Latest from IP

Age, period and cohort effects on the incidence of motorcyclist casualties in traffic crashes [ORIGINAL ARTICLE]

Sat, 1 Jun 2013 00:00:00 +0000

Objectives(1) Estimate age, period and cohort effects for motorcyclist traffic casualties 1979-2008 in New Zealand and (2) forecast the incidence of New Zealand motorcycle traffic casualties for the period 2019-2023 assuming future age, cohort and period effects, and compare these with an estimate based on simple linear extrapolation. MethodsAge-period-cohort (APC) modelling was used to estimate the individual effects of age, period and cohort after adjusting for the other two factors. Forecasting was produced for three period-effect scenarios. ResultsAfter adjusting for cohort and period effects, 15-19-year-olds have substantially elevated risk. The period effect reduced in significance over time until the last period, 2004-2008, where the risk was higher than the preceding period. The 10-year cohorts born 1949-1958, 1954-1963, 1959-1968 and 1964-1973, had elevated risk. The forecasting, based on APC modelling, resulted in the lowest estimates of the future incidence being approximately one-third that of the highest estimate (6641). ConclusionTrends in motorcycle casualties have been influenced by significant independent age, period and cohort effects. These need to be considered in forecasting future casualties. The selection of the period effect has a significant impact on the estimates. Which period-effect scenario readers choose to accept depends on their views about a wide range of factors which might influence motorcycle use and crash risk over time.

Effectiveness of breed-specific legislation in decreasing the incidence of dog-bite injury hospitalisations in people in the Canadian province of Manitoba [ORIGINAL ARTICLE]

Sat, 1 Jun 2013 00:00:00 +0000

BackgroundThe city of Winnipeg was the first among several jurisdictions in Manitoba, Canada, to introduce breed specific legislation (BSL) by banning pit-bull type dogs in 1990. The objective of the present work was to study the effectiveness of BSL in Manitoba. MethodsTemporal differences in incidence of dog-bite injury hospitalisations (DBIH) within and across Manitoba jurisdictions with and without BSL were compared. Incidence was calculated as the number of unique cases of DBIH divided by the total person-years at risk and expressed as the number per 100 000 person-years. Year of implementation determined the pre-BSL and post-BSL period for jurisdictions with BSL; for jurisdictions without BSL to date, the entire study period (1984-2006) was considered as the preimplementation period. The annual number of DBIH, adjusted for total population at risk, was modelled in a negative binomial regression analysis with repeated measures. Year, jurisdiction and BSL implementation were independent variables. An interaction term between jurisdiction and BSL was introduced. ResultsA total of 16 urban and rural jurisdictions with pit-bull bans were identified. At the provincial level, there was a significant reduction in DBIH rates from the pre-BSL to post-BSL period (3.47 (95% CI 3.17 to 3.77) per 100 000 person-years to 2.84 (95% CI 2.53 to 3.15); p=0.005). In regression restricted to two urban jurisdictions, DBIH rate in Winnipeg relative to Brandon (a city without BSL) was significantly (p<0.001) lower after BSL (rate ratio (RR)=1.10 in people of all ages and 0.92 in those aged <20 years) than before (RR=1.29 and 1.28, respectively). ConclusionsBSL may have resulted in a reduction of DBIH in Winnipeg, and appeared more effective in protecting those aged <20 years.

'The body we leave behind': a qualitative study of obstacles and opportunities for increasing uptake of male circumcision among Tanzanian Christians [RESEARCH]

Thu, 16 May 2013 00:00:00 +0000

ObjectivesMale circumcision (MC) reduces HIV infection by approximately 60% among heterosexual men and is recommended by the WHO for HIV prevention in sub-Saharan Africa. In northwest Tanzania, over 60% of Muslims but less than 25% of Christian men are circumcised. We hypothesised that the decision to circumcise may be heavily influenced by religious identity and that specific religious beliefs may offer both obstacles and opportunities to increasing MC uptake, and conducted focus group discussions to explore reasons for low rates of MC among Christian church attenders in the region. DesignQualitative study using focus group discussions and interpretative phenomenological analysis. SettingDiscussions took place at churches in both rural and urban areas of the Mwanza region of northwest Tanzania. ParticipantsWe included 67 adult Christian churchgoers of both genders in a total of 10 single-gender focus groups. ResultsChristians frequently reported perceiving MC as a Muslim practice, as a practice for the sexually promiscuous, or as unnecessary since they are taught to focus on circumcision of the heart'. Only one person had ever heard MC discussed at church, but nearly all Christian parishioners were eager for their churches to address MC and felt that MC could be consistent with their faith. ConclusionsChristian religious beliefs among Tanzanian churchgoers provide both obstacles and opportunities for increasing uptake of MC. Since half of adults in sub-Saharan Africa identify themselves as Christians, addressing these issues is critical for MC efforts in this region.

Identifying HIV most-at-risk groups in Malawi for targeted interventions. A classification tree model [RESEARCH]

Thu, 16 May 2013 00:00:00 +0000

ObjectivesTo identify HIV-socioeconomic predictors as well as the most-at-risk groups of women in Malawi. DesignA cross-sectional survey. SettingMalawi ParticipantsThe study used a sample of 6395 women aged 15-49 years from the 2010 Malawi Health and Demographic Surveys. InterventionsN/A Primary and secondary outcome measuresIndividual HIV status: positive or not. ResultsFindings from the Pearson {chi}2 and {chi}2 Automatic Interaction Detector analyses revealed that marital status is the most significant predictor of HIV. Women who are no longer in union and living in the highest wealth quintiles households constitute the most-at-risk group, whereas the less-at-risk group includes young women (15-24) never married or in union and living in rural areas. ConclusionsIn the light of these findings, this study recommends: (1) that the design and implementation of targeted interventions should consider the magnitude of HIV prevalence and demographic size of most-at-risk groups. Preventive interventions should prioritise couples and never married people aged 25-49 years and living in rural areas because this group accounts for 49% of the study population and 40% of women living with HIV in Malawi; (2) with reference to treatment and care, higher priority must be given to promoting HIV test, monitoring and evaluation of equity in access to treatment among women in union disruption and never married or women in union aged 30-49 years and living in urban areas; (3) community health workers, households-based campaign, reproductive-health services and reproductive-health courses at school could be used as canons to achieve universal prevention strategy, testing, counselling and treatment.

Effects of train noise and vibration on human heart rate during sleep: an experimental study [RESEARCH]

Thu, 16 May 2013 00:00:00 +0000

ObjectivesTransportation of goods on railways is increasing and the majority of the increased numbers of freight trains run during the night. Transportation noise has adverse effects on sleep structure, affects the heart rate (HR) during sleep and may be linked to cardiovascular disease. Freight trains also generate vibration and little is known regarding the impact of vibration on human sleep. A laboratory study was conducted to examine how a realistic nocturnal railway traffic scenario influences HR during sleep. DesignCase-control. SettingHealthy participants. Participants24 healthy volunteers (11 men, 13 women, 19-28 years) spent six consecutive nights in the sleep laboratory. InterventionsAll participants slept during one habituation night, one control and four experimental nights in which train noise and vibration were reproduced. In the experimental nights, 20 or 36 trains with low-vibration or high-vibration characteristics were presented. Primary and secondary outcome measuresPolysomnographical data and ECG were recorded. ResultsThe train exposure led to a significant change of HR within 1 min of exposure onset (p=0.002), characterised by an initial and a delayed increase of HR. The high-vibration condition provoked an average increase of at least 3 bpm per train in 79% of the participants. Cardiac responses were in general higher in the high-vibration condition than in the low-vibration condition (p=0.006). No significant effect of noise sensitivity and gender was revealed, although there was a tendency for men to exhibit stronger HR acceleration than women. ConclusionsFreight trains provoke HR accelerations during sleep, and the vibration characteristics of the trains are of special importance. In the long term, this may affect cardiovascular functioning of persons living close to railways.

Adjusting the obesity thresholds for self-reported BMI in Ireland: a cross-sectional analysis [RESEARCH]

Thu, 16 May 2013 00:00:00 +0000

ObjectiveTo investigate the optimal adjustment to be made to obesity thresholds when using self-reported body mass index (BMI). DesignA cross-sectional study. SettingData from the Survey of Lifestyle, Attitudes and Nutrition in Ireland, a nationally representative dataset using the Geodirectory (a listing of all residential addresses in Ireland compiled by the postal service) as the sampling frame. ParticipantsA nationally representative sample of 10 364 adults aged 18+, carried out by face-to-face interview with clinical measurement applied to a number of outcomes to a representative subsample of 2174. After discarding the observations with missing values and errors, the eventual sample was 1874. Primary and secondary outcome measuresBMI based on measured and self-reported weight and height. BackgroundIt is generally found that self-reported BMI understates true or measured BMI and accordingly revised obesity thresholds have been suggested. MethodsData from the 2007 Survey of Lifestyles, Attitudes and Nutrition in Ireland were used to analyse self-reported and measured BMI. The self-reported BMI threshold was adjusted to obtain the optimal signal for measured BMI using different criteria viz. efficiency (maximum number of correct classifications), maximisation of Youden's J, maximisation of OR, minimisation of cost of misclassification and constrained optimisation. ResultsThe optimal threshold differed substantially depending on the criterion adopted for choosing it, with thresholds of 29.1 (efficiency criterion), 27.5 (Youden's J) and 26.0 (FN rate of 5%). Standard criteria such as Youden's J index were shown to implicitly impose relative costs of false-negatives and false-positives which may not always correspond to the values of the analyst. ConclusionsWhen adjusting self-reported BMI thresholds in order to obtain the optimal signal for true' obesity, analysts should explicitly choose the relative costs of false-positives and false-negatives.

Assessing the short-term outcomes of a community-based intervention for overweight and obese children: The MEND 5-7 programme [RESEARCH]

Thu, 16 May 2013 00:00:00 +0000

ObjectiveThe aim of this study was to report outcomes of the UK service level delivery of MEND (Mind,Exercise,Nutrition...Do it!) 5-7, a multicomponent, community-based, healthy lifestyle intervention designed for overweight and obese children aged 5-7 years and their families. DesignRepeated measures. SettingCommunity venues at 37 locations across the UK. Participants440 overweight or obese children (42% boys; mean age 6.1 years; body mass index (BMI) z-score 2.86) and their parents/carers participated in the intervention. InterventionMEND 5-7 is a 10-week, family-based, child weight-management intervention consisting of weekly group sessions. It includes positive parenting, active play, nutrition education and behaviour change strategies. The intervention is designed to be scalable and delivered by a range of health and social care professionals. Primary and secondary outcome measuresThe primary outcome was BMI z-score. Secondary outcome measures included BMI, waist circumference, waist circumference z-score, children's psychological symptoms, parenting self-efficacy, physical activity and sedentary behaviours and the proportion of parents and children eating five or more portions of fruit and vegetables. Results274 (62%) children were measured preintervention and post-intervention (baseline; 10-weeks). Post-intervention, mean BMI and waist circumference decreased by 0.5 kg/m2 and 0.9 cm, while z-scores decreased by 0.20 and 0.20, respectively (p<0.0001). Improvements were found in children's psychological symptoms (-1.6 units, p<0.0001), parent self-efficacy (p<0.0001), physical activity (+2.9 h/week, p<0.01), sedentary activities (-4.1 h/week, p<0.0001) and the proportion of parents and children eating five or more portions of fruit and vegetables per day (both p<0.0001). Attendance at the 10 sessions was 73% with a 70% retention rate. ConclusionsParticipation in the MEND 5-7 programme was associated with beneficial changes in physical, behavioural and psychological outcomes for children with complete sets of measurement data, when implemented in UK community settings under service level conditions. Further investigation is warranted to establish if these findings are replicable under controlled conditions.

Evidence-based commissioning in the English NHS: who uses which sources of evidence? A survey 2010/2011 [RESEARCH]

Thu, 16 May 2013 00:00:00 +0000

ObjectivesTo investigate types of evidence used by healthcare commissioners when making decisions and whether decisions were influenced by commissioners' experience, personal characteristics or role at work. DesignCross-sectional survey of 345 National Health Service (NHS) staff members. SettingThe study was conducted across 11 English Primary Care Trusts between 2010 and 2011. ParticipantsA total of 440 staff involved in commissioning decisions and employed at NHS band 7 or above were invited to participate in the study. Of those, 345 (78%) completed all or a part of the survey. Main outcome measuresParticipants were asked to rate how important different sources of evidence (empirical or practical) were in a recent decision that had been made. Backwards stepwise logistic regression analyses were undertaken to assess the contributions of age, gender and professional background, as well as the years of experience in NHS commissioning, pay grade and work role. ResultsThe extent to which empirical evidence was used for commissioning decisions in the NHS varied according to the professional background. Only 50% of respondents stated that clinical guidelines and cost-effectiveness evidence were important for healthcare decisions. Respondents were more likely to report use of empirical evidence if they worked in Public Health in comparison to other departments (p<0.0005, commissioning and contracts OR 0.32, 95%CI 0.18 to 0.57, finance OR 0.19, 95%CI 0.05 to 0.78, other departments OR 0.35, 95%CI 0.17 to 0.71) or if they were female (OR 1.8 95% CI 1.01 to 3.1) rather than male. Respondents were more likely to report use of practical evidence if they were more senior within the organisation (pay grade 8b or higher OR 2.7, 95%CI 1.4 to 5.3, p=0.004 in comparison to lower pay grades). ConclusionsThose trained in Public Health appeared more likely to use external empirical evidence while those at higher pay scales were more likely to use practical evidence when making commissioning decisions. Clearly, National Institute for Clinical Excellence (NICE) guidance and government publications (eg, National Service Frameworks) are important for decision-making, but practical sources of evidence such as local intelligence, benchmarking data and expert advice are also influential. New Clinical Commissioning Groups will need a variety of different evidence sources and expert involvement to ensure that effective decisions are made for their populations.

Validation of a questionnaire measuring preschool children's reactions to and coping with noise in a repeated measurement design [RESEARCH]

Thu, 16 May 2013 00:00:00 +0000

ObjectivesThe aim of the study was to explore and describe the reliability and validity of an instrument to measure preschool children's reactions to and coping with indoor noise at preschools or day care centres. DesignData were derived from an acoustical before and after intervention study providing repeated measurements. SettingThe study was performed at seven preschools in Molndal, Sweden. ParticipantsChildren were recruited from these preschools and the final sample comprised 61 and 59 preschool children aged 4-5 years, with a response rate of 98% and 48% girls and 52% boys. Two children were excluded from analysis because they fell outside the age range. Primary and secondary outcome measuresThe instrument was developed based on a qualitative study performed in Swedish preschools. Questions pertained to preschool children's perception of noise when at school, their bodily and emotional reactions to it, non-specific symptoms and the coping strategies used by them to diminish the detrimental effects of the noise. ResultsConfirmative factor analysis yielded a three-factor model fitted to 10 items pertaining to angry reactions, symptoms and coping. The model fit was moderate to good (standardised root mean square residual=0.08, 0.12; adjusted goodness of fit=0.97/0.91) in the before and after conditions, respectively. The scales showed moderate to good reliability in terms of internal consistency, with an ranging between 0.52 and 0.67, and was stronger in the before condition. Concurrent validity was strongest for symptoms by comparing groups based on bodily reaction (general and sound specific). ConclusionsYoung children's emotional and bodily reactions to coping with noise can be reliably measured with this instrument. Like adults and older children, young children are able to distinguish between emotional reactions, bodily reactions, coping and unwell-being. Future research on larger groups of preschool children is needed to further refine the questions, in particular the questions pertaining to well-being.

Bed sharing when parents do not smoke: is there a risk of SIDS? An individual level analysis of five major case-control studies [RESEARCH]

Thu, 16 May 2013 00:00:00 +0000

ObjectiveTo resolve uncertainty as to the risk of Sudden Infant Death Syndrome (SIDS) associated with sleeping in bed with your baby if neither parent smokes and the baby is breastfed. DesignBed sharing was defined as sleeping with a baby in the parents' bed; room sharing as baby sleeping in the parents' room. Frequency of bed sharing during last sleep was compared between babies who died of SIDS and living control infants. Five large SIDS case-control datasets were combined. Missing data were imputed. Random effects logistic regression controlled for confounding factors. SettingHome sleeping arrangements of infants in 19 studies across the UK, Europe and Australasia. Participants1472 SIDS cases, and 4679 controls. Each study effectively included all cases, by standard criteria. Controls were randomly selected normal infants of similar age, time and place. ResultsIn the combined dataset, 22.2% of cases and 9.6% of controls were bed sharing, adjusted OR (AOR) for all ages 2.7; 95% CI (1.4 to 5.3). Bed sharing risk decreased with increasing infant age. When neither parent smoked, and the baby was less than 3 months, breastfed and had no other risk factors, the AOR for bed sharing versus room sharing was 5.1 (2.3 to 11.4) and estimated absolute risk for these room sharing infants was very low (0.08 (0.05 to 0.14)/1000 live-births). This increased to 0.23 (0.11 to 0.43)/1000 when bed sharing. Smoking and alcohol use greatly increased bed sharing risk. ConclusionsBed sharing for sleep when the parents do not smoke or take alcohol or drugs increases the risk of SIDS. Risks associated with bed sharing are greatly increased when combined with parental smoking, maternal alcohol consumption and/or drug use. A substantial reduction of SIDS rates could be achieved if parents avoided bed sharing.

