereas 28 (82% of the 34 that answered the question) knew of access in the private sector. There was a conflict of opinion on the availability of psychological and surgical services in several DHBs where there was more than one clinician responding. This may reflect the case experience of individual clinicians. There was restricted access to common surgical procedures in the public sector, and about half of respondents did not know if techniques were available locally.Our results support the development of specialist care services in tertiary centres in addition to the secondary services already available in New Zealand for people who identify as transgender. Development of multidisciplinary management and improved access to psychological support services for individual cases is required.

No abstract available.

Peripheral quantitative computed tomography (pQCT) captures novel aspects of bone geometry that may contribute to fracture risk and offers the ability to measure both volumetric bone mineral density (vBMD) and a separation of trabecular and cortical compartments of bone, but longitudinal data relating measures obtained from this technique to incident fractures are lacking. Here we report an analysis from the Hertfordshire Cohort Study, where we were able to study associations between measures obtained from pQCT and DXA in 182 men and 202 women aged 60-75 years at baseline with incident fractures over 6 years later. Among women, radial cortical thickness (HR 1.72, 95% CI 1.16, 2.54, p=0.007) and cortical area (HR 1.91, 95% CI 1.27, 2.85, p=0.002) at the 66% slice were both associated with incident fractures; these results remained significant after adjustment for confounders (age, BMI, social class, cigarette smoking and alcohol consumption, physical activity, dietary calcium, HRT and years since menopause). Further adjustment for aBMD made a little difference to the results. At the tibia, cortical area (HR 1.58, 95% CI 1.10, 2.28, p=0.01), thickness (HR 1.49, 95% CI 1.08, 2.07, p=0.02) and density (HR 1.64, 95% CI 1.18, 2.26, p=0.003) at the 38% site were all associated with incident fractures with the cortical area and density relationships remaining robust to adjustment for the confounders listed above. Further adjustment for aBMD at this site did lead to attenuation of relationships. Among men, tibial stress-strain index (SSI) was predictive of incident fractures (HR 2.30, 95% CI 1.28, 4.13, p=0.005). Adjustment for confounding variables and aBMD did not render this association non-significant. In conclusion, we have demonstrated relationships between measures of bone size, density and strength obtained by pQCT and incident fracture. These relationships were attenuated but in some cases remained significant after adjustment for BMD measures obtained by DXA, suggesting that some additional information may be conferred by this assessment.

We are most grateful to Dr Kawada for their comments on our study. We were delighted that they felt the topic of importance and were so supportive of the methodology and results. They correctly point out that, in keeping with the FRAX model(1), we utilised height and weight as clinical risk factors in the assessment of fracture prediction(2). In our model, the hazard ratios (HR) for fracture associated with a history of falls were 6.96 and 2.64 in men and women respectively after adjustment for clinical risk factors and femoral neck bone mineral density (BMD)(3). When body mass index (BMI) was utilised in place of height and weight, the values changed little (6.68 and 2.75 respectively). We entirely agree that the limited number of fractures in men will affect the stability of the male model risk prediction. In this regard, we would point out the imprecision of our estimates of risk, as illustrated by the 95% confidence intervals for men. Of course, our research paves the way for similar studies using larger populations or longer follow up to increase fracture numbers and statistical power. The correspondent also correctly identifies the important issue of exercise as a predictor of fracture. This was not incorporated in our study models as it is not a constituent of the FRAX algorithm. However assessments have been made in our cohort of self-perceived walking speed and habitual physical activity. The latter was calculated as a standardised score ranging from 0–100 derived from frequency of gardening, housework, climbing stairs and carrying loads in a typical week. Higher scores indicated greater levels of activity(4). An association was demonstrated between faster walking speed and a lower rate of both falls and fractures in women. However, when included in our fracture prediction models, these variables did not materially affect the HR for fracture in either sex, and multivariate analysis did not reveal any association between habitual physical activity and subsequent fracture in either men or women. Overall our study confirms the role of clinical risk factors and BMD in fracture risk prediction and provides evidence that fall history may further augment this. These findings are in accord with the recommendations of the FRAX Clinical Task Force(5) that suggested falls be accounted for alongside FRAX. They are also commensurate with their suggestion that a 30% increased risk of fracture be applied for every additional fall in the preceding year.

