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Preview: Journal of Epidemiology & Community Health current issue

Journal of Epidemiology & Community Health current issue



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Tackling Obesities: 10 years on

2018-01-11T04:10:28-08:00

Ten years ago, the report ‘Tackling obesities: future choices’1 was published. Commissioned under the then Labour government and prepared by the Foresight group within the Government Office for Science, it framed obesity as an emergent outcome of a complex system. This approach makes clear that there are multiple complex interacting influences on weight status—many of which lie outside the direct control of individuals or the health sector—that both drive and are driven by socioeconomic and other inequalities.

The Foresight report has had a far-reaching impact on both obesity science and policy since its publication, and remains highly influential, with 60% of its citations occurring in the last 4 years.i The report has yet to be superseded in its scope of examining the underlying causes of obesity, encompassing a broad range of influences including individual, social, psychological, economic, commercial and environmental factors. A complex systems approach accounts...




Associations between objectively measured physical activity and later mental health outcomes in children: findings from the UK Millennium Cohort Study

2018-01-11T04:10:28-08:00

Background

The beneficial effect of physical activity (PA) on mental health in adults is well established, but less is known about this relationship in children. We examine associations between objectively measured sedentary time, PA and mental health in 11-year-olds from the UK Millennium Cohort Study (MCS).

Methods

Longitudinal data from MCS sweeps 4 (age 7) and 5 (age 11) were used (n=6153). Accelerometer data were collected at MCS4, and mental health was measured at MCS4 and MCS5 using subscales (peer, emotional, conduct, hyperactivity) of the Strengths and Difficulties Questionnaire (SDQ). Associations between mean daily PA minutes at different intensities (sedentary, light, moderate-to-vigorous) at MCS4 and SDQ outcomes at MCS5 (score range 0–10) were estimated using multiple linear regression models, adjusting for SDQ at MCS4 and individual and family characteristics, and stratified by gender.

Results

In fully adjusted models, increased PA at MCS4 was associated with fewer peer problems in boys and girls at MCS5. For each additional 15 min in moderate-to-vigorous physical activity (MVPA), peer problems decreased –0.077 points (95% CI –0.133 to –0.022) in boys. For girls, light PA was associated with decreased peer problems (–0.071 points/30 min, 95% CI –0.130 to –0.013). Greater sedentary time was associated with more peer problems and fewer hyperactivity symptoms in boys and girls. Increased MVPA was associated with more conduct and hyperactivity problems in boys and more hyperactivity in girls.

Conclusions

Increased sedentary time is associated with more peer problems in children, and PA, generally, is beneficial for peer relations in children aged 11.




Trends in adolescent mental health during economic upturns and downturns: a multilevel analysis of Swedish data 1988-2008

2018-01-11T04:10:28-08:00

Background

A long-term trend of increasing mental health problems among adolescents in many Western countries indicates a great need to investigate if and how societal changes have contributed to the reported increase. Using seven waves of repeated cross-sectional data collected between 1988 and 2008 in Sweden, the current study examined if economic factors at the societal level (municipality unemployment rate) and at the individual level (worry about family finances), and their interaction could explain a secular trend in mental health problems.

Methods

Participants were 17 533 students of age 15–16 years (49.3% girls), from 14 municipalities in a county of Sweden. Data on adolescents’ mental health (psychosomatic problems) and worry about family finances were obtained using a self-report questionnaire. A series of multilevel regression analyses were conducted in order to explain the trends in adolescents’ mental health.

Results

The results indicated that the individual-level predictor (worry about family finances) significantly explained the increasing rates of adolescents’ psychosomatic problems. This was particularly the case during the mid-1990s, which was characterised by a severe recession in Sweden with high unemployment rates. For example, after accounting for adolescents’ worry, a significant increase in psychosomatic symptoms between 1988 and 1998 among girls (b=0.112, P<0.05) disappeared (b=0.018, P>0.05) and a non-significant decrease between 1988 and 1995 among boys (b=–0.017, P>0.05) became significant (b=–0.142, P<0.05). Neither municipality unemployment rate nor its interaction with adolescents’ worry explained psychosomatic problems.

Conclusions

The findings demonstrate the effects of adolescents’ worry about family finances on a secular trend in mental health problems during an economically bleak period of time. The study highlights the need for repeated measurements including a large number of time points over a long time period in order to analyse time-specific putative explanatory factors for trends in adolescent mental health problems.




Do patients who die from an alcohol-related condition 'drift into areas of greater deprivation? Alcohol-related mortality and health selection theory in Scotland

2018-01-11T04:10:28-08:00

Background

Health selection has been proposed to explain the patterning of alcohol-related mortality by area deprivation. This study investigated whether persons who die from alcohol-related conditions are more likely to experience social drift than those who die from other causes.