Asthma mortality in Australia in the 21st century: a case series analysis [RESEARCH]

Thu, 16 May 2013 00:00:00 +0000

ObjectiveAs previous asthma mortality studies were undertaken between 1986 and 1997, and treatments have evolved since that time, in order to direct future asthma interventions, we investigated the reasons for asthma deaths between 2005 and 2009. DesignWe undertook a case series analysis by searching the National Coroners' Information System using the most recent International Classification of Diseases-10 codes J45 and J46 and the keyword asthma' as the underlying cause of death. SettingRecords for 283 cases aged 70 years and under were retrieved from each Australian state and territory. Coroner's findings, autopsy, toxicology and police reports were reviewed to determine: if the team agreed the death was due to asthma and whether the death was preventable or modifiable factors existed? Owing to the likelihood of comorbidities or alternative diagnoses contributing to deaths in those over 70 years of age, this group was excluded. ResultsExamination of available data in those aged under 70 years identified risk factors associated with asthma death. These included physical barriers (rural and remote location, institutionalised care), psychosocial issues (social disengagement, mental illness, living alone, being unemployed), smoking, drug and alcohol dependence, allergies, respiratory tract infections, inadequate treatment and delay in seeking help. ConclusionsOur study provides a current assessment of death from asthma across Australia. Further reductions in the rate of asthma deaths will require interventions targeted at the personal, practice and policy levels. Asthma-related health literacy needs to be improved especially among those with episodic asthma. Reforms are also needed to address inequity in healthcare delivery to reach the unreached'. Our study points to the dangers associated with smoking, drug and alcohol use and the consequences of delay in seeking care among those with asthma.

Nocturnal sweating--a common symptom of obstructive sleep apnoea: the Icelandic sleep apnoea cohort [RESEARCH]

Tue, 14 May 2013 00:00:00 +0000

ObjectivesTo estimate the prevalence and characteristics of frequent nocturnal sweating in obstructive sleep apnoea (OSA) patients compared with the general population and evaluate the possible changes with positive airway pressure (PAP) treatment. Nocturnal sweating can be very bothersome to the patient and bed partner. DesignCase-control and longitudinal cohort study. SettingLandspitali--The National University Hospital, Iceland. ParticipantsThe Icelandic Sleep Apnea Cohort consisted of 822 untreated patients with OSA, referred for treatment with PAP. Of these, 700 patients were also assessed at a 2-year follow-up. The control group consisted of 703 randomly selected subjects from the general population. InterventionPAP therapy in the OSA cohort. Main outcome measuresSubjective reporting of nocturnal sweating on a frequency scale of 1-5: (1) never or very seldom, (2) less than once a week, (3) once to twice a week, (4) 3-5 times a week and (5) every night or almost every night. Full PAP treatment was defined objectively as the use for [≥]4 h/day and [≥]5 days/week. ResultsFrequent nocturnal sweating ([≥]3x a week) was reported by 30.6% of male and 33.3% of female OSA patients compared with 9.3% of men and 12.4% of women in the general population (p<0.001). This difference remained significant after adjustment for demographic factors. Nocturnal sweating was related to younger age, cardiovascular disease, hypertension, sleepiness and insomnia symptoms. The prevalence of frequent nocturnal sweating decreased with full PAP treatment (from 33.2% to 11.5%, p<0.003 compared with the change in non-users). ConclusionsThe prevalence of frequent nocturnal sweating was threefold higher in untreated OSA patients than in the general population and decreased to general population levels with successful PAP therapy. Practitioners should consider the possibility of OSA in their patients who complain of nocturnal sweating.

Predictive models to assess risk of type 2 diabetes, hypertension and comorbidity: machine-learning algorithms and validation using national health data from Kuwait--a cohort study [RESEARCH]

Tue, 14 May 2013 00:00:00 +0000

ObjectiveWe build classification models and risk assessment tools for diabetes, hypertension and comorbidity using machine-learning algorithms on data from Kuwait. We model the increased proneness in diabetic patients to develop hypertension and vice versa. We ascertain the importance of ethnicity (and natives vs expatriate migrants) and of using regional data in risk assessment. DesignRetrospective cohort study. Four machine-learning techniques were used: logistic regression, k-nearest neighbours (k-NN), multifactor dimensionality reduction and support vector machines. The study uses fivefold cross validation to obtain generalisation accuracies and errors. SettingKuwait Health Network (KHN) that integrates data from primary health centres and hospitals in Kuwait. Participants270 172 hospital visitors (of which, 89 858 are diabetic, 58 745 hypertensive and 30 522 comorbid) comprising Kuwaiti natives, Asian and Arab expatriates. Outcome measuresIncident type 2 diabetes, hypertension and comorbidity. ResultsClassification accuracies of >85% (for diabetes) and >90% (for hypertension) are achieved using only simple non-laboratory-based parameters. Risk assessment tools based on k-NN classification models are able to assign high' risk to 75% of diabetic patients and to 94% of hypertensive patients. Only 5% of diabetic patients are seen assigned low' risk. Asian-specific models and assessments perform even better. Pathological conditions of diabetes in the general population or in hypertensive population and those of hypertension are modelled. Two-stage aggregate classification models and risk assessment tools, built combining both the component models on diabetes (or on hypertension), perform better than individual models. ConclusionsData on diabetes, hypertension and comorbidity from the cosmopolitan State of Kuwait are available for the first time. This enabled us to apply four different case-control models to assess risks. These tools aid in the preliminary non-intrusive assessment of the population. Ethnicity is seen significant to the predictive models. Risk assessments need to be developed using regional data as we demonstrate the applicability of the American Diabetes Association online calculator on data from Kuwait.

Falling sex ratios and emerging evidence of sex-selective abortion in Nepal: evidence from nationally representative survey data [RESEARCH]

Tue, 14 May 2013 00:00:00 +0000

ObjectivesTo quantify trends in changing sex ratios of births before and after the legalisation of abortion in Nepal. While sex-selective abortion is common in some Asian countries, it is not clear whether the legal status of abortion is associated with the prevalence of sex-selection when sex-selection is illegal. In this context, Nepal provides an interesting case study. Abortion was legalised in 2002 and prior to that, there was no evidence of sex-selective abortion. Changes in the sex ratio at birth since legalisation would suggest an association with legalisation, even though sex-selection is expressly prohibited. DesignAnalysis of data from four Demographic and Health Surveys, conducted in 1996, 2001, 2006 and 2011. SettingNepal. Participants31 842 women aged 15-49. Main outcome measureConditional sex ratios (CSRs) were calculated, specifically the CSR for second-born children where the first-born was female. This CSR is where the evidence of sex-selective abortion will be most visible. CSRs were looked at over time to assess the impact of legalisation as well as for population sub-groups in order to identify characteristics of women using sex-selection. ResultsFrom 2007 to 2010, the CSR for second-order births where the first-born was a girl was found to be 742 girls per 1000 boys (95% CI 599 to 913). Prior to legalisation of abortion (1998-2000), the same CSR was 1021 (906-1150). After legalisation, it dropped most among educated and richer women, especially in urban areas. Just 325 girls were born for every 1000 boys among the richest urban women. ConclusionsThe fall in CSRs witnessed post-legalisation indicates that sex-selective abortion is becoming more common. This change is very likely driven by both supply and demand factors. Falling fertility has intensified the need to bear a son sooner, while legal abortion services have reduced the costs and risks associated with obtaining an abortion.

Physical activity and self-reported health status among adolescents: a cross-sectional population-based study [RESEARCH]

Tue, 14 May 2013 00:00:00 +0000

ObjectivesLittle is known about the dose-response relationship between physical activity and health benefits among young people. Our objective was to analyse the association between the frequency of undertaking moderate-to-vigorous physical activity (MVPA) and the self-reported health status of the adolescent population. DesignCross-sectional study. SettingAll regions of Spain. ParticipantsStudents aged 11-18 years participating in the Spanish Health Behaviour in School-aged Children survey 2006. A total of 375 schools and 21 188 students were selected. Main outcomesThe frequency of undertaking MVPA was measured by a questionnaire, with the following four health indicators: self-rated health, health complaints, satisfaction with life and health-related quality of life. Linear and logistic regression models were used to analyse the association, adjusting for potential confounding variables and the modelling of the dose-response relationship. ResultsAs the frequency of MVPA increased, the association with health benefits was stronger. A linear trend (p<0.05) was found for self-rated health and health complaints in males and females and for satisfaction with life among females; for health-related quality of life this relationship was quadratic for both sexes (p<0.05). For self-reported health and health complaints, the effect was found to be of greater magnitude in males than in females and, in all scales, the benefits were observed from the lowest frequencies of MVPA, especially in males. ConclusionsA protective effect of MVPA was found in both sexes for the four health indicators studied, and this activity had a gradient effect. Among males, health benefits were detected from very low levels of physical activity and the magnitude of the relationship was greater than that for females.

Addressing the human resources crisis: a case study of Cambodia's efforts to reduce maternal mortality (1980-2012) [RESEARCH]

Tue, 14 May 2013 00:00:00 +0000

ObjectiveTo identify factors that have contributed to the systematic development of the Cambodian human resources for health (HRH) system with a focus on midwifery services in response to high maternal mortality in fragile resource-constrained countries. DesignQualitative case study. Review of the published and grey literature and in-depth interviews with key informants and stakeholders using an HRH system conceptual framework developed by the authors ( House Model'; Fujita et al, 2011). Interviews focused on the perceptions of respondents regarding their contributions to strengthening midwifery services and the other external influences which may have influenced the HRH system and reduction in the maternal mortality ratio (MMR). SettingThree rounds of interviews were conducted with senior and mid-level managers of the Ministries of Health (MoH) and Education, educational institutes and development partners. ParticipantsA total of 49 interviewees, who were identified through a snowball sampling technique. Main outcome measuresScaling up the availability of 24 h maternal health services at all health centres contributing to MMR reduction. ResultsThe incremental development of the Cambodian HRH system since 2005 focused on the production, deployment and retention of midwives in rural areas as part of a systematic strategy to reduce maternal mortality. The improved availability and access to midwifery services contributed to significant MMR reduction. Other contributing factors included improved mechanisms for decision-making and implementation; political commitment backed up with necessary resources; leadership from the top along with a growing capacity of mid-level managers; increased MoH capacity to plan and coordinate; and supportive development partners in the context of a conducive external environment. ConclusionsLessons from this case study point to the importance of a systemic and comprehensive approach to health and HRH system strengthening and of ongoing capacity enhancement and leadership development to ensure effective planning, implementation and monitoring of HRH policies and strategies.

Determinants of vulnerability in early childhood development in Ireland: a cross-sectional study [RESEARCH]

Tue, 14 May 2013 00:00:00 +0000

ObjectivesEarly childhood development strongly influences lifelong health. The Early Development Instrument (EDI) is a well-validated population-level measure of five developmental domains (physical health and well-being, social competence, emotional maturity, language and cognitive skills, and communication skills and general knowledge) at school entry age. The aim of this study was to explore the potential of EDI as an indicator of early development in Ireland. DesignA cross-sectional design was used. SettingThe study was conducted in 42 of 47 primary schools in a major Irish urban centre. ParticipantsEDI (teacher completed) scores were calculated for 1243 children in their first year of full-time education. Contextual data from a subset of 865 children were collected using a parental questionnaire. Primary and secondary outcome measuresChildren scoring in the lowest 10% of the population in one or more domains were deemed developmentally vulnerable'. Scores were correlated with contextual data from the parental questionnaire. ResultsIn the sample population, 29% of children were not developmentally ready to engage in school. Factors associated with increased risk of vulnerability were being male OR 2.1 (CI 1.6 to 2.7); under 5 years OR 1.5 (CI 1.1 to 2.1) and having English as a second language OR 3.7 (CI 2.6 to 5.2). Adjusted for these demographics, low birth weight, poor parent/child interaction and mother's lower level of education showed the most significant ORs for developmental vulnerability. Calculating population attributable fractions, the greatest population-level risk factors were being male (35%), mother's education (27%) and having English as a second language (12%). ConclusionsThe EDI and linked parental questionnaires are promising indicators of the extent, distribution and determinants of developmental vulnerability among children in their first year of primary school in Ireland.

Differences in drug utilisation between men and women: a cross-sectional analysis of all dispensed drugs in Sweden [RESEARCH]

Fri, 3 May 2013 00:00:00 +0000

ObjectivesAscertain the extent of differences between men and women in dispensed drugs since there is a lack of comprehensive overviews on sex differences in the use of prescription drugs. DesignCross-sectional population database analysis. MethodsData on all dispensed drugs in 2010 to the entire Swedish population (9.3 million inhabitants) were obtained from the Swedish Prescribed Drug Register. All pharmacological groups with ambulatory care prescribing accounting for >75% of the total volume in Defined Daily Doses and a prevalence of >1% were included in the analysis. Crude and age-adjusted differences in prevalence and incidence were calculated as risk ratios (RRs) of women/men. ResultsIn all, 2.8 million men (59%) and 3.6 million women (76%) were dispensed at least one prescribed drug during 2010. Women were dispensed more drugs in all age groups except among children under the age of 10. The largest sex difference in prevalence in absolute numbers was found for antibiotics that were more common in women, 265.5 patients (PAT)/1000 women and 191.3 PAT/1000 men, respectively. This was followed by thyroid therapy (65.7 PAT/1000 women and 13.1 PAT/1000 men) and antidepressants (106.6 PAT/1000 women and 55.4 PAT/1000 men). Age-adjusted relative sex differences in prevalence were found in 48 of the 50 identified pharmacological groups. The pharmacological groups with the largest relative differences of dispensed drugs were systemic antimycotics (RR 6.6 CI 6.4 to 6.7), drugs for osteoporosis (RR 4.9 CI 4.9 to 5.0) and thyroid therapy (RR 4.5 CI 4.4 to 4.5), which were dispensed to women to a higher degree. Antigout agents (RR 0.4 CI 0.4 to 0.4), psychostimulants (RR 0.6 CI 0.6 to 0.6) and ACE inhibitors (RR 0.7 CI 0.7 to 0.7) were dispensed to men to a larger proportion. ConclusionsSubstantial differences in the prevalence and incidence of dispensed drugs were found between men and women. Some differences may be rational and desirable and related to differences between the sexes in the incidence or prevalence of disease or by biological differences. Other differences are more difficult to explain on medical grounds and may indicate unequal treatment.

Overactive bladder symptom severity is associated with falls in community-dwelling adults: LOHAS study [RESEARCH]

Fri, 3 May 2013 00:00:00 +0000

ObjectivesTo examine the association between overactive bladder (OAB) symptom severity and falls and the contribution of OAB symptoms to falls in a community-dwelling population. DesignCross-sectional study. Setting2 Japanese municipalities. ParticipantsA total of 2505 residents aged over 40 years, who participated in health check-ups conducted in 2010. OAB symptom assessed via overactive bladder symptom score (OABSS) was divided into six categories based on distribution and Japanese clinical guidelines. Mobility problems and depressive symptoms were assessed via the Timed Up and Go test and the short form of the Center for Epidemiologic Studies Depression Scale, respectively. Primary outcome measuresSelf-reported any fall and frequent fall ([≥]2) over the 1-month period. Independent contributions to any fall and frequent falls were assessed via logistic regression to generate population-attributable fractions (PAFs), assuming separate causal relationships between OAB symptoms, mobility problems and depressive symptoms and any or frequent falls. ResultsAmong the total 1350 participants (mean age: 68.3 years) analysed, any fall and frequent falls were reported by 12.7% and 4.4%, respectively. Compared with no OABSS score, moderate-to-severe OAB and mild OAB were associated with any fall (adjusted ORs 2.37 (95% CI 1.12 to 4.98) and 2.51 (95% CI 1.14 to 5.52), respectively). Moderate-to-severe OAB was also strongly associated with frequent falls (adjusted OR 6.90 (95% CI 1.50 to 31.6)). Adjusted PAFs of OAB symptoms were 40.7% (95% CI 0.7% to 64.6%) for any fall and 67.7% (95% CI -23.1% to 91.5%) for frequent falls. Further, these point estimates were similar to or larger than those of mobility problems and depressive symptoms. ConclusionsAn association does indeed exist between OAB symptom severity and falls, and OAB symptoms might be important contributors to falls among community-dwelling adults. Further longitudinal studies are warranted to examine whether or not OAB symptoms predict risk of future falls and fall-related injuries.