OBJECTIVES: Lower muscle strength is associated with a range of adverse health outcomes in later life. The variation in muscle strength between individuals is only partly accounted for by factors in adult life such as body size and physical activity. The aim of this review was to assess the strength of the association between intrauterine development (indicated by birth weight) and subsequent muscle strength. DESIGN: Systematic review and meta-analysis of studies that assessed the association between birth weight and subsequent muscle strength. RESULTS: Nineteen studies met inclusion criteria with 17 studies showing that higher birth weight was associated with greater muscle strength. Grip strength was used as a single measure of muscle strength in 15 studies. Meta-analysis (13 studies, 20 481 participants, mean ages 9.3 to 67.5) showed a 0.86 kg (95% CI 0.58, 1.15) increase in muscle strength per additional kilogram of birth weight, after adjustment for age, gender and height at the time of strength measurement. CONCLUSION: This review has found consistent evidence of a positive association between birth weight and muscle strength which is maintained across the lifecourse. Future work will be needed to elucidate the biological mechanisms underlying this association, but it suggests the potential benefit of an early intervention to help people maintain muscle strength in later life.

Background Sexually transmitted infection (STI) rates are known to be high in New Zealand, for example the incidence rate of Chlamydia is almost double that of Australia and the United Kingdom. If public awareness about STIs is low, including knowledge about transmission, risk factors, symptoms and treatment, this could be a contributing factor to the high rates observed. To date however, there has been very little assessment of STI knowledge in New Zealand. We addressed this in this pilot study. Methods This analysis is part of a larger study assessing health-seeking behaviour for STI among students. A questionnaire-based survey was used to obtain basic demographic information and STI knowledge information from students attending a university health centre in the North Island of New Zealand. Students could self-select to take part by picking up a copy of the questionnaire in the waiting room. Seven STI knowledge questions were used, each comprising a statement for which the respondent was asked to indicate ‘True’, ‘False’ or ‘I don’t know’. Correct answers were contrasted with incorrect and ‘I don’t know’ answers to give a general overview of STI knowledge in this population. Results Preliminary analysis of the first 159 questionnaires returned showed variable knowledge of STI transmission, treatment and possible consequences. Students had a good knowledge of transmission, with 88% knowing that STIs can be spread even when symptoms are not present. However, knowledge about treatment and potential sequelae was poor, with 58% of respondents indicating they did not know whether Gonorrhoea could usually be treated with antibiotics, and 44% indicating that they were not aware that some kinds of cancer could be caused by STIs. Conclusion This analysis indicates that some areas of STI knowledge could be improved in this population. This is important because knowledge can be addressed through public health interventions. Disclosure of interest statement The authors declare no conflicts of interest.

Background Recruiting individuals to take part in studies about sexual health can often be difficult due to the sensitive nature of the study topic. As a result, the sample may be less representative of the general population than desired. Understanding potential participants’ views, motivations and concerns may aid in the design of a recruitment protocol that maximises participation and minimises bias. Methods During the initial stages of a study concerning sexually transmitted infections (STIs) at a New Zealand university health centre, a series of focus groups were carried out in order to understand acceptable methods of recruitment. The focus group participants were sought from the study target population and were recruited via posters displayed around the university. Three focus groups of between five and seven participants were conducted. Discussions were audio-recorded and transcribed verbatim. Content analysis methodology was employed using a constant comparative method. Results A key theme that emerged centred around the timing of any approach; students almost unanimously agreed that an approach prior to an STI consultation would be more acceptable than after. Reasons given included wanting to “just get out of there” after seeing the clinician, as well as having something to do during idle time in the waiting room. Many students suggested that they would be less likely to take part after receiving a STI test result that was positive, as they would “not want to think about it”. Conclusion Understanding students’ views around STI testing and research participation helped us to develop a protocol that was sympathetic to the target population’s attitudes and desires, thus improving its acceptability and attractiveness to this population. This information may be useful to other researchers planning sexual health surveys in similar populations. Disclosure of interest statement The authors declare no conflicts of interest.