Methods

Deaths recorded in Scotland (2013, >21 years) were coded as ‘alcohol-related’ or ‘other’ and by deprivation decile of residence at death. Acute hospital admissions data from 1996 to 2012 were used to provide premortality deprivation data. ² tests estimated the difference between observed and expected alcohol-related deaths by first Scottish Index of Multiple Deprivation (SIMD) decile and type of death. Logistic regression models were fitted using type of death as the outcome of interest and change in SIMD decile as the exposure of interest.

Results

Of 47 012 deaths, 1458 were alcohol-related. Upward and downward mobility was observed for both types of death. An estimated 31 more deaths than expected were classified ‘alcohol-related’ among cases whose deprivation score decreased, while 204 more deaths than expected were classified ‘alcohol-related’ among cases whose initial deprivation ranking was in the four most deprived deciles. Becoming more deprived and first deprivation category were both associated with increased odds of type of death being alcohol-related after adjusting for confounders.

Conclusion

This study suggests that health selection appears to contribute less to the deprivation gradient in alcohol-related mortality in Scotland than an individual’s initial area deprivation category.




Association between psychosocial work conditions and latent alcohol consumption trajectories among men and women over a 16-year period in a national Canadian sample

2018-01-11T04:10:28-08:00

Background

It is unclear how psychosocial working conditions influence future alcohol consumption. Using group-based trajectory modelling, this study aimed to determine: the number of latent alcohol consumption trajectories over 16 years in a representative sample of the Canadian workforce; the association between psychosocial working conditions and longitudinal alcohol consumption; and if the association between psychosocial work factors and longitudinal alcohol consumption differed among men and women.

Methods

We included 5458 employed adults from the longitudinal Canadian National Population Health Survey. Average daily alcohol consumption was measured every 2 years from 1994 to 2010. Psychosocial work factors were measured in 1994 using the Job Content Questionnaire. Group-based trajectory modelling was used to derive the appropriate number of alcohol behaviour trajectories. The association between psychosocial work factors and alcohol trajectory membership was estimated using multinomial logistic regression. Models were stratified by sex to determine if these associations differed among men and women.

Results

Three alcohol consumption trajectories were present: non-drinkers, light drinkers (0.5–1 drinks/day) and moderate drinkers (2–3 drinks/day). Higher workplace physical exertion and lower social support levels were associated with membership in the moderate drinking trajectory. Among men, lower psychological demands and higher physical exertion levels were associated with membership in the moderate drinking trajectory. Among women, lower levels of physical exertion were associated with membership in the light drinking trajectory, and higher psychological demand levels were associated with membership in the moderate drinking trajectory.

Conclusions

Our study suggests that workplace physical exertion and psychological demands may be associated with different alcohol consumption trajectories among men and women.




Investigating associations between the built environment and physical activity among older people in 20 UK towns

2018-01-11T04:10:28-08:00

Background

Policy initiatives such as WHO Age Friendly Cities recognise the importance of the urban environment for improving health of older people, who have both low physical activity (PA) levels and greater dependence on local neighbourhoods. Previous research in this age group is limited and rarely uses objective measures of either PA or the environment.

Methods

We investigated the association between objectively measured PA (Actigraph GT3x accelerometers) and multiple dimensions of the built environment, using a cross-sectional multilevel linear regression analysis. Exposures were captured by a novel foot-based audit tool that recorded fine-detail neighbourhood features relevant to PA in older adults, and routine data.

Results

795 men and 638 women aged 69–92 years from two national cohorts, covering 20 British towns, were included in the analysis. Median time in moderate to vigorous PA (MVPA) was 27.9 (lower quartile: 13.8, upper quartile: 50.4) minutes per day. There was little evidence of associations between any of the physical environmental domains (eg, road and path quality defined by latent class analysis; number of bus stops; area aesthetics; density of shops and services; amount of green space) and MVPA. However, analysis of area-level income deprivation suggests that the social environment may be associated with PA in this age group.

Conclusions

Although small effect sizes cannot be discounted, this study suggests that older individuals are less affected by their local physical environment and more by social environmental factors, reflecting both the functional heterogeneity of this age group and the varying nature of their activity spaces.




Association between individual and neighbourhood socioeconomic factors and masticatory efficiency: a cross-sectional analysis of the Paris Prospective Study 3

2018-01-11T04:10:28-08:00

Background

There is a lack of evidence on the impact of socioeconomic factors on masticatory efficiency. The present study investigates the relationship between individual and neighbourhood socioeconomic factors (main exposure) and the number of masticatory units (MUs) used as surrogate of the masticatory efficiency (main outcome).

Methods

In this cross-sectional study nested in the Paris Prospective Study 3, 4270 adults aged 50–75 and recruited from 13 June 2008 to 31 May 2012 underwent a full-mouth examination. Number of MUs defined as pairs of opposing teeth or dental prostheses allowing mastication, number of missing teeth and gingival inflammation were documented. The individual component of the socioeconomic status was evaluated with an individual multidimensional deprivation score and education level. The neighbourhood component of the socioeconomic status was evaluated with the FDep99 deprivation index. Associations were quantified using marginal models.