Determining immunisation status of children from history: a diagnostic accuracy study [RESEARCH]

Fri, 3 May 2013 00:00:00 +0000

ObjectivesChildren presenting unplanned to healthcare services are routinely asked about previous immunisations as part of their assessment. We aimed to assess the accuracy of screening children for immunisation status by history. DesignDiagnostic accuracy study. We compared information from patient history by a retrospective review of notes and used a central database of child immunisation records as the reference standard. SettingPaediatric emergency department in a tertiary hospital in Oxford, UK. ParticipantsConsecutive children aged 6 months to 6 years presenting over a 2-month period. Outcome measuresProportion of children with documented immunisation history; sensitivity and specificity of detecting overdue immunisations by history compared to central records. Results1166 notes were surveyed. 76.3% children were asked about immunisations. The proportion of children who were fully immunised on central records was 93.1%. History had a sensitivity of 41.3% (95% CI 27% to 56.8%) and a specificity of 98.7% (95% CI 97.5% to 99.4%) for detecting those who were overdue. Negative predictive value was 95.8% (95% CI 93.9% to 97.2%). Only around a third of children with overdue immunisations are detected by the current screening methods, and approximately 1 in 20 children stated as being up to date are in fact overdue. ConclusionsHistory had poor sensitivity for identifying overdue immunisation. Strategies to improve detection of children overdue with immunisation should focus on alternative strategies for alerting clinicians, such as linkage of community and hospital electronic records.

Comparison of health confidence in rural, suburban and urban areas in the UK and the USA: a secondary analysis [RESEARCH]

Thu, 2 May 2013 00:00:00 +0000

ObjectiveConfidence in healthcare may influence the patients' utilisation of healthcare resources and perceptions of healthcare quality. We sought to determine whether self-reported confidence in healthcare differed between the UK and the USA, as well as by rurality or urbanicity. DesignA secondary analysis of a subset of survey questions regarding self-reported confidence in healthcare from the 2010 Commonwealth Fund International Health Policy Survey. SettingTelephone survey of participants from the UK and the USA. ParticipantsOur final analysis included 1511 UK residents (688 rural, 446 suburban, 372 urban, 5 uncategorised) and 2501 US residents (536 rural, 1294 suburban, 671 urban). Outcome measuresQuestions assessed respondents' confidence in the effectiveness and affordability of the treatment. We compared survey outcomes from these questions between, and within, the two regions and among, and within, residence types (rural, suburban and urban). ResultsSignificant differences were found in self-reported confidence in healthcare between the UK and US, among residence types, and between the two regions within residence types. Reported levels were higher in the UK. Within regions, significant differences by residence type were found for the US, but not the UK. Within the US, suburban respondents had the highest self-reported confidence in healthcare. ConclusionsSignificant differences exist between the UK and US in confidence in healthcare. In the US, but not in the UK, self-reported confidence is related to residence type. Within countries, significant differences by residence type were found for the US, but not the UK. Our findings warrant the examination of causes for relative confidence levels in healthcare between regions and among US residence types.

Injecting drug users, sex workers and men who have sex with men: a national cross-sectional study to develop a framework and prevalence estimates for national HIV/AIDS programmes in the Republic of Serbia [RESEARCH]

Thu, 2 May 2013 00:00:00 +0000

ObjectiveThe aim of this study was to develop a framework and best estimates of prevalence for the most at risk populations (MARPs) for HIV/AIDS to include sex workers (SW), men who have sex with men (MSM) and injecting drug users (IDUs) in order to evaluate national HIV/AIDS programmatic targets across the Republic of Serbia. DesignA national, cross-sectional study and direct enumeration, multiplier and benchmark methods with integrated bio-behavioural surveys, capture/recapture and methods with Wald and Clopper-Pearson CIs were used. SettingThis study was carried out in the three largest cities and main regions of Serbia, the capital city, Belgrade, (population 1 639 121 persons), the Vojvodina region with main city Novi Sad (population 335 701) and the rest of Serbia with main city Nis (population 257 867). ParticipantsA total of 1301 respondents from the defined MARPs completed the survey in the 2009/2010 period across the three cities. Primary outcome measuresEstimates of the hidden numbers at risk of HIV/AIDS. ResultsIt was estimated that there were 1775-6027 SW between 18 and 49 years in Serbia in 2009. For MSM, national estimates for 2009 ranged from 20 789 to 90 104 individuals aged between 20 and 49 years. For IDU, a possible range of 12 682-48 083 individuals aged between 15 and 59 years in 2009 was estimated. ConclusionsFor service planning across Central and Eastern Europe, it is important to highlight how credible estimates can be achieved and compared with numbers within HIV/AIDS-prevention programmes. Within needle exchange programmes, only 5.4-20.5% of the estimated population was observed and this proportion was lower within methadone treatment data. Results have implications for future IDU treatment and HIV incidence and spread across all populations at risk.

Do social interactions explain ethnic differences in psychological distress and the protective effect of local ethnic density? A cross-sectional study of 226 487 adults in Australia [RESEARCH]

Thu, 2 May 2013 00:00:00 +0000

BackgroundA frequently proposed, but under-researched hypothesis is that ethnic density benefits mental health through increasing social interactions. We examined this hypothesis in 226 487 adults from 19 ethnic groups aged 45 years and older in Australia. MethodsMultilevel logit regression was used to measure the association between ethnicity, social interactions, own-group ethnic density and scores of 22+ on the Kessler scale of psychological distress. Self-reported ancestry was used as a proxy for ethnicity. Measures of social interactions included a number of times in the past week were (i) spent with friends or family participants did not live with; (ii) talked to someone on the telephone; (iii) attended meetings of social groups and (iv) how many people could be relied upon outside their home, but within 1 h of travel. Per cent own-group ethnic density was measured at the Census Collection District scale. ResultsPsychological distress was reported by 11% of Australians born in Australia. The risk of experiencing psychological distress varied among ethnic minorities and by country of birth (eg, 33% for the Lebanese born in Lebanon and 4% for the Swiss born in Switzerland). These differences remained after full adjustment. Social interactions varied between ethnic groups and were associated with lower psychological distress and ethnic density. Ethnic density was associated with reduced psychological distress for some groups. This association, however, was explained by individual and neighbourhood characteristics and not by social interactions. ConclusionsSocial interactions are important correlates of mental health, but fully explain neither the ethnic differences in psychological distress nor the protective effect of own-group density.

Job strain and supervisor support in primary care health centres and glycaemic control among patients with type 2 diabetes: a cross-sectional study [RESEARCH]

Thu, 2 May 2013 00:00:00 +0000

ObjectivesThis study investigates associations between healthcare personnel's perceived job strain, supervisor support and the outcome of care in terms of glycaemic control among patients with type 2 diabetes. DesignA cross-sectional study from 2006. Setting18 primary care health centres (HCs) from five municipalities in Finland. ParticipantsAggregated survey data on perceived job strain and supervisor support from healthcare personnel (doctors, n=122, mean age 45.5 years, nurses, n=300, mean age 47.1 years) were combined with registered data (Electronic Medical Records) from 8975 patients (51% men, mean age 67 years) with type 2 diabetes. Outcome measurePoor glycaemic control (glycated haemoglobin (HbA1c) [≥]7%). ResultsThe mean HbA1c level among patients with type 2 diabetes was 7.1 (SD 1.2, range 4.5-19.1), and 43% had poor glycaemic control (HbA1c [≥]7%). Multilevel logistic regression analyses, adjusted for patient's age and sex, and HC and HC service area-level characteristics, showed that patients' HbA1c-levels were less optimal in high-strain HCs than in low-strain HCs (OR 1.44, 95% CI 1.12 to 1.86). Supervisor support in HCs was not associated with the outcome of care. ConclusionsThe level of job strain among healthcare personnel may play a role in achieving good glycaemic control among patients with type 2 diabetes.

The association of alcohol drinking pattern and self-inflicted intentional injury in Korea: a cross-sectional WHO collaborative emergency room study [RESEARCH]

Tue, 30 Apr 2013 00:00:00 +0000

ObjectivesSelf-inflicted intentional injuries are increasing at an alarming rate in the Republic of Korea, yet few reports describe their relationship with alcohol consumption. The aim of this study was to characterise the association of alcohol drinking patterns and self-inflicted intentional injury in Korean emergency departments (EDs) using WHO collaborative study protocol. DesignCross-sectional study. SettingData were collected from four general hospital EDs in four geographically diverse regions of Korea: Seoul, Suwon, Chuncheon and Gwangju. ParticipantsInformation was collected on 1989 patients aged 18 and above. A representative probability sample was drawn from patients admitted to each ED for the first time within 6 h of injury. Primary and secondary outcome measuresAlcohol-related non-fatal injuries. ResultsAmong 467 persons with alcohol-related injuries, 33 (7.1%), were self-inflicted intentional injuries and 137 (29.3%) were intentional injuries caused by someone else. The adjusted odds of self-inflicted intentional injury verses unintentional injury were calculated for heavy (OR 1.764; 95% CI 0.783 to 3.976), binge (OR 2.125; 95% CI 0.930 to 4.858) and moderate drinking (OR 3.039; 95% CI 1.129 to 8.178) after controlling for demographic variables. Similar odds were reported for pooled intentional injury data (self-inflicted and caused by someone else) and drinking patterns. ConclusionsThese data show a strong association between all patterns of acute alcohol consumption and self-inflicted intentional injury in the Republic of Korea.

Safety and acceptability of practice-nurse-managed care of depression in patients with diabetes or heart disease in the Australian TrueBlue study [RESEARCH]

Tue, 30 Apr 2013 00:00:00 +0000

ObjectivesTo determine the safety and acceptability of the TrueBlue model of nurse-managed care in the primary healthcare setting. DesignA mixed methods study involving clinical record audit, focus groups and nurse interviews as a companion study investigating the processes used in the TrueBlue randomised trial. SettingAustralian general practices involved in the TrueBlue trial. ParticipantsFive practice nurses and five general practitioners (GPs) who had experienced nurse-managed care planning following the TrueBlue model of collaborative care. InterventionThe practice nurse acted as case manager, providing screening and protocol-management of depression and diabetes, coronary heart disease or both. Primary outcome measuresProportion of patients provided with stepped care when needed, identification and response to suicide risk and acceptability of the model to practice nurses and GPs. ResultsAlmost half the patients received stepped care when indicated. All patients who indicated suicidal ideations were identified and action taken. Practice nurses and GPs acknowledged the advantages of the TrueBlue care-plan template and protocol-driven care, and the importance of peer support for the nurse in their enhanced role. ConclusionsPractice nurses were able to identify, assess and manage mental-health risk in patients with diabetes or heart disease.

Semen quality of 1559 young men from four cities in Japan: a cross-sectional population-based study [RESEARCH]

Mon, 29 Apr 2013 00:00:00 +0000

ObjectivesTo provide information of semen quality among normal young Japanese men and indicate the frequency of reduced semen quality. DesignCross-sectional, coordinated studies of Japanese young men included from university areas. The men had to be 18-24 years, and both the man and his mother had to be born in Japan. Background information was obtained from questionnaires. Standardised and quality-controlled semen analyses were performed, reproductive hormones analysed centrally and results adjusted for confounding factors. SettingFour study centres in Japan (Kawasaki, Osaka, Kanazawa and Nagasaki). Participants1559 men, median age 21.1 years, included during 1999-2003. Outcome measuresSemen volume, sperm concentration, total sperm count, sperm motility, sperm morphology and reproductive hormone levels. ResultsMedian sperm concentration was 59 (95% CI 52 to 68) million/ml, and 9% and 31.9% had less than 15 and 40 million/ml, respectively. Median percentage of morphologically normal spermatozoa was 9.6 (8.8 to 10.3)%. Small, but statistically significant, differences were detected for both semen and reproductive hormone variables between men from the four cities. Overall, the semen values were lower than those of a reference population of 792 fertile Japanese men. ConclusionsAssuming that the investigated men were representative for young Japanese men, a significant proportion of the population had suboptimal semen quality with reduced fertility potential, and as a group they had lower semen quality than fertile men. However, the definitive role--if any--of low semen quality for subfertility and low fertility rates remain to be investigated.

The benefits of thermal clothing during winter in patients with heart failure: a pilot randomised controlled trial [RESEARCH]

Mon, 29 Apr 2013 00:00:00 +0000

ObjectivesTo examine whether providing thermal clothing to heart failure patients improves their health during winter. DesignA randomised controlled trial with an intervention group and a usual care group. SettingHeart failure clinic in a large tertiary referral hospital in Brisbane, Australia. ParticipantsEligible participants were those with known systolic heart failure who were over 50 years of age and lived in Southeast Queensland. Participants were excluded if they lived in a residential aged care facility, had incontinence or were unable to give informed consent. Fifty-five participants were randomised and 50 completed. InterventionsParticipants randomised to the intervention received two thermal hats and tops and a digital thermometer. Primary and secondary outcome measuresThe primary outcome was the mean number of days in hospital. Secondary outcomes were the number of general practitioner (GP) visits and self-rated health. ResultsThe mean number of days in hospital per 100 winter days was 2.5 in the intervention group and 1.8 in the usual care group, with a mean difference of 0.7 (95% CI -1.5 to 5.4). The intervention group had 0.2 fewer GP visits on average (95% CI -0.8 to 0.3), and a higher self-rated health, mean improvement -0.3 (95% CI -0.9 to 0.3). The thermal tops were generally well used, but even in cold temperatures the hats were only worn by 30% of the participants. ConclusionsThermal clothes are a cheap and simple intervention, but further work needs to be done on increasing compliance and confirming the health and economic benefits of providing thermals to at-risk groups. Trial registrationThe study was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12612000378820)

Investigation of a safety-engineered device to prevent needlestick injury: why has not StatLock stuck? [RESEARCH]

Wed, 24 Apr 2013 00:00:00 +0000

ObjectiveThis article sought to define whether an alternative safety-engineered device (SED) could help prevent needlestick injury (NSI) in healthcare workers (HCWs) who place central venous catheters (CVCs). DesignThe study involved three phases: (1) A retrospective analysis of deidentified occupational health records from our tertiary care urban US hospital to clearly identify NSI risk and rates to an HCW during invasive catheter placement; (2) 95 residents were surveyed regarding their knowledge and experience with NSIs and SEDs; (3) A random sample of six residents participated in a focus group session discussing barriers to the use of SED. SettingA single urban US tertiary care teaching hospital. ParticipantsA retrospective analysis of NSI to HCWs in a tertiary care urban US hospital was conducted over a 4-year period (July 2007-June 2011). Ninety-five residents from specialties that often place CVC during training (surgery, surgical subspecialties, internal medicine, anaesthesia and emergency medicine) were surveyed regarding their experience with NSIs and SEDs. A random sample of six residents participated in a focus group session discussing barriers to the use of SED. Results314 NSIs were identified via occupational health records. 16% (21 of 131) of NSIs occurring in residents and fellows occurred during the securement of an invasive catheter such as a CVC. If an SED device had been used, the 5.25 NSIs/year could have been avoided. Each NSI occurring in an HCW incurred at least $2723 in charges. Thus, utilisation of the SED could have saved a minimum of $57 183 over the 4-year period. ConclusionsSEDs are currently available and can be used as an alternative to sharps. If safety and efficacy can be demonstrated, then implementation of such devices can significantly reduce the number of NSIs.

Parental modelling, media equipment and screen-viewing among young children: cross-sectional study [RESEARCH]

Wed, 24 Apr 2013 00:00:00 +0000

ObjectiveTo examine whether parental screen-viewing, parental attitudes or access to media equipment were associated with the screen-viewing of 6-year-old to 8-year-old children. DesignCross-sectional survey. SettingOnline survey. Main outcomeParental report of the number of hours per weekday that they and, separately, their 6-year-old to 8-year-old child spent watching TV, using a games console, a smart-phone and multiscreen viewing. Parental screen-viewing, parental attitudes and pieces of media equipment were exposures. ResultsOver 75% of the parents and 62% of the children spent more than 2 h/weekday watching TV. Over two-thirds of the parents and almost 40% of the children spent more than an hour per day multiscreen viewing. The mean number of pieces of media equipment in the home was 5.9 items, with 1.3 items in the child's bedroom. Children who had parents who spent more than 2 h/day watching TV were over 7.8 times more likely to exceed the 2 h threshold. Girls and boys who had a parent who spent an hour or more multiscreen viewing were 34 times more likely to also spend more than an hour per day multiscreen viewing. Media equipment in the child's bedroom was associated with higher TV viewing, computer time and multiscreen viewing. Each increment in the parental agreement that watching TV was relaxing for their child was associated with a 49% increase in the likelihood that the child spent more than 2 h/day watching TV. ConclusionsChildren who have parents who engage in high levels of screen-viewing are more likely to engage in high levels of screen-viewing. Access to media equipment, particularly in the child's bedroom, was associated with higher levels of screen-viewing. Family-based strategies to reduce screen-viewing and limit media equipment access may be important ways to reduce child screen-viewing.