Background Poor sleep quality in older people is common and positively associated with morbidity and mortality. In particular, recent studies have suggested that sleep disturbance may be associated with impaired physical performance (PP) in American older adults. We attempted to replicate these findings in a population of UK community-dwelling older adults. Methods The study population comprised 443 men and women aged 71–80 years from the Hertfordshire Cohort Study, UK. Sleep quality was assessed using the validated Pittsburgh Sleep Quality Index (PSQI). The PSQI is a 10-item questionnaire that assesses a variety of factors related to sleep quality, and results in a global score where >5 is indicative of poor sleep quality. PP was assessed using the Guralnik short physical performance battery (SPPB), a timed up and go (TUG) test and grip strength. Results Completed questionnaires were returned by 373 (84%) participants. 153 (41%) of these participants had a PSQI score of >5, indicating poor sleep. Men, but not women, who reported poor sleep had a significantly lower SPPB score (≤9) after adjustment (age, smoking, alcohol, social class and BMI) (OR 2.42, 95% CI 1.14, 5.14, p = 0.022). This association was robust to additional adjustment for number of co-morbidities and number of medications. Sleep quality was associated with TUG time in men but not women. Men who had poorer sleep quality (PSQI >5) had an average increase (poorer performance) in TUG z-score of 0.30 compared with those with good sleep quality (PSQI ≤5) (95% CI 0.01, 0.59, p Conclusion We found further evidence in support of an association between poor sleep quality and worse PP in older adults. However, differences were observed between men and women. Our results suggest that co-morbidities and medication use may explain some of these observations. Further research into the association between sleep and PP is warranted.

Background.– The loss of muscle mass and strength combined with the gain in abdominal fat may act synergistically to exacerbate metabolic disorders and to increase disability. Despite their enormous clinical importance, associations of SO with various health outcome in Asian are under-recognized. This study aimed to examine the association of sarcopenic obesity with the prevalence of chronic illness and mobility limitation among 1204 subjects (576 men and 628 women) aged 60 years or older from The Fifth Korea NationalHealth andNutritionExamination Survey (KNHANESV-1). Method.– This study was based on the data obtained from The Fifth Korea National Health and Nutrition Examination Survey (KNHANES V-1), 2010, a cross-sectional and nationally representative survey conducted by the Korean Ministry of Health and Welfare. Participants completed four parts of a questionnaire that included health interview, health behavior, health examination survey and a whole body dual energy X-ray absortiometry(DXA) scan. Sarcopenia was defined as an appedicular skeletal muscle mass (ASM) divided by weight(%) of 2 SD below the sex-specific mean for young adults. Obesity was defined as percent body fat above 60th percentile of the study sample. Body composition was categorized into four categories: Normal, sarcopenic nonobese, normal obese, Sarcopenic obese(SO). Data for functional dimensions were extracted from the EQ-5D in KNHANES data (mobility, self-care, usual activities) and pain/discomfort. Results.– The prevalence of SO was 4.1% in men and 7.3% in women, respectively.Hypertension (men: odds ratio[OR], 3.14, 95% CI, 1.51–6.53, women: OR: 2.80, 95% CI, 1.65–4.73) and arthritis (women: OR: 2.39, 95% CI., 1.43–3.99) were associated with a significantly increased likelihood for SO. Older persons with SO are likely to report problems in mobility (OR: 3.34, 95% CI., 1.97–5.65), self-care (men: OR: 2.92, 95% CI., 1.05–8.07, women: OR: 2.33, 95% CI., 1.29–4.21), usual activity (men: OR: 2.28, 95% CI.,1.02–5.08, women: OR: 2.13, 95% CI., 1.29–3.52). Conclusion.– In conclusion, our results showed that sarcopenic obese group was more closely associated mobility, self-care, and usual activity problems. Considering that Korean population is becoming older and more obese, more attention should be given for the prevention and management of sarcopenic obese seniors.