Results

In multivariate analyses, having less than 5 MUs was associated with (1) the most deprived neighbourhoods (OR=2.27 (95% CI 1.63 to 3.17)), (2) less than 12 years of educational attainment (OR=2.20 (95% CI 1.66 to 2.92)) and (3) the highest individual score of deprivation (OR=3.23 (95% CI 2.24 to 4.65)). Associations with education and individual score of deprivation were consistent across the level of neighbourhood deprivation. Comparable associations were observed with the number of missing teeth. Associations with gingival inflammation were of lower magnitude; the relationship was present for deprivation markers but not for education.

Conclusion

Poor masticatory efficiency is associated with low educational attainment and high deprivation scores.




Geographical epidemiology of health and overall deprivation in England, its changes and persistence from 2004 to 2015: a longitudinal spatial population study

2018-01-11T04:10:28-08:00

Background

Socioeconomic deprivation is a key determinant for health. In England, the Index of Multiple Deprivation (IMD) is a widely used composite measure of deprivation. However, little is known about its spatial clustering or persistence across time.

Methods

Data for overall IMD and its health domain were analysed for 2004–2015 at a low geographical area (average of 1500 people). Levels and temporal changes were spatially visualised for the whole of England and its 10 administrative regions. Spatial clustering was quantified using Moran’s I, correlations over time were quantified using Pearson’s r.

Results

Between 2004 and 2015 we observed a strong persistence for both overall (r=0.94) and health-related deprivation (r=0.92). At the regional level, small changes were observed over time, but with areas slowly regressing towards the mean. However, for the North East, North West and Yorkshire, where health-related deprivation was the highest, the decreasing trend in health-related deprivation reversed and we noticed increases in 2015. Results did not support our hypothesis of increasing spatial clustering over time. However, marked regional variability was observed in both aggregate deprivation outcomes. The lowest autocorrelation was seen in the North East and changed very little over time, while the South East had the highest autocorrelation at all time points.

Conclusions

Overall and health-related deprivation patterns persisted in England, with large and unchanging health inequalities between the North and the South. The spatial aspect of deprivation can inform the targeting of health and social care interventions, particularly in areas with high levels of deprivation clustering.




Methodological, political and legal issues in the assessment of the effects of nanotechnology on human health

2018-01-11T04:10:28-08:00

Engineered nanomaterials (ENMs) raise questions among the scientific community and public health authorities about their potential risks to human health. Studying a prospective cohort of workers exposed to ENMs would be considered the gold standard for identifying potential health effects of nanotechnology and confirming the ‘no effect’ levels derived from cellular and animal models. However, because only small, cross-sectional studies have been conducted in the past 5 years, questions remain about the health risks of ENMs. This essay addresses the scientific, methodological, political and regulatory issues that make epidemiological research in nanotechnology-exposed communities particularly complex. Scientific challenges include the array of physicochemical parameters and ENM production conditions, the lack of universally accepted definitions of ENMs and nanotechnology workers, and the lack of information about modes of action, target organs and likely dose–response functions of ENMs. Standardisation of data collection and harmonisation of research protocols are needed to eliminate misclassification of exposures and health effects. Forming ENM worker cohorts from a combination of smaller cohorts and overcoming selection bias are also challenges. National or international registries for monitoring the exposures and health of ENM workers would be helpful for epidemiological studies, but the creation of such a registry and ENM worker cohorts will require political support and dedicated funding at the national and international levels. Public authorities and health agencies should consider carrying out an ENM awareness campaign to educate and engage all stakeholders and concerned communities in discussion of such a project.




Pathways of undue influence in health policy-making: a main actors perspective

2018-01-11T04:10:28-08:00

Background

It is crucial to know the extent to which influences lead to policy capture—by which the policy-making process is shifted away from the public interest towards narrow private interests. Using the case study of Spain, our aim was to identify interactions between public administration, civil society and private companies that could influence health policies.

Methods

54 semistructured interviews with key actors related to health policy. The interviews were used to gather information on main policy actors as well as on direct and subtle influences that could modify health policies. The analysis identified and described, from the interviewed persons’ experiences, both the inappropriate influences exerted on the actors and those that they exerted.

Results

Inappropriate influences were identified at all levels of administration and policy. They included actions for personal benefits, pressure for blocking health policies and pressure from high levels of government in favour of private corporations. The private sector played a significant role in these strategies through bribery, personal gifts, revolving doors, negative campaigns and by blocking unfavourable political positions or determining the knowledge agenda. The interviewees reported subtle forms of influence (social events, offers of technical support, invitations, etc) that contributed to the intellectual and cultural capture of health officials.