Risk of childhood injuries after prenatal exposure to maternal bereavement: a Danish National Cohort Study [RESEARCH]

Mon, 22 Apr 2013 00:00:00 +0000

ObjectivesThe aim of this study was to assess the risk of injuries among children exposed to a stressful life exposure (defined as bereavement) before conception or during fetal life. DesignPopulation-based cohort study. SettingDenmark. ParticipantsAll singleton births in Denmark between 1 January 1995 and 31 December 2006 were identified. These newborns were then linked to mothers, fathers, grandparents and siblings using individually assigned civil personal registration numbers. Primary and secondary outcome measuresWe identified that data on childhood injuries were obtained from the Danish National Patient Registry, which contains data on all hospital stays and outpatient visits. Incidence rate ratios (IRRs) were estimated from birth using log-linear Poisson regression models, and person-years were used as the offset variable. Age, residence, calendar period, maternal education, maternal income and parental-cohabitation status are treated as time-dependent variables (records were extracted from the offspring's birth year). ResultsExposure to maternal bereavement due to a father's death had the strongest association with childhood injuries, especially when the cause of death was due to a traumatic event (adjusted estimates of IRR (aIRR): 1.25, 95%CI: 0.99 to 1.58). We did not find an association for childhood injuries and maternal bereavement due to grandparent's death, and we only found an association for sibling death when restricting to deaths due to traumatic events (aIRR: 1.20, 95%CI:1.03 to 1.39). ConclusionsThe aetiology of childhood injuries is complex and may be related to events that take place during prenatal life. This study suggests that exposure to a stressful life event during gestation may be linked to injury susceptibility in childhood. However, changes in postnatal family conditions related to loss or genetic factors may also play a role. BackgroundDevelopmental plasticity related to early life exposures leading to disease programming in offspring is a theory with substantial theoretical and empirical support. Prenatal stress exposure has been linked to neurological outcomes, such as temperament, behavioural problems, cognitive function and affective disorders. If exposure modifies risk-seeking behaviour, perceived danger and reaction time, it is also expected to modify injury risk.

Women's responses to information about overdiagnosis in the UK breast cancer screening programme: a qualitative study [RESEARCH]

Mon, 22 Apr 2013 00:00:00 +0000

ObjectivesTo explore the influence of overdiagnosis information on women's decisions about mammography. DesignA qualitative focus group study with purposive sampling and thematic analysis, in which overdiagnosis information was presented. SettingCommunity and university settings in London. Participants40 women within the breast screening age range (50-71 years) including attenders and non-attenders were recruited using a recruitment agency as well as convenience sampling methods. ResultsWomen expressed surprise at the possible extent of overdiagnosis and recognised the information as important, although many struggled to interpret the numerical data. Overdiagnosis was viewed as less-personally relevant than the possibility of under diagnosis' (false negatives), and often considered to be an issue for follow-up care decisions rather than screening participation. Women also expressed concern that information on overdiagnosis could deter others from attending screening, although they rarely saw it as a deterrent. After discussing overdiagnosis, few women felt that they would make different decisions about breast screening in the future. ConclusionsWomen regard it as important to be informed about overdiagnosis to get a complete picture of the risks and benefits of mammography, but the results of this study indicate that understanding overdiagnosis may not always influence women's attitudes towards participation in breast screening. The results also highlight the challenge of communicating the individual significance of information derived from population-level modelling.

{Omega}-3 fatty acid supplement use in the 45 and Up Study Cohort [RESEARCH]

Thu, 18 Apr 2013 00:00:00 +0000

ObjectiveThere has been a dramatic increase in the use of dietary supplements in Western societies over the past decades. Our understanding of the prevalence of {Omega}-3 fatty acid supplement consumption is of significance for future nutrition planning, health promotion and care delivery. However, we know little about {Omega}-3 fatty acid supplement consumption or users. This paper, drawing upon the largest dataset with regard to {Omega}-3 fatty acid supplement use (n=266 848), examines the use and users of this supplement among a large sample of older Australians living in New South Wales. DesignA cross-sectional study. Data were analysed from the 45 and Up Study, the largest study of healthy ageing ever undertaken in the Southern Hemisphere. SettingNew South Wales, Australia. Participants266 848 participants of the 45 and Up Study. Primary and secondary outcome measuresParticipants' use of {Omega}-3, demographics (geographical location, marital status, education level, income and level of healthcare insurance) and health status (quality of life, history of smoking and alcohol consumption, health conditions) were measured. ResultsOf the 266 848 participants, 32.6% reported having taken {Omega}-3 in the 4 weeks prior to the survey. Use of {Omega}-3 fatty acid supplements was higher among men, non-smokers, non-to-mild (alcoholic) drinkers, residing in a major city, having higher income and private health insurance. Osteoarthritis, osteoporosis, high cholesterol and anxiety and/or depression were positively associated with {Omega}-3 fatty acid supplement use, while cancer and high blood pressure were negatively associated with use of {Omega}-3 fatty acid supplements. ConclusionsThis study, analysing data from the 45 and Up Study cohort, suggests that a considerable proportion of older Australians consume {Omega}-3 fatty acid supplements. There is a need for primary healthcare practitioners to enquire with patients about this supplement use and for work to ensure provision of good-quality information for patients and providers with regard to {Omega}-3 fatty acid products.

Cardiovascular mortality in bipolar disorder: a population-based cohort study in Sweden [RESEARCH]

Thu, 18 Apr 2013 00:00:00 +0000

ObjectiveTo estimate the cardiovascular mortality among persons with bipolar disorder in Sweden compared to the general population. DesignPopulation register-based cohort study with a 20-year follow-up. SettingSweden. ParticipantsThe entire population of Sweden (n=10.6 million) of whom 17 101 persons were diagnosed with bipolar disorder between 1987 and 2006. Main outcome measuresMortality rate ratios (MRR), excess mortality (excess deaths), cardiovascular disorder (CVD) and specifically cerebrovascular disease, coronary heart disease, acute myocardial infarction, sudden cardiac deaths and hospital admission rate ratio (ARR). ResultsPersons with bipolar disorder died of CVD approximately 10 years earlier than the general population. One third (38%) of all deaths in persons with bipolar disorder were caused by CVD and almost half (44%) by other somatic diseases, whereas suicide and other external causes accounted for less than a fifth of all deaths (18%). Excess mortality of both CVD (n=824) and other somatic diseases (n=988) was higher than that of suicide and other external causes (n=675 deaths). MRRs for cerebrovascular disease, coronary heart disease and acute myocardial infarction were twice as high in persons with bipolar disorder compared to the general population. Despite the increased mortality of CVD, hospital admissions (ARR) for CVD treatment were only slightly increased in persons with bipolar disorder when compared to the general population. ConclusionsThe increased cardiovascular mortality in persons with bipolar disorder calls for renewed efforts to prevent and treat somatic diseases in this group. Specifically, our findings further imply that it would be critical to ensure that persons with bipolar disorder receive the same quality care for CVD as persons without bipolar disorder.

The high cost of diarrhoeal illness for urban slum households-a cost-recovery approach: a cohort study [RESEARCH]

Thu, 18 Apr 2013 00:00:00 +0000

ObjectivesRapid urbanisation has often meant that public infrastructure has not kept pace with growth leading to urban slums with poor access to water and sanitation and high rates of diarrhoea with greater household costs due to illness. This study sought to determine the monetary cost of diarrhoea to urban slum households in Kaula Bandar slum in Mumbai, India. The study also tested the hypotheses that the cost of water and sanitation infrastructure may be surpassed by the cumulative costs of diarrhoea for households in an urban slum community. DesignA cohort study using a baseline survey of a random sample followed by a systematic longitudinal household survey. The baseline survey was administered to a random sample of households. The systematic longitudinal survey was administered to every available household in the community with a case of diarrhoea for a period of 5 weeks. ParticipantsEvery household in Kaula Bandar was approached for the longitudinal survey and all available and consenting adults were included. ResultsThe direct cost of medical care for having at least one person in the household with diarrhoea was 205 rupees. Other direct costs brought total expenses to 291 rupees. Adding an average loss of 55 rupees per household from lost wages and monetising lost productivity from homemakers gave a total loss of 409 rupees per household. During the 5-week study period, this community lost an estimated 163 600 rupees or 3635 US dollars due to diarrhoeal illness. ConclusionsThe lack of basic water and sanitation infrastructure is expensive for urban slum households in this community. Financing approaches that transfer that cost to infrastructure development to prevent illness may be feasible. These findings along with the myriad of unmeasured benefits of preventing diarrhoeal illness add to pressing arguments for investment in basic water and sanitation infrastructure.

Socioeconomic patterning of excess alcohol consumption and binge drinking: a cross-sectional study of multilevel associations with neighbourhood deprivation [RESEARCH]

Mon, 15 Apr 2013 00:00:00 +0000

ObjectivesThe influence of neighbourhood deprivation on the risk of harmful alcohol consumption, measured by the separate categories of excess consumption and binge drinking, has not been studied. The study objective was to investigate the effect of neighbourhood deprivation with age, gender and socioeconomic status (SES) on (1) excess alcohol consumption and (2) binge drinking, in a representative population survey. DesignCross-sectional study: multilevel analysis. SettingWales, UK, adult population [~]2.2 million. Participants58 282 respondents aged 18 years and over to four successive annual Welsh Health Surveys (2003/2004-2007), nested within 32 692 households, 1839 census lower super output areas and the 22 unitary authority areas in Wales. Primary outcome measureMaximal daily alcohol consumption during the past week was categorised using the UK Department of Health definition of none/never drinks', within guidelines', excess consumption but less than binge' and binge'. The data were analysed using continuation ratio ordinal multilevel models with multiple imputation for missing covariates. ResultsRespondents in the most deprived neighbourhoods were more likely to binge drink than in the least deprived (adjusted estimates: 17.5% vs 10.6%; difference=6.9%, 95% CI 6.0 to 7.8), but were less likely to report excess consumption (17.6% vs 21.3%; difference=3.7%, 95% CI 2.6 to 4.8). The effect of deprivation varied significantly with age and gender, but not with SES. Younger men in deprived neighbourhoods were most likely to binge drink. Men aged 35-64 showed the steepest increase in binge drinking in deprived neighbourhoods, but men aged 18-24 showed a smaller increase with deprivation. ConclusionsThis large-scale population study is the first to show that neighbourhood deprivation acts differentially on the risk of binge drinking between men and women at different age groups. Understanding the socioeconomic patterns of harmful alcohol consumption is important for public health policy development.

Patient-reported outcomes of cancer survivors in England 1-5 years after diagnosis: a cross-sectional survey [RESEARCH]

Fri, 12 Apr 2013 00:00:00 +0000

ObjectivesTo determine the feasibility of collecting population-based patient-reported outcome measures (PROMs) in assessing quality of life (QoL) to inform the development of a national PROMs programme for cancer and to begin to describe outcomes in a UK cohort of survivors. DesignCross-sectional postal survey of cancer survivors using a population-based sampling approach. SettingEnglish National Health Service. Participants4992 breast, colorectal, prostate and non-Hodgkin's lymphoma (NHL) survivors 1-5 years from diagnosis. Primary and secondary outcome measuresImplementation issues, response rates, cancer-specific morbidities utilising items including the EQ5D, tumour-specific subscales of the Functional Assessment of Cancer Therapy and Social Difficulties Inventory. Results3300 (66%) survivors returned completed questionnaires. The majority aged 85+ years did not respond and the response rates were lower for those from more deprived area. Response rates did not differ by gender, time since diagnosis or cancer type. The presence of one or more long-term conditions was associated with significantly lower QoL scores. Individuals from most deprived areas reported lower QoL scores and poorer outcomes on other measures, as did those self-reporting recurrent disease or uncertainty about disease status. QoL scores were comparable at all time points for all cancers except NHL. QoL scores were lower than those from the general population in Health Survey for England (2008) and General Practice Patient Survey (2012). 47% of patients reported fear of recurrence, while 20% reported moderate or severe difficulties with mobility or usual activities. Bowel and urinary problems were common among colorectal and prostate patients. Poor bowel and bladder control were significantly associated with lower QoL. ConclusionsThis method of assessing QoL of cancer survivors is feasible and acceptable to most survivors. Routine collection of national population-based PROMs will enable the identification of, and the support for, the specific needs of survivors while allowing for comparison of outcome by service provider.

Specific antibodies against vaccine-preventable infections: a mother-infant cohort study [RESEARCH]

Thu, 11 Apr 2013 00:00:00 +0000

ObjectivesTo determine maternal and neonatal specific antibody levels to selected vaccine-preventable infections (pertussis, Haemophilus influenzae type b (Hib), tetanus and pneumococcus). DesignProspective cohort study. SettingA UK secondary care maternity unit (March 2011-January 2012). ParticipantsMothers and infants within 72 h of delivery were eligible. Unwell individuals, mothers less than 18 years of age, and infants born at less than 36 weeks gestation, or weighing less than 2500 g, were excluded. HIV-infected mothers were included. 112 mother-infant pairs were recruited. Samples from 111 mothers and 109 infants (108 pairs) were available for analysis. Outcome measuresSpecific antibody levels were determined using standard commercial ELISAs. Specific antibody to pertussis antigens (PT and FHA) of >50 IU/ml, defined as positive' by the test manufacturer, were interpreted as protective. Antitetanus antibody titres >0.1 IU/ml and anti-Hib antibody titres >1 mg/l were regarded as protective. ResultsOnly 17% (19/111) of women exhibited a protective antibody response against pertussis. 50% (56/111) of women had levels of antibody protective against Hib and 79% (88/111) against tetanus. There was a strong positive correlation between maternal-specific and infant-specific antibodies' responses against pertussis (rs=0.71, p<0.001), Hib (rs=0.80, p<0.001), tetanus (rs=0.90, p<0.001) and pneumococcal capsular polysaccharide (rs=0.85, p<0.001). Only 30% (33/109) and 42% (46/109) of infants showed a protective antibody response to pertussis and Hib, respectively. Placental transfer (infant:mother ratio) of specific IgG to pertussis, Hib, pneumococcus and tetanus was significantly reduced from HIV-infected mothers to their HIV-exposed, uninfected infants (n=12 pairs) compared with HIV-uninfected mothers with HIV-unexposed infants (n=96 pairs) by 58% (<0.001), 61% (<0.001), 28% (p=0.034) and 32% (p=0.035), respectively. ConclusionsLow baseline antibody levels against pertussis in this cohort suggest the recently implemented UK maternal pertussis immunisation programme has potential to be effective.

A community cohort study about childhood social and economic circumstances: racial/ethnic differences and associations with educational attainment and health of older adults [RESEARCH]

Thu, 11 Apr 2013 00:00:00 +0000

ObjectivesTypical measures of childhood socioeconomic status (SES), such as father's occupation, have limited the ability to elucidate mechanisms by which childhood SES affects adult health. Mechanisms could include schooling experiences or work opportunities. Having previously used qualitative methods for concept development, we developed new retrospective measures of multiple domains of childhood social and economic circumstances in ethnically diverse older adults. We administered the new measures in a large sample and explored their association with adult SES. DesignWe used a cross-sectional survey design with a community sample. SettingThe San Francisco Bay Area in California. Participants400 community-dwelling adults from diverse racial/ethnic backgrounds (Whites, African Americans, Latinos and Asians/Pacific Islanders) aged 55 and older (mean=67 years); 61% were women. Primary and secondary outcome measuresWe measured attitudes towards schooling, extracurricular activities and adult encouragement and discouragement during the childhood/teen years. Bivariate analysis tested racial/ethnic differences on the various measures. Multivariate regression models estimated the extent to which retrospective circumstances were independently associated with adult educational attainment and adult health. ResultsMost of the childhood circumstances measures differed across racial/ethnic groups. In general, Whites reported more positive circumstances than non-Whites. Family financial circumstances, respondent's perception of schooling as a means to get ahead, high school extracurricular activities, summer travel and summer reading were each statistically significantly associated with adult SES. Family composition, age began work, high school extracurricular activities, attitudes towards schooling and adult discouragement were associated with adult health.

Students' attitude and smoking behaviour following the implementation of a university smoke-free policy: a cross-sectional study [RESEARCH]

Thu, 11 Apr 2013 00:00:00 +0000

ObjectiveIn view of the high-smoking rate among university students in Lebanon and the known adverse effects of second-hand smoking, the American University of Beirut (AUB) decided to implement a non-smoking policy on campus. This study sought to examine the students' compliance and attitudes following the ban. DesignCross-sectional study. SettingA private university in Lebanon. Participants545 randomly selected students were approached. A stratified cluster sample of classes offered in the spring semester of the 2008/2009 academic year was selected. Students completed a self-administered paper and pencil survey during class time. Primary and secondary outcome measuresThe main outcomes were compliance with and attitudes towards the ban. Other secondary outcomes were the perception of barriers to implementation of the ban and attitudes towards tobacco control in general. Results535 students participated in the study. Smokers were generally compliant with the ban (72.7%) and for some (20%) it led to a decrease in their smoking. Students' attitude towards the ban and the enforcement of a non-smoking policy in public places across Lebanon varied according to their smoking status whereby non-smokers possessed a more favourable attitude and strongly supported such policies compared with smokers; overall, the largest proportions of students were satisfied to a large extent with the ban and considered it justified (58.6% and 57.2%, respectively). While much smaller percentages reported that the ban would help in reducing smoking to a large extent (16.7%) or it would help smokers quit (7.4%). Perceived barriers to implementation of the non-smoking policy in AUB included the lack of compliance with and strict enforcement of the policy as well as the small number and crowdedness of the smoking areas. ConclusionsAn education campaign, smoking cessation services and strict enforcement of the policy might be necessary to boost its effect in further reducing students' cigarette use.