Setting Use of dietary supplements has increased over recent decades in the UK. Although dietary supplement use has been described in a number of populations we know little about patterns of supplement use in older people. Objective The objectives of this study were to describe dietary supplement use in the Hertfordshire Cohort Study (HCS), to determine patterns of supplement use, and to investigate the extent to which supplement user groups differ in terms of their characteristics, diets and morbidity. Methods 3217 HCS participants, aged 59 to 73, were interviewed. Diet over the preceding 3 months was assessed by FFQ; compliance with “healthy” eating recommendations was defined using individual scores for a “prudent” dietary pattern, identified using principal components analysis. Details of the brand and dose of all dietary supplements taken in the preceding 3 months were recorded. Individual supplements were allocated to one of 10 groups based on their nutrient composition, and cluster analysis was used to define groups of supplement users. The demographic and lifestyle characteristics, and morbidity of the supplement user groups was examined. Results 45.4% of men and 57.5% of women reported taking at least one dietary supplement in the previous 3-month period; the most commonly taken type of supplement was oils (43% of total supplement products taken), particularly fish liver oil. There were five distinct clusters of supplement users; these were common to men and women. They were labelled according to the principal supplement taken; oils, glucosamine, single vitamins, vitamins and minerals, and herbal products. For men, there were differences between the groups for BMI (p=0.030), “prudent” diet score (p=0.002), Hospital Anxiety and Depression score (p=0.013) and social class (p=0.012). For women, there were differences between the groups for age (p=0.030), “prudent” diet score (p=0.014) and social class (p=0.005). There was no significant difference between the groups for Hospital Anxiety and Depression score among the women. With the exception of a difference in diagnosis of diabetes among the women (p=0.021), there were no differences in morbidity between the supplement groups in either men or women. Conclusion There were distinct patterns of supplement use in the HCS. Supplement user groups differed in their characteristics, but there were few differences in morbidity.

Hip fracture is the most significant complication of osteoporosis in terms of mortality, long-term disability and decreased quality of life. In the recent years, different techniques have been developed to assess lower limb strength and ultimately fracture risk. Here we examine relationships between two measures of lower limb bone geometry and strength; proximal femoral geometry and tibial peripheral quantitative computed tomography. We studied a sample of 431 women and 488 men aged in the range 59–71 years. The hip structural analysis (HSA) programme was employed to measure the structural geometry of the left hip for each DXA scan obtained using a Hologic QDR 4500 instrument while pQCT measurements of the tibia were obtained using a Stratec 2000 instrument in the same population. We observed strong sex differences in proximal femoral geometry at the narrow neck, intertrochanteric and femoral shaft regions. There were significant (p < 0.001) associations between pQCT-derived measures of bone geometry (tibial width; endocortical diameter and cortical thickness) and bone strength (strength strain index) with each corresponding HSA variable (all p < 0.001) in both men and women. These results demonstrate strong correlations between two different methods of assessment of lower limb bone strength: HSA and pQCT. Validation in prospective cohorts to study associations of each with incident fracture is now indicated.