Conclusion

The health policy decision-making processes in Spain are subject to influences by stakeholders that determine a degree of policy capture, which is avoidable. The private sector uses different strategies, from subtle influences to outright corruption, taking advantage in many cases of flexible legislation.




Do socioeconomic inequalities in pain, psychological distress and oral health increase or decrease over the life course? Evidence from Sweden over 43 years of follow-up

2018-01-11T04:10:28-08:00

Background

Inequalities over the life course may increase due to accumulation of disadvantage or may decrease because ageing can work as a leveller. We report how absolute and relative socioeconomic inequalities in musculoskeletal pain, oral health and psychological distress evolve with ageing.

Methods

Data were combined from two nationally representative Swedish panel studies: the Swedish Level-of-Living Survey and the Swedish Panel Study of Living Conditions of the Oldest Old. Individuals were followed up to 43 years in six waves (1968, 1974, 1981, 1991/1992, 2000/2002, 2010/2011) from five cohorts: 1906–1915 (n=899), 1925–1934 (n=906), 1944–1953 (n=1154), 1957–1966 (n=923) and 1970–1981 (n=1199). The participants were 15–62 years at baseline. Three self-reported outcomes were measured as dichotomous variables: teeth not in good conditions, psychological distress and musculoskeletal pain. The fixed-income groups were: (A) never poor and (B) poor at least once in life. The relationship between ageing and the outcomes was smoothed with locally weighted ordinary least squares, and the relative and absolute gaps were calculated with Poisson regression using generalised estimating equations.

Results

All outcomes were associated with ageing, birth cohort, sex and being poor at least once in live. Absolute inequalities increased up to the age of 45–64 years, and then they decreased. Relative inequalities were large already in individuals aged 15–25 years, showing a declining trend over the life course. Selective mortality did not change the results. The socioeconomic gap was larger for current poverty than for being poor at least once in life.

Conclusion

Inequalities persist into very old age, though they are more salient in midlife for all three outcomes observed.




High percentage of undiagnosed HIV cases within a hyperendemic South African community: a population-based study

2018-01-11T04:10:28-08:00

Background

Undiagnosed HIV infections could undermine efforts to reverse the global AIDS epidemic by 2030. In this study, we estimated the percentage of HIV-positive persons who remain undiagnosed within a hyperendemic South African community.

Methods

The data come from a population-based surveillance system located in the Umkhanyakude district of the northern KwaZulu-Natal province, South Africa. We annually tested 38 661 adults for HIV between 2005 and 2016. Using the HIV-positive test results of 12 039 (31%) participants, we then back-calculated the incidence of infection and derived the number of undiagnosed cases from this result.

Results

The percentage of undiagnosed HIV cases decreased from 29.3% in 2005 to 15.8% in 2011. During this period, however, approximately 50% of the participants refused to test for HIV, which lengthened the average time from infection to diagnosis. Consequently, the percentage of undiagnosed HIV cases reversed direction and steadily increased from 16.1% to 18.9% over the 2012–2016 period.

Conclusions

Results from this hyperendemic South African setting show that the HIV testing rate is low, with long infection times, and an unsatisfactorily high percentage of undiagnosed cases. A high level of repeat HIV testing is needed to minimise the time from infection to diagnosis if the global AIDS epidemic is to be reversed within the next two decades.




Generalisability of an online randomised controlled trial: an empirical analysis

2018-01-11T04:10:28-08:00

Background

Investigators increasingly use online methods to recruit participants for randomised controlled trials (RCTs). However, the extent to which participants recruited online represent populations of interest is unknown. We evaluated how generalisable an online RCT sample is to men who have sex with men in China.

Methods

Inverse probability of sampling weights (IPSW) and the G-formula were used to examine the generalisability of an online RCT using model-based approaches. Online RCT data and national cross-sectional study data from China were analysed to illustrate the process of quantitatively assessing generalisability. The RCT (identifier NCT02248558) randomly assigned participants to a crowdsourced or health marketing video for promotion of HIV testing. The primary outcome was self-reported HIV testing within 4 weeks, with a non-inferiority margin of –3%.

Results

In the original online RCT analysis, the estimated difference in proportions of HIV tested between the two arms (crowdsourcing and health marketing) was 2.1% (95% CI, –5.4% to 9.7%). The hypothesis that the crowdsourced video was not inferior to the health marketing video to promote HIV testing was not demonstrated. The IPSW and G-formula estimated differences were –2.6% (95% CI, –14.2 to 8.9) and 2.7% (95% CI, –10.7 to 16.2), with both approaches also not establishing non-inferiority.

Conclusions

Conducting generalisability analysis of an online RCT is feasible. Examining the generalisability of online RCTs is an important step before an intervention is scaled up.

Trial registration number

NCT02248558.