Use of simulation to assess electronic health record safety in the intensive care unit: a pilot study [RESEARCH]

Wed, 10 Apr 2013 00:00:00 +0000

ObjectiveTo establish the role of high-fidelity simulation training to test the efficacy and safety of the electronic health record (EHR)-user interface within the intensive care unit (ICU) environment. DesignProspective pilot study. SettingMedical ICU in an academic medical centre. ParticipantsPostgraduate medical trainees. InterventionsA 5-day-simulated ICU patient was developed in the EHR including labs, hourly vitals, medication administration, ventilator settings, nursing and notes. Fourteen medical issues requiring recognition and subsequent changes in management were included. Issues were chosen based on their frequency of occurrence within the ICU and their ability to test different aspects of the EHR-user interface. ICU residents, blinded to the presence of medical errors within the case, were provided a sign-out and given 10 min to review the case in the EHR. They then presented the case with their management suggestions to an attending physician. Participants were graded on the number of issues identified. All participants were provided with immediate feedback upon completion of the simulation. Primary and secondary outcomesTo determine the frequency of error recognition in an EHR simulation. To determine factors associated with improved performance in the simulation. Results38 participants including 9 interns, 10 residents and 19 fellows were tested. The average error recognition rate was 41% (range 6-73%), which increased slightly with the level of training (35%, 41% and 50% for interns, residents, and fellows, respectively). Over-sedation was the least-recognised error (16%); poor glycemic control was most often recognised (68%). Only 32% of the participants recognised inappropriate antibiotic dosing. Performance correlated with the total number of screens used (p=0.03). ConclusionsDespite development of comprehensive EHRs, there remain significant gaps in identifying dangerous medical management issues. This gap remains despite high levels of medical training, suggesting that EHR-specific training may be beneficial. Simulation provides a novel tool in order to both identify these gaps as well as foster EHR-specific training.

Socioeconomic characteristics of residential areas and risk of death: is variation in spatial units for analysis a source of heterogeneity in observed associations? [RESEARCH]

Wed, 3 Apr 2013 00:00:00 +0000

ObjectivesEvidence on the association between the adverse socioeconomic characteristics of residential area and mortality is mixed. We examined whether the choice of spatial unit is critical in detecting this association. DesignRegister-linkage study. SettingData were from the Finnish Public Sector study's register cohort. ParticipantsThe place of residence of 146 600 cohort participants was linked to map grids and administrative areas, and they were followed up for mortality from 2000 to 2011. Residential area socioeconomic deprivation and household crowding were aggregated into five alternative areas based on map grids (250x250 m, 1x1 km and 10x10 km squares), and administrative borders (zip-code area and town). Primary and secondary outcome measuresAll-cause mortality. ResultsFor the 250x250 m area, mortality risk increased with increasing socioeconomic deprivation (HR for top vs bottom quintile 1.36, 95% CI 1.21 to 1.52). This association was either weaker or missing when broader spatial units were used. For household crowding, excess mortality was observed across all spatial units, the HRs ranging from 1.14 (95% CI 1.03 to 1.25) for zip code, and 1.21 (95% CI 1.11 to 1.31) for 250x250 m areas to 1.28 (95% CI 1.10 to 1.50) for 10x10 km areas. ConclusionsVariation in spatial units for analysis is a source of heterogeneity in observed associations between residential area characteristics and risk of death.

Influence of the 2009 financial crisis on detection of advanced pulmonary tuberculosis in Osaka city, Japan: a cross-sectional study [RESEARCH]

Wed, 3 Apr 2013 00:00:00 +0000

ObjectiveTo investigate the association between the economic recession and the detection of advanced cases of pulmonary tuberculosis in Osaka city from 2007 to 2009. DesignA repeated cross-sectional study. SettingOsaka city has been the highest tuberculosis burden area in Japan. After the previous global financial crisis, the unemployment rate in Osaka prefecture has deteriorated from 5.3% in 2008 to 6.6% in 2009. ParticipantsDuring the study period, 3406 pulmonary tuberculosis cases were enrolled: 2530 males and 876 females; 1546 elderly cases (65 years and above) and 1860 young cases (under 65 years); 417 homeless cases and 2989 non-homeless cases. Outcome measuresPatients' information included the sex, age, registry, health insurances, places of detection, sputum smear test results, patients' delay, doctors' delay and the grade of chest x-ray findings. They were statistically analysed between 2007 and 2008, two years before and just before the financial crisis, and between 2008 and 2009, just before and after the financial crisis. ResultsThe total numbers of pulmonary tuberculosis cases were 1172 in 2007, 1083 in 2008 and 1151 in 2009. In health examinations for non-homeless people, higher number of cases in 2009 were sputum smear positive, had respiratory symptoms and showed advanced disease in chest x-rays than those in 2008, with a longer patients' delay. On the contrary, in health examination for homeless people, fewer cases of advanced pulmonary tuberculosis were found in 2009 than in 2008, with a shorter patients' delay. In clinical examinations, there was no trend towards a difference between non-homeless and homeless people. ConclusionsAlthough homeless people might be protected by public assistance, tuberculosis prevention and control need to be reinforced for the non-homeless population after the financial crisis.

Are there differences in injury mortality among refugees and immigrants compared with native-born? [ORIGINAL ARTICLE]

Mon, 1 Apr 2013 00:00:00 +0000

BackgroundThe authors studied injury mortality in Denmark among refugees and immigrants compared with that among native Danes. MethodA register-based, historical prospective cohort design. All refugees (n=29 139) and family reunited immigrants (n=27 134) who between 1 January 1993 and 31 December 1999 received residence permission were included and matched 1:4 on age and sex with native Danes. Civil registration numbers were cross-linked to the Register of Causes of Death, and fatalities due to unintentional and intentional injuries were identified based on ICD-10 diagnosis. Sex-specific mortality ratios were estimated by migrant status and region of birth, adjusting for age and income and using a Cox regression model after a median follow-up of 11-12 years. ResultsCompared with native Danes, both female (RR=0.44; 95% CI 0.23 to 0.83) and male (RR=0.40; 95% CI 0.29 to 0.56) refugees as well as female (RR=0.40; 95% CI 0.21 to 0.76) and male (RR=0.22; 95% CI 0.12 to 0.42) immigrants had significantly lower mortality from unintentional injuries. Suicide rates were significantly lower for male refugees (RR=0.38; 95% CI 0.24 to 0.61) and male immigrants (RR=0.24; 95% CI 0.10 to 0.59), whereas their female counterparts showed no significant differences. Only immigrant women had a significantly higher homicide rate (RR=3.09; 95% CI 1.11 to 8.60) compared with native Danes. ConclusionsOverall results were advantageous to migrant groups. Research efforts should concentrate on investigating protective factors among migrants, which may benefit injury prevention in the majority population.

Pandemic influenza in Papua New Guinea: a modelling study comparison with pandemic spread in a developed country [RESEARCH]

Tue, 26 Mar 2013 00:00:00 +0000

ObjectivesThe possible occurrence of a highly pathogenic influenza strain is of concern to health authorities worldwide. It is known that during past influenza pandemics developing countries have experienced considerably higher death rates compared with developed countries. Furthermore, many developing countries lack appropriate pandemic preparedness plans. Mathematical modelling studies to guide the development of such plans are largely focused on predicting pandemic influenza spread in developed nations. However, intervention strategies shown by modelling studies to be highly effective for developed countries give limited guidance as to the impact which an influenza pandemic may have on low-income countries given different demographics and resource constraints. To address this, an individual-based model of a Papua New Guinean (PNG) community was created and used to simulate the spread of a novel influenza strain. The results were compared with those obtained from a comparable Australian model. DesignA modelling study. SettingThe towns of Madang in PNG (population [~]35 000) and Albany (population [~]30 000) in Australia. Outcome measuresDaily and cumulative illness attack rates in both models following introduction of a novel influenza strain into a naive population, for an unmitigated scenario and two social distancing intervention scenarios. ResultsThe unmitigated scenario indicated an approximately 50% higher attack rate in PNG compared with the Australian model. The two social distancing-based interventions strategies were 60-70% less effective in a PNG setting compared with an Australian setting. ConclusionsThis study provides further evidence that an influenza pandemic occurring in a low-income country such as PNG may have a greater impact than one occurring in a developed country, and that PNG-feasible interventions may be substantially less effective. The larger average household size in PNG, the larger proportion of the population under 18 and greater community-wide contact all contribute to this feature.

Incidence and risk factors for mortality of vertebral osteomyelitis: a retrospective analysis using the Japanese diagnosis procedure combination database [RESEARCH]

Mon, 25 Mar 2013 00:00:00 +0000

ObjectiveTo examine the incidence of vertebral osteomyelitis (VO) and the clinical features of VO focusing on risk factors for death using a Japanese nationwide administrative database. DesignRetrospective observational study. SettingHospitals adopting the Diagnosis Procedure Combination system during 2007-2010. ParticipantsWe identified 7118 patients who were diagnosed with VO (International Classification of Diseases, 10th Revision codes: A18.0, M46.4, M46.5, M46.8, M46.9, M48.9 and M49.3, checked with the detailed diagnoses in each case and all other codes indicating the presence of a specific infection) and hospitalised between July and December, 2007-2010, using the Japanese Diagnosis Procedure Combination database. Main outcome measuresThe annual incidence of VO was estimated. Logistic regression analysis was performed to analyse factors affecting in-hospital mortality in the VO patients. Dependent variables included patient characteristics (age, sex and comorbidities), procedures (haemodialysis and surgery) and hospital factors (type of hospital and hospital volume). ResultsOverall, 58.9% of eligible patients were men and the average age was 69.2 years. The estimated incidence of VO increased from 5.3/100 000 population per year in 2007 to 7.4/100 000 population per year in 2010. In-hospital mortality was 6%. There was a linear trend between higher rates of in-hospital mortality and greater age. A higher rate of in-hospital mortality was significantly associated with haemodialysis use (ORs, 10.56 (95% CI 8.12 to 13.74)), diabetes (2.37 (1.89 to 2.98)), liver cirrhosis (2.63 (1.49 to 4.63)), malignancy (2.68, (2.10 to 3.42)) and infective endocarditis (3.19 (1.80 to 5.65)). ConclusionsOur study demonstrates an increasing incidence of VO, and defines risk factors for death with a nationwide database. Several comorbidities were significantly associated with higher rates of in-hospital death in VO patients.

Analysis of 2009 pandemic influenza A/H1N1 outcomes in 19 European countries: association with completeness of national strategic plans [RESEARCH]

Thu, 21 Mar 2013 00:00:00 +0000

ObjectiveTo describe changes in reported influenza activity associated with the 2009 H1N1 pandemic in European countries and determine whether there is a correlation between these changes and completeness of national strategic pandemic preparedness. DesignA retrospective correlational study. SettingCountries were included if their national strategic plans had previously been analysed and if weekly influenza-like illness (ILI) data from sentinel networks between week 21, 2006 and week 20, 2010 were more than 50% complete. Outcome measuresFor each country we calculated three outcomes: the percentage change in ILI peak height during the pandemic relative to the prepandemic mean; the timing of the ILI peak and the percentage change in total cases relative to the prepandemic mean. Correlations between these outcomes and completeness of a country's national strategic pandemic preparedness plan were assessed using the Pearson product-moment correlation coefficient. ResultsNineteen countries were included. The ILI peak occurred earlier than the mean seasonal peak in 17 countries. In 14 countries the pandemic peak was higher than the seasonal peak, though the difference was large only in Norway, the UK and Greece. Nine countries experienced more total ILI cases during the pandemic compared with the mean for prepandemic years. Five countries experienced two distinct pandemic peaks. There was no clear pattern of correlation between overall completeness of national strategic plans and pandemic influenza outcome measures and no evidence of association between these outcomes and components of pandemic plans that might plausibly affect influenza outcomes (public health interventions, vaccination, antiviral use, public communication). Amongst the 17 countries with a clear pandemic peak, only the correlation between planning for essential services and change in total ILI cases significantly differed from zero: correlation coefficient (95% CI) 0.50 (0.02, 0.79). ConclusionsThe diversity of pandemic influenza outcomes across Europe is not explained by the marked variation in the completeness of pandemic plans.

Psychiatric disorders among women and men in assisted reproductive technology (ART) treatment. The Danish National ART-Couple (DANAC) cohort: protocol for a longitudinal, national register-based cohort study [PROTOCOL]

Thu, 21 Mar 2013 00:00:00 +0000

IntroductionThere are complex causal associations between mental disorders, fertility treatment, fertility treatment outcome and infertility per se. Eating disorders cause endocrine disturbances, anovulation and thereby infertility, and research has shown that infertility as well as unsuccessful assisted reproductive technology (ART) treatment are potential risk factors for developing a depression on a long-term basis. Despite the fact that worldwide more than 400 000 ART treatment cycles are performed every year, the causal associations between mental disorders, use of medication for mental disorders and ART treatment in both sexes have only been sparsely explored. Method and analysisThe main objective of this national register-based cohort study is to assess women's and men's mental health before, during, and after ART treatment in comparison with the mental health in an age-matched population-based cohort of couples with no history of ART treatment. Furthermore, the objective is to study the reproductive outcome of ART treatment among women who have a registered diagnosis of a mental disorder or have used medication for mental disorders prior to ART treatment compared with women in ART treatment without a mental disorder. We will establish the Danish National ART-Couple (DANAC) cohort including all women registered with ART treatment in the Danish in vitro fertilisation Register during 1994-2009 (N=42 915) and their partners. An age-matched population-based comparison cohort of women without ART treatment (n=215 290) and their partners will be established. Data will be cross-linked with data from national registers on psychiatric disorders, medical prescriptions for mental disorders, births, causes of deaths and sociodemographic data. Survival analyses and other statistical analyses will be conducted on the development of mental disorders and use of medication for mental disorders for women and men both prior to and after ART treatment.

Young adult women smokers' response to using plain cigarette packaging: a naturalistic approach [RESEARCH]

Mon, 18 Mar 2013 00:00:00 +0000

ObjectivesTo explore young adult women smokers' cognitive and emotional response to using dark brown plain' cigarette packs in natural settings and whether plain packaging is associated with any short-term change in smoking behaviour. DesignA naturalistic approach. Participants used plain cigarette packs provided to them for 1 week and for 1 week their own fully branded packs, but otherwise smoked and socialised as normal. Participants completed questionnaires twice a week. SettingThe six most populated cities and towns in Scotland. Participants301 young women smokers were recruited, with a final sample of 187 (62.1%). To meet the inclusion criteria women had to be between the ages of 18 and 35, daily cigarette smokers and provide a breath sample to confirm smoking status. Primary and secondary outcome measuresPack perceptions and feelings, feelings about smoking, salience and perceptions of health warnings and avoidant and cessation behaviours. ResultsIn comparison to fully branded packaging, plain packaging was associated with more negative perceptions and feelings about the pack and about smoking (p<0.001). No significant overall differences in salience, seriousness or believability of health warnings were found between the pack types, but participants reported looking more closely at the warnings on plain packs and also thinking more about what the warnings were telling them (p<0.001). Participants reported being more likely to engage in avoidant behaviours, such as hiding or covering the pack (p<0.001), and cessation behaviours, such as foregoing cigarettes (p<0.05), smoking less around others (p<0.001), thinking about quitting (p<0.001) and reduced consumption (p<0.05), while using the plain packs. Results did not differ by dependence level or socioeconomic status. ConclusionsNo research design can capture the true impacts of plain packaging prior to its introduction, but this study suggests that plain packaging may help reduce cigarette consumption and encourage cessation in the short term.

A nationally representative survey of healthcare provider counselling and provision of the female condom in South Africa and Zimbabwe [RESEARCH]

Mon, 18 Mar 2013 00:00:00 +0000

ObjectivesFemale condoms are the only female-initiated HIV and pregnancy prevention technology currently available. We examined female condom counselling and provision among providers in South Africa and Zimbabwe, high HIV-prevalence countries. DesignA cross-sectional study using a nationally representative survey. SettingAll facilities that provide family planning or HIV/sexually transmitted infection (STI) services. ParticipantsNational probability sample of 1444 nurses and physicians who provide family planning or HIV/STI services. Primary and secondary outcome measuresFemale condom practices with different female patients, including adolescents, married women, women using hormonal contraception and by HIV status. Using multivariable logistic analysis, we measured variations in condom counselling by provider characteristics. ResultsMost providers reported offering female condoms (88%; 1239/1415), but perceived a need for novel female barrier methods for HIV/STI prevention (85%; 1191/1396). By patient type, providers reported less frequent female condom counselling of adolescents (55%; 775/1411), women using hormonal contraception (65%; 909/1409) and married women (66%; 931/1416), compared to unmarried (74%; 1043/1414) or HIV-positive women (82%; 1161/1415). Multivariable results showed providers in South Africa were less likely to counsel women on female condoms than in Zimbabwe (OR=0.48, 95% CI 0.35 to 0.68, p[≤]0.001). However, South African providers were more likely to counsel women on male condoms (OR=2.39, 95% CI 1.57 to 3.65, p[≤]0.001). Nurses counselled patients on female condoms more frequently than physicians (OR=5.41, 95% CI 3.26 to 8.98, p[≤]0.001). HIV training, family planning training, location (urban vs rural) and facility type (hospital vs clinic) were not associated with greater condom counselling. ConclusionsFemale condoms were integrated into provider counselling and care, although providers reported a need for new female-initiated multipurpose prevention technologies, suggesting female condoms do not meet all patient/provider needs or are not adequately well known or accessible. Providers should be included in HIV training efforts to raise awareness of new and existing products, and encouraged to educate all women.