BACKGROUND: Anti‐fungals are available for oral and intra‐vaginal treatment of uncomplicated vulvovaginal candidiasis. OBJECTIVES: The primary objective of this review is to assess the relative effectiveness (clinical cure) of oral versus intra‐vaginal anti‐fungals for the treatment of uncomplicated vulvovaginal candidiasis. Secondary objectives include the assessment of the relative effectiveness in terms of mycological cure, in addition to safety, side effects, treatment preference, time to first relief of symptoms, and costs. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, and two trials registers on 29 August 2019 together with reference checking and citation searching. SELECTION CRITERIA: We included randomised controlled trials published in any language comparing at least one oral anti‐fungal with one intra‐vaginal anti‐fungal in women (aged 16 years or over) with a mycological diagnosis (positive culture, microscopy for yeast, or both) of uncomplicated vulvovaginal candidiasis. We excluded trials if they solely involved participants who were HIV positive, immunocompromised, pregnant, breast feeding or diabetic. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures as recommended by Cochrane. MAIN RESULTS: This review includes 26 trials (5007 participants). Eight anti‐fungals are represented. All but three trials included participants with acute vulvovaginal candidiasis. Trials were conducted in Europe: UK (3), Croatia (2). Finland (2), the Netherlands (2), Germany (1), Italy (1), Sweden (1) and one trial across multiple European countries, USA (7) Thailand (2), Iran (2), Japan (1) and Africa (Nigeria) (1). The duration of follow‐up varied between trials. The overall risk of bias of the included trials was high. There was probably little or no difference shown between oral and intra‐vaginal anti‐fungal treatment for clinical cure at short‐term follow‐up (OR 1.14, 95% CI 0.91 to 1.43; 13 trials; 1859 participants; moderate‐certainty evidence) and long‐term follow‐up (OR 1.07, 95% CI 0.77 to 1.50; 9 trials; 1042 participants; moderate‐certainty evidence). The evidence suggests that if the rate of clinical cure at short‐term follow‐up with intra‐vaginal treatment is 77%, the rate with oral treatment would be between 75% and 83%; if the rate of clinical cure at long term follow‐up with intra‐vaginal treatment is 84%, the rate with oral treatment would be between 80% and 89%. Oral treatment probably improves mycological cure over intra‐vaginal treatment at short term (OR 1.24, 95% CI 1.03 to 1.50: 19 trials; 3057 participants; moderate‐certainty evidence) and long‐term follow‐up (OR 1.29, 95% CI 1.05 to 1.60; 13 trials; 1661 participants; moderate‐certainty evidence). The evidence suggests that if the rate of mycological cure at short‐term follow‐up with intra‐vaginal treatment is 80%, the rate with oral treatment would be between 80% and 85%; if the rate of mycological cure at long‐term follow‐up with intra‐vaginal treatment is 66%, the rate with oral treatment would be between 67% and 76%. In terms of patient safety, there is a low risk of participants withdrawing from the studies due to adverse drug effects for either treatment (23 trials; 4637 participants; high‐certainty evidence). Due to the low certainty of evidence, it is undetermined whether oral treatments reduced the number of side effects compared with intra‐vaginal treatments (OR 1.04, 95% CI 0.84 to 1.29; 16 trials; 3155 participants; low‐certainty evidence). The evidence suggests that if the rate of side effects with intra‐vaginal treatment is 12%, the rate with oral treatment would be between 10% and 15%. We noted that the type of side effects differed, with intra‐vaginal treatments being more often associated with local reactions, and oral treatments being more often associated with systemic effects including gastro‐intestinal symptoms and headaches. Oral treatment appeared to be the favoured treatment preference over intra‐vaginal treatment or no preference (12 trials; 2206 participants), however the data were poorly reported and the certainty of the evidence was low. There was little or no difference in time to first relief of symptoms between oral and intra‐vaginal treatments: four trials favoured the oral treatment, four favoured intra‐vaginal, one study reported no difference and one was unclear. The measurements varied between the 10 trials (1910 participants) and the certainty of the evidence was low. Costs were not reported in any of the trials. AUTHORS' CONCLUSIONS: Oral anti‐fungal treatment probably improves short‐ and long‐term mycological cure over intra‐vaginal treatment for uncomplicated vaginal candidiasis. Oral treatment was the favoured treatment preference by participants, though the certainty of this evidence is low. The decision to prescribe or recommend an anti‐fungal for oral or intra‐vaginal administration should take into consideration safety in terms of withdrawals and side effects, as well as cost and treatment preference. Unless there is a previous history of adverse reaction to one route of administration or contraindications, women who are purchasing their own treatment should be given full information about the characteristics and costs of treatment to make their own decision. If health services are paying the treatment cost, decision‐makers should consider whether the higher cost of some oral anti‐fungals is worth the gain in convenience, if this is the patient's preference.