The clustering of cardiovascular disease risk factors and their impacts on annual medical expenditure in Japan: community-based cost analysis using Gamma regression models [RESEARCH]

Fri, 15 Mar 2013 00:00:00 +0000

ObjectiveThe clustering of cardiovascular disease (CVD) risk factors is a serious threat for increasing medical expenses. The age-specific proportion and distribution of medical expenditure attributable to CVD risk factors, especially focused on the elderly, is thus indispensable for formulating public health policy given the extent of the ageing population in developed countries. DesignCost analysis using individuals' medical expenses and their corresponding health examination measures. SettingShiga prefecture, Japan, from April 2000 to March 2006. Participants33 213 participants aged 40 years and over. Main outcome measuresMean medical expenditure per year. MethodsGamma regression models were applied to examine how the number of CVD risk factors affects mean medical expenditure. The four CVD risk factors analysed in this study were defined as follows: hypertension (systolic blood pressure [≥]140 mm Hg or diastolic blood pressure [≥]90 mm Hg), hypercholesterolaemia (serum total cholesterol [≥]240 mg/dl), high blood glucose (casual blood glucose [≥]200 mg/dl) and smoking (current smoker). Sex-specific and age-specific investigations were carried out on the elderly (aged 65 and over) and non-elderly (aged 40-64) populations. ResultsThe mean medical expenditure (per year) for the no CVD risk-factor group was only 110 000 yen at age 50 (men, 110 708 yen; women, 107 109 yen), but this expenditure was 6-7 times higher for 80-year-olds who have three or four CVD risk factors (men, 603 351 yen; women, 765 673 yen). The total overspend (excess fraction) was larger for the non-elderly (men, 15.4%; women, 11.1%) than that for the elderly (men, 0.1%; women, 5.2%) and largely driven by people with one or two CVD risk factors, except for elderly men. ConclusionsThe age-specific proportion and distribution of medical expenditure attributable to CVD risk factors showed that a high-risk approach for the elderly and a population approach for the majority are both necessary to reduce total medical expenditure in Japan.

Social inequality in breast, lung and colorectal cancers: a sibling approach [RESEARCH]

Fri, 15 Mar 2013 00:00:00 +0000

ObjectiveTo examine whether family factors shared by siblings explained the association between education and risk of lung, colorectal and breast cancer. DesignWe used conventional cohort and intersibling Cox regression analyses to analyse the association between education and risk of cancer. SettingDenmark. ParticipantsWe retrieved register data from Statistics Denmark on individuals born in Denmark 1950-1979 with at least one full sibling. The cohorts included between 391 931 and 1 381 369 individuals followed from age 28 for incident lung, colorectal and breast cancer until the end of 2009. ResultsIn the cohort analysis, low education was associated with an increased risk of colorectal cancer before age 45 and lung cancer, and with a decreased risk of colorectal cancer after age 45 and breast cancer. When compared with the cohort analyses, the intersibling associations were stronger for colorectal cancer after age 45 and weaker for lung cancer. Serious health conditions in childhood/young adulthood did not explain the associations. ConclusionsFamily factors shared by siblings confounded some of the association between education and colorectal cancer after age 45 and lung cancer, but not the associations found for colorectal cancer before age 45 or breast cancer.

A cohort study for the impact of activity-limiting injuries based on the Canadian National Population Health Survey 1994-2006 [RESEARCH]

Wed, 13 Mar 2013 00:00:00 +0000

ObjectiveTo examine the prevalence and factors affecting activity-limiting injuries (ALI) in individuals and in the Canadian population; to estimate the short and long term impact on health status and well-being because of ALI in Canada from 1994 to 2006 using the Canadian National Population Health Survey (NPHS). DesignThe NPHS is a randomised longitudinal cohort study with biennial interviews, with information on age, sex, education, marital status, income, residence, height and weight to self-perceived health status, healthcare utilisation and medication use in addition to ALI. SettingThe study population was a random sample of male and female participants 20 years and older from 10 provinces and three territories in Canada. Primary and secondary outcome measuresLogistic regression models were used to assess the potential impact of ALI on individuals and on the Canadian population. The interviews 2 years before and 2 years after the ALI were compared to examine long-term effects, and the McNemar test option in SAS was used for the matched analysis. ResultsThe immediate impacts of ALI were pain, disability and disruption of regular life. Long-term effects in patients were chronic pain and increased medical doctor visits. Population impact included a considerable increase in healthcare access and cost. The odds ratios (OR) for the 20-39 age group compared with those 60+ was 2.2; 95% CI 1.8 to 2.7, while the OR associated with male participants was 1.4; 95% CI 1.1 to 1.6. Individuals consuming nine or more alcoholic drinks per week were also significantly more likely to report an ALI (OR, 1.5; 95% CI 1.3 to 1.8). ConclusionsThe findings from this study illustrated the immediate and long-term impact of individuals and population level injuries in Canada. Injury control policies should aim to prevent the number of injuries, fatalities as well as the consequences among survivors.

Associations between body weight perception and weight control behaviour in South Indian children: a cross-sectional study [RESEARCH]

Sat, 9 Mar 2013 00:00:00 +0000

ObjectiveTo examine the patterns of weight loss behaviour and the association between weight loss attempts with actual weight status and children's and parental perceptions of weight status. DesignA cross-sectional study. SettingKarnataka, South India. Participants1874 girls and boys aged 8-14 years from seven schools in Karnataka, South India. Main outcome measuresThe association between weight loss attempts and sociodemographic factors, weight status and the child's or the parent's perception of weight status. ResultsApproximately 73% of overweight and obese, 35% of normal weight and 22% of underweight children attempted to lose weight. Children of lower socioeconomic groups studying in schools in the local vernacular and overweight/obese children were more likely to attempt to lose weight (adjusted OR ie, AOR=1.57, 95% CI 1.11 to 2.25; AOR=4.38, 95% CI 2.64 to 7.28, respectively). Perception of weight status was associated with weight loss attempts. Thus, children who were of normal weight but perceived themselves to be overweight/obese were three times more likely to attempt weight loss compared with those who accurately perceived themselves as being of normal weight, while the odds of attempting weight loss were the highest for those who were overweight and perceived themselves to be so (AOR[~]18). ConclusionsChildren are likely to attempt weight loss in India irrespective of their weight status, age and gender. Children who were actually overweight as well as those who were perceived by themselves or by their parents to be overweight or obese were highly likely to try to lose weight. It is necessary to understand body weight perceptions in communities with a dual burden of being overweight and undernourished, if intervention programmes for either are to be successful.

Cadmium exposure, intercellular adhesion molecule-1 and peripheral artery disease: a cohort and an experimental study [RESEARCH]

Wed, 6 Mar 2013 00:00:00 +0000

ObjectivesCadmium exposure has been found to be associated with atherosclerotic plaques in the carotid arteries and with circulating levels of the proatherogenic intercellular adhesion molecule-1 (ICAM-1). The research questions were (1) if blood and urinary cadmium levels are associated with low ankle-brachial index (ABI) as a measure of peripheral artery disease in a longitudinal study and (2) if ICAM-1 mediates proatherogenic effects of cadmium exposure. DesignA prospective, observational cohort study with a 5-year follow-up and an experimental study of cultured human aortic endothelial cells exposed to cadmium. SettingResearch unit at a university hospital. ParticipantsA cohort of 64-year-old women (n=489) recruited by stratified sampling of similarly sized groups with normal, impaired and diabetic glucose tolerance as assessed in a population-based screening examination. Primary and secondary outcome measuresABI (ratio of the systolic blood pressures in the tibial and brachial arteries [≤]0.9 in any artery) in relation to cadmium exposure; ICAM-1 concentrations in the cell culture medium after cadmium incubation. ResultsHigh (tertile 3 vs 1) concentrations of blood (B-Cd) or creatine-adjusted urinary cadmium (U-Cd) at baseline were found to predict low ABI after adjustment for smoking and other cardiovascular risk factors at baseline. For U-Cd the OR was 2.5 (95% CI 1.1 to 5.8). After exclusion of participants with ultrasound-assessed femoral atherosclerosis at baseline the OR for U-Cd was unchanged, and for B-Cd it was 3.7 (95% CI 1.05 to 13.3). Inclusion of serum ICAM-1 levels did not affect the cadmium-related ORs in multivariate analyses. The experimental study did not show any cadmium-induced increase of the production of ICAM-1 from human endothelial cells. ConclusionsCadmium exposure was associated with future peripheral artery disease, supporting the concept that cadmium exposure in the population has proatherogenic effects, although ICAM-1 mediated effects do not seem to be involved.

Self-rated health and type 2 diabetes risk in the European Prospective Investigation into Cancer and Nutrition-InterAct study: a case-cohort study [RESEARCH]

Wed, 6 Mar 2013 00:00:00 +0000

ObjectivesTo investigate the association between self-rated health and risk of type 2 diabetes and whether the strength of this association is consistent across five European centres. DesignPopulation-based prospective case-cohort study. SettingEnrolment took place between 1992 and 2000 in five European centres (Bilthoven, Cambridge, Heidelberg, Potsdam and Umea). ParticipantsSelf-rated health was assessed by a baseline questionnaire in 3399 incident type 2 diabetic case participants and a centre-stratified subcohort of 4619 individuals from the European Prospective Investigation into Cancer and Nutrition (EPIC)-InterAct study which was drawn from a total cohort of 340 234 participants in the EPIC. Primary outcome measurePrentice-weighted Cox regression was used to estimate centre-specific HRs and 95% CIs for incident type 2 diabetes controlling for age, sex, centre, education, body mass index (BMI), smoking, alcohol consumption, energy intake, physical activity and hypertension. The centre-specific HRs were pooled across centres by random effects meta-analysis. ResultsLow self-rated health was associated with a higher hazard of type 2 diabetes after adjusting for age and sex (pooled HR 1.67, 95% CI 1.48 to 1.88). After additional adjustment for health-related variables including BMI, the association was attenuated but remained statistically significant (pooled HR 1.29, 95% CI 1.09 to 1.53). I2 index for heterogeneity across centres was 13.3% (p=0.33). ConclusionsLow self-rated health was associated with a higher risk of type 2 diabetes. The association could be only partly explained by other health-related variables, of which obesity was the strongest. We found no indication of heterogeneity in the association between self-rated health and type 2 diabetes mellitus across the European centres.

Characteristics, risk factors and mortality of stroke patients in Kyoto, Japan [RESEARCH]

Tue, 5 Mar 2013 00:00:00 +0000

ObjectivesThe aim of the study was to evaluate the characteristics, risk factors and outcome of recent stroke patients in Kyoto, Japan. DesignWe analysed stroke patients in the registry with regard to their characteristics, risk factors and mortality. Cox proportional hazards regressions were used to calculate adjusted HRs for death. SettingsThe Kyoto prefecture of Japan has established a registry to enrol new stroke patients in cooperation with the Kyoto Medical Association and its affiliated hospitals ParticipantsThe registry now has data on 14 268 patients enrolled from 1 January 1999 to 31 December 2009. Of these, 12 774(89.5%) underwent CT, 9232 (64.7%) MRI, 2504 (17.5%) angiography and 342 (2.4%) scintigraphy. Excluding 480 (3.3%) unclassified patients, 13 788 (96.6%) patients formed the basis of further analyses which were divided into three subtypes: cerebral infarction (CI), cerebral haemorrhage (CH) and subarachnoid haemorrhage (SAH). ResultsA total of 13 788 confirmed stroke patients in the study cohort comprised 9011 (86.3%) CI, 3549 (25.7%) CH and 1197 (8.7%) SAH cases. The mean age {+/-}SD was 73.3{+/-}11.8, 69.1{+/-}13.6 and 62.7{+/-}13.5 in the CI, CH and SAH cases, respectively. Men were predominant in the CI and CH cases, whereas women were predominant in the SAH cases. The frequencies of risk factors were different among the subtypes. Mortality was worst in SAH, followed by CH, and least in CI. HRs for death adjusted for age, sex, histories of hypertension, arrhythmia, diabetes mellitus and hyperlipaemia and use of tobacco and/or alcohol showed a significant (p<0.001) difference among CI (as reference), CH (3.71; 3.11 to 4.43) and SAH (8.94; 7.21 to 11.11). ConclusionsThe characteristics, risk factors and mortality were evaluated in a quantitative manner in a large Japanese study cohort to shed light on the present status of stroke medicine.

Low prevalence of methicillin-resistant Staphylococcus aureus among men who have sex with men attending an STI clinic in Amsterdam: a cross-sectional study [RESEARCH]

Tue, 5 Mar 2013 00:00:00 +0000

ObjectiveCommunity-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is common among men who have sex with men (MSM) in the USA. It is unknown whether this is also the case in Amsterdam, the Netherlands. DesignCross-sectional study. SettingSexually transmitted infection outpatient low-threshold clinic, Amsterdam, the Netherlands. ParticipantsBetween October 2008 and April 2010, a total of 211 men were included, in two groups: (1) 74 MSM with clinical signs of a skin or soft tissue infection (symptomatic group) and (2) 137 MSM without clinical signs of such infections (asymptomatic group). Primary outcome measuresS aureus and MRSA infection and/or colonisation. Swabs were collected from the anterior nasal cavity, throat, perineum, penile glans and, if present, from infected skin lesions. Culture for S aureus was carried out on blood agar plates and for MRSA on selective chromagar plates after enrichment in broth. If MRSA was found, the spa-gene was sequenced. Secondary outcome measuresAssociated demographic characteristics, medical history, risk factors for colonisation with S aureus and high-risk sexual behaviour were collected through a self-completed questionnaire. ResultsThe prevalence of S aureus colonisation in the nares was 37%, the pharynx 11%, the perianal region 12%, the glans penis 10% and in skin lesions 40%. In multivariable analysis adjusting for age, anogenital S aureus colonisation was significantly associated with the symptomatic group (p=0.01) and marginally with HIV (p=0.06). MRSA was diagnosed in two cases: prevalence 0.9% (95% CI 0.1% to 3.4%)). Neither had CA-MRSA strains. ConclusionsCA-MRSA among MSM in Amsterdam is rare. Genital colonisation of S aureus is not associated with high-risk sexual behaviour.

An evaluation of the performance of the NHS Health Check programme in identifying people at high risk of developing type 2 diabetes [RESEARCH]

Tue, 5 Mar 2013 00:00:00 +0000

ObjectiveTo evaluate the performance of the National Health Service (NHS) Health Check in identifying people at high risk of having or developing type 2 diabetes. DesignRetrospective evaluation of the performance of the NHS Health Check diabetes filter (based on ethnicity, body mass index and blood pressure) in identifying people at risk for type 2 diabetes (glycated haemoglobin (HbA1c) [≥]42 mmol/mol recorded within 3 months of their NHS Health Check). SettingHeart of Birmingham Primary Care Trust (HoB PCT). Subjects34 022 patients with a Read code in the general practitioners' (GP) clinical record indicating that they had attended an NHS Health Check over the period April 2009 - February 2012. Outcome measuresPrimary outcome measure: proportion (%) of patients at risk of diabetes or non-diabetes hyperglycaemia not identified by a simple application of the NHS Health Check diabetes filter. Secondary outcome measures included sensitivity, positive predictive value (PPV) and specificity of the NHS Health Check diabetes filter. ResultsIn HoB PCT, the simple application of the NHS Health Check diabetes filter led to a failure to identify 1990/5968 (33.3% (95% CI, 31.2% to 35.4%)) of patients of known ethnicity at risk of having or developing diabetes (HbA1c[≥]42 mmol/mol). The NHS Health Check diabetes filter has a sensitivity of 66.8% (95% CI 65.7% to 68.0%), and the PPV was 41.1% (95% CI 40.1% to 42.1%). Specificity was 34.7% (95%CI 33.9% to 35.6%). Sensitivity and PPV of the NHS Health Check diabetes filter in the HoB PCT population are significantly greater for patients of Asian ethnic origin than for those of other ethnic backgrounds. ConclusionsThis evaluation, which was based on a large population sample, demonstrates that the NHS Health Check programme diabetes filter failed to identify a third of people at high risk of having or developing diabetes.

Meteorological factors and risk of community-acquired Legionnaires' disease in Switzerland: an epidemiological study [RESEARCH]

Tue, 5 Mar 2013 00:00:00 +0000

ObjectivesThe aim of this study was to identify meteorological factors that could be associated with an increased risk of community-acquired Legionnaires' disease (LD) in two Swiss regions. DesignRetrospective epidemiological study using discriminant analysis and multivariable Poisson regression. SettingWe analysed legionellosis cases notified between January 2003 and December 2007 and we looked for a possible relationship between incidence rate and meteorological factors. ParticipantsCommunity-acquired LD cases in two Swiss regions, the Canton Ticino and the Basle region, with climatically different conditions were investigated. Primary outcome measuresVapour pressure, temperature, relative humidity, wind, precipitation and radiation recorded in weather stations of the two Swiss regions during the period January 2003 and December 2007. ResultsDiscriminant analysis showed that the two regions are characterised by different meteorological conditions. A multiple Poisson regression analysis identified region, temperature and vapour pressure during the month of infection as significant risk factors for legionellosis. The risk of developing LD was 129.5% (or 136.4% when considering vapour pressure instead of temperature in the model) higher in the Canton Ticino as compared to the Basle region. There was an increased relative risk of LD by 11.4% (95% CI 7.70% to 15.30%) for each 1 hPa rise of vapour pressure or by 6.7% (95% CI 4.22% to 9.22%) for 1{degrees}C increase of temperature. ConclusionsIn this study, higher water vapour pressure and heat were associated with a higher risk of community-acquired LD in two regions of Switzerland.

The incidence and impact of recurrent workplace injury and disease: a cohort study of WorkSafe Victoria, Australia compensation claims [RESEARCH]

Fri, 1 Mar 2013 00:00:00 +0000

ObjectiveTo determine the incidence and impact of recurrent workplace injury and disease over the period 1995-2008. DesignPopulation-based cohort study using data from the state workers' compensation system database. SettingState of Victoria, Australia. ParticipantsA total of 448 868 workers with an accepted workers' compensation claim between 1 January 1995 and 31 December 2008 were included into this study. Of them, 135 349 had at least one subsequent claim accepted for a recurrent injury or disease during this period. Main outcome measuresIncidence of initial and recurrent injury and disease claims and time lost from work for initial and recurrent injury and disease. ResultsOver the study period, 448 868 workers lodged 972 281 claims for discrete occurrences of work-related injury or disease. 53.4% of these claims were for recurrent injury or disease. On average, the rates of initial claims dropped by 5.6%, 95% CI (-5.8% to -5.7%) per annum, while the rates of recurrent injuries decreased by 4.1%, 95% CI (-4.2% to -0.4%). In total, workplace injury and disease resulted in 188 978 years of loss in full-time work, with 104 556 of them being for the recurrent injury. ConclusionsRecurrent work-related injury and disease is associated with a substantial social and economic impact. There is an opportunity to reduce the social, health and economic burden of workplace injury by enacting secondary prevention programmes targeted at workers who have incurred an initial occupational injury or disease.

Predictors of non-response in a UK-wide cohort study of children's accelerometer-determined physical activity using postal methods [RESEARCH]

Fri, 1 Mar 2013 00:00:00 +0000

ObjectivesTo investigate the biological, social, behavioural and environmental factors associated with non-consent, and non-return of reliable accelerometer data ([≥]2 days lasting [≥]10 h/day), in a UK-wide postal study of children's activity. DesignNationally representative prospective cohort study. SettingChildren born across the UK, between 2000 and 2002. Participants13 681 7 to 8-year-old singleton children who were invited to wear an accelerometer on their right hip for 7 consecutive days. Consenting families were posted an Actigraph GT1M accelerometer and asked to return it by post. Primary outcome measuresStudy consent and reliable accelerometer data acquisition. ResultsConsent was obtained for 12 872 (94.5%) interviewed singletons, of whom 6497 (50.5%) returned reliable accelerometer data. Consent was less likely for children with a limiting illness or disability, children who did not have people smoking near them, children who had access to a garden, and those who lived in Northern Ireland. From those who consented, reliable accelerometer data were less likely to be acquired from children who: were boys; overweight/obese; of white, mixed or other' ethnicity; had an illness or disability limiting daily activity; whose mothers did not have a degree; who lived in rented accommodation; who exercised once a week or less; who had been breastfed; were from disadvantaged wards; had younger mothers or lone mothers; or were from households with just one, or more than three children. ConclusionsStudies need to encourage consent and reliable data return in the wide range of groups we have identified to improve response and reduce non-response bias. Additional efforts targeted at such children should increase study consent and data acquisition while also reducing non-response bias. Adjustment must be made for missing data that account for missing data as a non-random event.

The interactions of ethical notions and moral values of immediate stakeholders of immunisation services in two Indian states: a qualitative study [RESEARCH]

Fri, 1 Mar 2013 00:00:00 +0000

ObjectivesThis study examines the existing norms regarding immunisation within the communities and the ethical notions that govern the actions of different health professionals and their collective synergistic or conflicting effects on the governance of the programme. DesignWe used descriptive and analytical qualitative methods as it suited the research question. SettingThe data were collected from areas under 16 primary health centres in Kerala and Tamil Nadu identified through a three-step sampling process. ParticipantsThis involved in-depth interviews with stakeholders including providers, beneficiaries and other stakeholders, focus group discussions with mothers of under-five children and participant and non-participant observations of vaccination-related activities. ResultsUnlike most other ethical analyses that look at the ethics of vaccination policies, the interactions of normative principles and notions are analysed in this article. Moral obligation of parents towards their children, beneficence of healthcare providers and the utilitarian aspirations of the state are the key normative principles involved. Our analysis points to the interplay of both synergy and conflict in ethical notions and moral values in the context of immunisation services. Paternalistic interventions like special immunisation campaigns against polio and Japanese encephalitis are a case in point: they generate conflict at the normative level and create mistrust. ConclusionsAnalysis of vaccination policies and programmes needs to go beyond factors that assess monetary benefits or herd immunity. Understanding the interactions of normative notions that shape the social organisation of the providers and the users of vaccination is important in creating a sustainable environment for the programme.

Initiation rites at menarche and self-reported dysmenorrhoea among indigenous women of the Colombian Amazon: a cross-sectional study [RESEARCH]

Fri, 1 Mar 2013 00:00:00 +0000

ObjectivesTo investigate the association between self-reported dysmenorrhoea and patterns of female initiation rites at menarche among Amazonian indigenous peoples of Vaupes in Colombia. DesignA cross-sectional study of all women in seven indigenous communities. Questionnaire administered in local language documented female initiation rites and experience of dysmenorrhoea. Analysis examined 10 initiation components separately, then together, comparing women who underwent all rites, some rites and no rites. SettingsSeven indigenous communities belonging to the Tukano language group in the Great Eastern Reservation of Vaupes (Colombia) in 2008. ParticipantsAll women over the age of 13 years living in the seven communities in Vaupes, who had experienced at least two menstruations (n=185), aged 13-88 years (mean 32.5; SD 15.6). Primary and secondary outcome measuresThe analysis rested on pelvic pain to define dysmenorrhoea as the main outcome. Women were also asked about other disorders present during menstruation or the precedent days, and about the interval between two menstruations and duration of each one. ResultsOnly 17.3% (32/185) completed all initiation rites and 52.4% (97/185) reported dysmenorrhoea. Women not completing the rites were more likely to report dysmenorrhoea than those who did so (p=0.01 Fisher exact), taking into account age, education, community, parity and use of family planning. Women who completed less than the full complement of rites had higher risk than those who completed all rites. Those who did not complete all rites reported increased severity of dysmenorrhoea (p=0.00014). ConclusionsOur results are compatible with an association between traditional practices and women's health. We could exclude indirect associations with age, education, parity and use of family planning as explanations for the association. The study indicates feasibility, possible utility and limits of intercultural epidemiology in small groups.

Protocol for an experimental study design to evaluate computer-enabled intervention to prevent and manage metabolic syndrome [PROTOCOL]

Fri, 1 Mar 2013 00:00:00 +0000

IntroductionThe rising prevalence of overweight and obesity has a direct correlation with increasing prevalence of hypertension, dyslipidaemia, type 2 diabetes, metabolic syndrome (MetS) and cardiovascular diseases. Most of the previous studies have been cross-sectional in nature and have looked at the prevalence of metabolic syndrome. Despite the clinical and public health importance of this phenomenon, not enough work has been carried out so far to study and remedy this situation. The objectives of the proposed study is to develop an innovative user-centred informatics platform that will facilitate delivery of a multifactorial intervention after taking into account user sociodemographics, health behaviour, prior disease state and knowledge attitudes and practices. ObjectiveThe objective of the proposed study is to develop an innovative user-centred informatics platform that will facilitate delivery of a multifactorial intervention after taking into account users' sociodemographics, health behaviour, prior disease state and knowledge, attitudes and behaviour. Methods and analysisA randomised two-group repeated-measures clinical trial design will be used, on 750 subjects from urban, rural and slum areas, in an Indian setting. The study participants will be randomly assigned to either the intervention (computer-based MetS Program, CBMP) or control (printed educational material, PEM) group. Both the groups will undergo screening, learning and evaluation assessments at the time of the visit and at follow-up visits 30, 60 and 90 days after the first visit. OutcomesThe outcomes expected in the intervention group include improvement in Mets-related knowledge, adherence to self-care practices, better quality of life and increased satisfaction with medical care. Ethics and disseminationThe study has been approved by the Institutional Review Board of Asian Institute of Public Health (IRB#621). The proposed study will also help us assess the usefulness and challenges of technology to disseminate health education among diverse users. Findings will be disseminated through peer-reviewed publications and national and international conference presentations to various stakeholders and local community health leaders. The ClinicalTrials.gov Identifier is NCT01713465.

Use of record-linkage to handle non-response and improve alcohol consumption estimates in health survey data: a study protocol [PROTOCOL]

Fri, 1 Mar 2013 00:00:00 +0000

IntroductionReliable estimates of health-related behaviours, such as levels of alcohol consumption in the population, are required to formulate and evaluate policies. National surveys provide such data; validity depends on generalisability, but this is threatened by declining response levels. Attempts to address bias arising from non-response are typically limited to survey weights based on sociodemographic characteristics, which do not capture differential health and related behaviours within categories. This project aims to explore and address non-response bias in health surveys with a focus on alcohol consumption. Methods and analysisThe Scottish Health Surveys (SHeS) aim to provide estimates representative of the Scottish population living in private households. Survey data of consenting participants (92% of the achieved sample) have been record-linked to routine hospital admission (Scottish Morbidity Records (SMR)) and mortality (from National Records of Scotland (NRS)) data for surveys conducted in 1995, 1998, 2003, 2008, 2009 and 2010 (total adult sample size around 40 000), with maximum follow-up of 16 years. Also available are census information and SMR/NRS data for the general population. Comparisons of alcohol-related mortality and hospital admission rates in the linked SHeS-SMR/NRS with those in the general population will be made. Survey data will be augmented by quantification of differences to refine alcohol consumption estimates through the application of multiple imputation or inverse probability weighting. The resulting corrected estimates of population alcohol consumption will enable superior policy evaluation. An advanced weighting procedure will be developed for wider use. Ethics and disseminationEthics approval for SHeS has been given by the National Health Service (NHS) Multi-Centre Research Ethics Committee and use of linked data has been approved by the Privacy Advisory Committee to the Board of NHS National Services Scotland and Registrar General. Funding has been granted by the MRC. The outputs will include four or five public health and statistical methodological international journal and conference papers. Primary subject headingPublic health. Secondary subject headingAddiction: health policy; mental health.

Does childhood adversity account for poorer mental and physical health in second-generation Irish people living in Britain? Birth cohort study from Britain (NCDS) [RESEARCH]

Fri, 1 Mar 2013 00:00:00 +0000

ObjectivesWorldwide, the Irish diaspora experience elevated mortality and morbidity across generations, not accounted for through socioeconomic position. The main objective of the present study was to assess if childhood disadvantage accounts for poorer mental and physical health in adulthood, in second-generation Irish people. DesignAnalysis of prospectively collected birth cohort data, with participants followed to midlife. SettingEngland, Scotland and Wales. ParticipantsApproximately 17 000 babies born in a single week in 1958. Six per cent of the cohort were of second-generation Irish descent. OutcomesPrimary outcomes were common mental disorders assessed at age 44/45 and self-rated health at age 42. Secondary outcomes were those assessed at ages 23 and 33. ResultsRelative to the rest of the cohort, second-generation Irish children grew up in marked material and social disadvantage, which tracked into early adulthood. By midlife, parity was reached between second-generation Irish cohort members and the rest of the sample on most disadvantage indicators. At age 23, Irish cohort members were more likely to screen positive for common mental disorders (OR 1.44; 95% CI 1.06 to 1.94). This had reduced slightly by midlife (OR 1.27; 95% CI 0.96 to 1.69). Although at age 23 second-generation cohort members were just as likely to report poorer self-rated health (OR 1.06; 95% CI 0.79 to 1.43), by midlife this difference had increased (OR 1.25; 95% CI 0.98 to 1.60). Adjustment for childhood and early adulthood adversity fully attenuated differences in adult health disadvantages. ConclusionsSocial and material disadvantage experienced in childhood continues to have long-range adverse effects on physical and mental health at midlife, in second-generation Irish cohort members. This suggests important mechanisms over the life-course, which may have important policy implications in the settlement of migrant families.

Hospitalisation rates for children with intellectual disability or autism born in Western Australia 1983-1999: a population-based cohort study [RESEARCH]

Wed, 27 Feb 2013 00:00:00 +0000

ObjectivesTo describe the hospitalisation patterns in children with intellectual disability (ID) and/or autism spectrum disorder (ASD) after the first year of life and compare with those unaffected. DesignProspective cohort study using data linkage between health, ID and hospitalisation population-based datasets. SettingWestern Australia. Participants416 611 individuals born between 1983 and 1999 involving 1 027 962 hospital admission records. Five case categories were defined (mild/moderate ID, severe ID, biomedically caused ID, ASD with ID and ASD without ID) and compared with the remainder of children and young people. Primary and secondary outcome measuresTime to event analysis was used to compare time hospitalisation and rate of hospitalisation between the different case-groups by estimating HR, accounting for birth year and preterm birth status. ResultsID and/or ASD were found to be associated with an increased risk of hospitalisation compared with the remainder of the population. The increase in risk was highest in those with severe ID and no ASD (HR=10.33, 95% CI 8.66 to 12.31). For those with ID of known biomedical cause or mild ID of unknown cause, the risk of hospitalisation was lower (HR=7.36, 95% CI 6.73 to 8.07 and HR=3.08, 95% CI 2.78 to 3.40, respectively). Those with ASDs had slightly increased risk (HR=2.82, 95% CI 2.26 to 3.50 for those with ID and HR=2.09, 95% CI 1.85 to 2.36 for those without ID). ConclusionsChildren with an ID or ASD experience an increased risk of hospitalisation after the first year of life which varied from 2 to 10 times that of the rest of the population. Findings can inform service planning or resource allocation for these children with special needs.

Exploring the potential of expatriate social networks to reduce HIV and STI transmission: a protocol for a qualitative study [PROTOCOL]

Tue, 26 Feb 2013 00:00:00 +0000

IntroductionHIV diagnoses acquired among Australian men working or travelling overseas including Southeast Asia are increasing. This change within transmission dynamics means traditional approaches to prevention need to be considered in new contexts. The significance and role of social networks in mediating sexual risk behaviours may be influential. Greater understanding of expatriate and traveller behaviour is required to understand how local relationships are formed, how individuals enter and are socialised into networks, and how these networks may affect sexual intentions and behaviours. This paper describes the development of a qualitative protocol to investigate how social networks of Australian expatriates and long-term travellers might support interventions to reduce transmission of HIV and sexually transmitted infections. Methods and analysisTo explore the interactions of male expatriates and long-term travellers within and between their environments, symbolic interactionism will be the theoretical framework used. Grounded theory methods provide the ability to explain social processes through the development of explanatory theory. The primary data source will be interviews conducted in several rounds in both Australia and Southeast Asia. Purposive and theoretical sampling will be used to access participants whose data can provide depth and individual meaning. Ethics and disseminationThe role of expatriate and long-term traveller networks and their potential to impact health are uncertain. This study seeks to gain a deeper understanding of the Australian expatriate culture, behavioural contexts and experiences within social networks in Southeast Asia. This research will provide tangible recommendations for policy and practice as the findings will be disseminated to health professionals and other stakeholders, academics and the community via local research and evaluation networks, conference presentations and online forums. The Curtin University Human Research Ethics Committee has granted approval for this research.

School closures and influenza: systematic review of epidemiological studies [RESEARCH]

Tue, 26 Feb 2013 00:00:00 +0000

ObjectiveTo review the effects of school closures on pandemic and seasonal influenza outbreaks. DesignSystematic review. Data sourcesMEDLINE and EMBASE, reference lists of identified articles, hand searches of key journals and additional papers from the authors' collections. Study selectionStudies were included if they reported on a seasonal or pandemic influenza outbreak coinciding with a planned or unplanned school closure. ResultsOf 2579 papers identified through MEDLINE and EMBASE, 65 were eligible for inclusion in the review along with 14 identified from other sources. Influenza incidence frequently declined after school closure. The effect was sometimes reversed when schools reopened, supporting a causal role for school closure in reducing incidence. Any benefits associated with school closure appeared to be greatest among school-aged children. However, as schools often closed late in the outbreak or other interventions were used concurrently, it was sometimes unclear how much school closure contributed to the reductions in incidence. ConclusionsSchool closures appear to have the potential to reduce influenza transmission, but the heterogeneity in the data available means that the optimum strategy (eg, the ideal length and timing of closure) remains unclear.

Exposure to benzene and childhood leukaemia: a pilot case-control study [RESEARCH]

Tue, 26 Feb 2013 00:00:00 +0000

ObjectivesMain purpose To evaluate the feasibility of a measurement-based assessment of benzene exposure in case-control studies of paediatric cancer; Additional aims To identify the sources of exposure variability; to assess the performance of two benzene biomarkers; to verify the occurrence of participation bias; to check whether exposures to benzene and to 50 Hz magnetic fields were correlated, and might exert reciprocal confounding effects. DesignPilot case-control study of childhood leukaemia and exposure to benzene assessed by repeated seasonal weekly measurements in breathing zone air samples and outside the children's dwellings, with concurrent determinations of cotinine, t-t-muconic acid (MA) and sulfo-phenylmercapturic acid (S-PMA) in urine. Participants108 cases and 194 controls were eligible for inclusion. ResultsFull-participation was obtained from 46 cases and 60 controls, with low dropout rates before four repeats (11% and 17%); an additional 23 cases and 80 controls allowed the collection of outdoor air samples only. The average benzene concentration in personal and outdoor air samples was 3 g/m3 (SD 1.45) and 2.7 g/m3 (SD 1.41), respectively. Personal exposure was strongly influenced by outdoor benzene concentrations, higher in the cold seasons than in warm seasons, and not affected by gender, age, area of residence or caseness. Urinary excretion of S-PMA and personal benzene exposure were well correlated. Outdoor benzene levels were lower among participant controls compared with non-participants, but did not differ between participant and non-participant cases; the direction of the bias was found to depend on the cut-point chosen to distinguish exposed and unexposed. Exposures to benzene and extremely low-frequency magnetic fields were positively correlated. ConclusionsRepeated individual measurements are needed to account for the seasonal variability in benzene exposure, and they have the additional advantage of increasing the study power. Measurement-based assessment of benzene exposure in studies of childhood leukaemia appears feasible, although it is financially and logistically demanding.

The incidence of rugby-related catastrophic injuries (including cardiac events) in South Africa from 2008 to 2011: a cohort study [RESEARCH]

Tue, 26 Feb 2013 00:00:00 +0000

ObjectivesTo establish an accurate and comprehensive injury incidence registry of all rugby union-related catastrophic events in South Africa between 2008 and 2011. An additional aim was to investigate correlates associated with these injuries. DesignProspective. SettingThe South African amateur and professional rugby-playing population. ParticipantsAn estimated 529 483 Junior and 121 663 Senior rugby union ( rugby') players (population at risk). Outcome measuresAnnual average incidences of rugby-related catastrophic injuries by type (cardiac events, traumatic brain and acute spinal cord injuries (ASCIs)) and outcome (full recoveries--fatalities). Playing level (junior and senior levels), position and event (phase of play) were also assessed. ResultsThe average annual incidence of ASCIs and Traumatic Brain Injuries combined was 2.00 per 100 000 players (95% CI 0.91 to 3.08) from 2008 to 2011. The incidence of ASCIs with permanent outcomes was significantly higher at the Senior level (4.52 per 100 000 players, 95% CI 0.74 to 8.30) than the Junior level (0.24 per 100 000 players, 95% CI 0 to 0.65) during this period. The hooker position was associated with 46% (n=12 of 26) of all permanent ASCI outcomes, the majority of which (83%) occurred during the scrum phase of play. ConclusionsThe incidence of rugby-related catastrophic injuries in South Africa between 2008 and 2011 is comparable to that of other countries and to most other collision sports. The higher incidence rate of permanent ASCIs at the Senior level could be related to the different law variations or characteristics (eg, less regular training) compared with the Junior level. The hooker and scrum were associated with high proportions of permanent ASCIs. The BokSmart injury prevention programme should focus efforts on these areas (Senior level, hooker and scrum) and use this study as a reference point for the evaluation of the effectiveness of the programme.

An exploratory study on the consequences and contextual factors of intimate partner violence among immigrant and Canadian-born women [RESEARCH]

Mon, 25 Feb 2013 00:00:00 +0000

ObjectiveTo compare immigrant and Canadian-born women on the physical and psychological consequences of intimate partner violence (IPV), as well as examine important sociodemographic, health and social support and network factors that may shape their experiences of abuse. MethodNational, population-based, cross-sectional survey conducted in 2009. Participants6859 women reported contact with a current or former partner in the previous 5 years, of whom 1480 reported having experienced emotional, financial, physical and/or sexual IPV. Of these women, 218 (15%) were immigrants and 1262 (85%) were Canadian-born. ResultsImmigrant women were less likely than Canadian-born women to report having experienced emotional abuse (15.3% vs 18.2%, p=0.04) and physical and/or sexual violence (5.1% vs 6.9%, p=0.04) from a current or former partner. There were no differences between immigrant and Canadian-born women in the physical and psychological consequences of physical and/or sexual IPV. However, compared with Canadian-born women, immigrant women reported lower levels of trust towards their neighbours (50.7% vs 41.5%, p=0.04) and people they work or go to school with (38.6% vs 27.5%, p=0.02), and were more likely to report having experienced discrimination based on ethnicity or culture (18.8% vs 6.8%, p<0.0001), race or skin colour (p=0.003) and language (10.1% vs 3.2%, p<0.0001). Immigrant women were less likely than Canadian-born women to report activity limitations (p=0.01) and medication use for sleep problems (14.1% vs 20.6%, p=0.05) and depression (11.5% vs 17.6%, p=0.05). ConclusionsOur exploratory study revealed no differences between immigrant and Canadian-born women in the physical and psychological consequences of IPV. Abused immigrant women's lower levels of trust for certain individuals and experiences of discrimination may have important implications for seeking help for IPV and underscores the need for IPV-related intervention and prevention services that are culturally sensitive and appropriate.

Design and baseline characteristics of the PODOSA (Prevention of Diabetes & Obesity in South Asians) trial: a cluster, randomised lifestyle intervention in Indian and Pakistani adults with impaired glycaemia at high risk of developing type 2 diabetes [RESEARCH]

Fri, 22 Feb 2013 00:00:00 +0000

ObjectivesTo describe the design and baseline population characteristics of an adapted lifestyle intervention trial aimed at reducing weight and increasing physical activity in people of Indian and Pakistani origin at high risk of developing type 2 diabetes. DesignCluster, randomised controlled trial. SettingCommunity-based in Edinburgh and Glasgow, Scotland, UK. Participants156 families, comprising 171 people with impaired glycaemia, and waist sizes [≥]90 cm (men) and [≥]80 cm (women), plus 124 family volunteers. InterventionsFamilies were randomised into either an intensive intervention of 15 dietitian visits providing lifestyle advice, or a light (control) intervention of four visits, over a period of 3 years. Outcome measuresThe primary outcome is a change in mean weight between baseline and 3 years. Secondary outcomes are changes in waist, hip, body mass index, plasma blood glucose and physical activity. The cost of the intervention will be measured. Qualitative work will seek to understand factors that motivated participation and retention in the trial and families' experience of adhering to the interventions. ResultsBetween July 2007 and October 2009, 171 people with impaired glycaemia, along with 124 family volunteers, were randomised. In total, 95% (171/196) of eligible participants agreed to proceed to the 3-year trial. Only 13 of the 156 families contained more than one recruit with impaired glycaemia. We have recruited sufficient participants to undertake an adequately powered trial to detect a mean difference in weight of 2.5 kg between the intensive and light intervention groups at the 5% significance level. Over half the families include family volunteers. The main participants have a mean age of 52 years and 64% are women. ConclusionsPrevention of Diabetes & Obesity in South Asians (PODOSA) is one of the first community-based, randomised lifestyle intervention trials in a UK South Asian population. The main trial results will be submitted for publication during 2013. Trial registrationCurrent controlled trials ISRCTN25729565 (http://www.controlled-trials.com/isrctn/).

Limited potential of school textbooks to prevent tobacco use among students grade 1-9 across multiple developing countries: a content analysis study [RESEARCH]

Thu, 21 Feb 2013 00:00:00 +0000

ObjectiveTo evaluate the content of school textbooks as a tool to prevent tobacco use in developing countries. DesignContent analysis was used to evaluate if the textbooks incorporated the following five core components recommended by the WHO: (1) consequences of tobacco use; (2) social norms; (3) reasons to use tobacco; (4) social influences and (5) resistance and life skills. SettingNine developing countries: Bangladesh, Cambodia, Laos, Nepal, Sri Lanka, Benin, Ghana, Niger and Zambia. Textbooks analysedOf 474 textbooks for primary and junior secondary schools in nine developing countries, 41 were selected which contained descriptions about tobacco use prevention. ResultsOf the 41 textbooks, the consequences of tobacco use component was covered in 30 textbooks (73.2%) and the social norms component was covered in 19 (46.3%). The other three components were described in less than 20% of the textbooks. ConclusionsA rather limited number of school textbooks in developing countries contained descriptions of prevention of tobacco use, but they did not fully cover the core components for tobacco use prevention. The chance of tobacco prevention education should be seized by improving the content of school textbooks.

Tobacco use and associated factors among adolescent students in Dharan, Eastern Nepal: a cross-sectional questionnaire survey [RESEARCH]

Thu, 14 Feb 2013 00:00:00 +0000

IntroductionThe tobacco use among the youth, in both smoking and smokeless forms, is quite high in the South East Asian region. Tobacco use is a major proven risk factor and contributes substantially to the rising epidemic of non-communicable diseases. ObjectivesTo estimate the prevalence of tobacco use and determine associated factors among adolescent students of Dharan municipality. DesignCross-sectional study. SettingSecondary and higher secondary schools of Dharan municipality in Sunsari district of Nepal. ParticipantsStudents in middle (14-15 years) and late adolescence (16-19 years) from grades 9, 10, 11 and 12 were included. Primary outcome measureEver tobacco use which was defined as one who had not used any form of tobacco in the past 1 month but had tried in the past. MethodologySelf-administered questionnaire adapted from Global Youth Tobacco Survey was used to assess tobacco use among the representative sample of 1312 adolescent students selected by stratified random sampling from July 2011 to July 2012. ResultsOut of 1454 students, 1312 students completed the questionnaires with a response rate of 90.23%. Prevalence of ever use of any tobacco product was 19.7% (95% CI 17.7 to 21.6). More than half of the tobacco users (51.9%) consumed tobacco in public places whereas almost a third (75.6%) of the consumers purchased tobacco from shops. Multivariate analysis showed that tobacco use was associated with late adolescence (OR: 1.64; 95% CI 1.17 to 2.28), male gender (OR: 12.20; 95% CI 7.78 to 19.14), type of school (OR=1.72; 95% CI 1.01 to 2.94), Janajati ethnicity (OR: 2.05; 95% CI 1.39 to 3.01) and receiving pocket money [≥]Nepalese rupees 500/month (OR: 1.45; 95% CI 1.04 to 2.03). ConclusionsTobacco-focused interventions are required for school/college going students to promote cessation among users and prevent initiation, focussing on late adolescence, male gender, government schools, Janajati ethnicity and higher amount of pocket money.

Comparing the effects of infrastructure on bicycling injury at intersections and non-intersections using a case-crossover design [ORIGINAL ARTICLE]

Thu, 14 Feb 2013 00:00:00 +0000

BackgroundThis study examined the impact of transportation infrastructure at intersection and non-intersection locations on bicycling injury risk. MethodsIn Vancouver and Toronto, we studied adult cyclists who were injured and treated at a hospital emergency department. A case-crossover design compared the infrastructure of injury and control sites within each injured bicyclist's route. Intersection injury sites (N=210) were compared to randomly selected intersection control sites (N=272). Non-intersection injury sites (N=478) were compared to randomly selected non-intersection control sites (N=801). ResultsAt intersections, the types of routes meeting and the intersection design influenced safety. Intersections of two local streets (no demarcated traffic lanes) had approximately one-fifth the risk (adjusted OR 0.19, 95% CI 0.05 to 0.66) of intersections of two major streets (more than two traffic lanes). Motor vehicle speeds less than 30 km/h also reduced risk (adjusted OR 0.52, 95% CI 0.29 to 0.92). Traffic circles (small roundabouts) on local streets increased the risk of these otherwise safe intersections (adjusted OR 7.98, 95% CI 1.79 to 35.6). At non-intersection locations, very low risks were found for cycle tracks (bike lanes physically separated from motor vehicle traffic; adjusted OR 0.05, 95% CI 0.01 to 0.59) and local streets with diverters that reduce motor vehicle traffic (adjusted OR 0.04, 95% CI 0.003 to 0.60). Downhill grades increased risks at both intersections and non-intersections. ConclusionsThese results provide guidance for transportation planners and engineers: at local street intersections, traditional stops are safer than traffic circles, and at non-intersections, cycle tracks alongside major streets and traffic diversion from local streets are safer than no bicycle infrastructure.

Socioeconomic, cultural and behavioural features of prior and anticipated influenza vaccine uptake in urban and rural Pune district, India: a mixed-methods case study [PROTOCOL]

Wed, 13 Feb 2013 00:00:00 +0000

IntroductionEnsuring production capacity of efficacious vaccines for pandemic preparedness alone may not be sufficient for effective influenza control. Community willingness to accept the vaccine is also critical. Population acceptance must therefore be recognised as a major determinant of vaccine effectiveness, and the social, cultural and economic determinants of population acceptance require study for effective policy and action. Pune is a focus of pandemic influenza in India. The experience of the 2009/2010 pandemic in Pune, capacity for vaccine production and experience with vaccine use provide a unique opportunity to address key questions about an effective vaccine intervention strategy for influenza control in India. This study will examine the socioeconomic, cultural and behavioural determinants of anticipated acceptance of influenza vaccines among the urban and rural populations of Pune district. Additionally, community ideas about seasonal influenza and its distinction from pandemic influenza will be investigated. Proposed research also considers the influence of health professionals, policy makers and media professionals on the awareness, preference and use of influenza vaccines. Methods and analysisThis is a mixed-methods study including urban and rural community surveys, in-depth interviews with health professionals, case studies at two hospitals where suspected influenza cases were referred during the pandemic and in-depth interviews with media professionals and public health policy makers. Ethics and disseminationThis protocol was approved by the ethics review committees of the Maharashtra Association of Anthropological Sciences and the WHO, and by the Ethics Commission of Basel, Switzerland. The proposed research will provide a better understanding of communication and education needs for vaccine action for influenza control in India and other low-income and middle-income countries. The findings and the approach for health social science research will have implications for containment of pandemic influenza in other settings and for effective vaccine action planning for other vaccines.

Psychological distress mediates the association between daytime sleepiness and consumption of sweetened products: cross-sectional findings in a Catholic Middle-Eastern Canadian community [RESEARCH]

Wed, 13 Feb 2013 00:00:00 +0000

ObjectiveTo examine the associations between consumption of sweetened products, daytime sleepiness (DS) and psychological distress (PD) in a Catholic Middle-Eastern Canadian community, and to test the hypothesis that the association between DS and consumption of sweetened products is mediated by PD. DesignA cross-sectional study. SettingA Catholic Middle-Eastern Canadian community. Participants186 men and women aged between 18 and 60 years. Primary and secondary outcome measuresSweetened product consumption was measured using a food frequency questionnaire (total sugars/day). DS and PD were measured using standardised questionnaires. The generalised linear model was used to estimate associations between sweetened product consumption, age, sex, self-reported body mass index, DS and PD. Baron and Kenny's four-step approach in addition to the Sobel test were used to establish mediation. ResultsAverage DS score was 8.2 (SD=4.5) with 19.5% having excessive scores (>12). Mean PD score was 20.8 (SD=6.2) with 11.8% having high distress scores. Average consumption of sweetened products was 15.5 g/day (SD=13.9). Baron and Kenny's three steps to establish partial mediation were confirmed. First, DS was associated with consumption of sweetened products (p<0.03). Second, DS and PD were correlated (r=0.197; p<0.04). Third, PD was associated with consumption of sweetened products (p<0.01) when both PD and DS were entered as predictors in a multivariate regression. However, Baron and Kenny's fourth step to establish complete mediation was not met. The effect of DS on consumption of sweetened products controlling for PD was reduced, but it was not zero. Finally, the Sobel test was significant (2.14; p<0.03). ConclusionsThe association between DS and consumption of sweetened products in the Catholic Middle-Eastern Canadian community is partially mediated by psychological distress. Further work should test this mediation relationship in larger samples and verify the potential effects of other sleep variables in this relationship.

The impact of smoke-free legislation on fetal, infant and child health: a systematic review and meta-analysis protocol [PROTOCOL]

Wed, 13 Feb 2013 00:00:00 +0000

IntroductionSecond-hand smoke (SHS) exposure is estimated to kill 600 000 people worldwide annually. The WHO recommends that smoke-free indoor public environments are enforced through national legislation. Such regulations have been shown to reduce SHS exposure and, consequently, respiratory and cardiovascular morbidity. Evidence of particular health benefit in children is now emerging, including reductions in low birthweight deliveries, preterm birth and asthma exacerbations. We aim to comprehensively assess the impact of smoke-free legislation on fetal, infant and childhood outcomes. This can inform further development and implementation of global policy and strategies to reduce early life SHS exposure. MethodsTwo authors will search online databases (1975-present; no language restrictions) of published and unpublished/in-progress studies, and references and citations to articles of interest. We will consult experts in the field to identify additional studies. Studies should describe associations between comprehensive or partial smoking bans in public places and health outcomes among children (0-12 years): stillbirth, preterm birth, low birth weight, small for gestational age, perinatal mortality, congenital anomalies, bronchopulmonary dysplasia, upper and lower respiratory infections and wheezing disorders including asthma. The Cochrane Effectiveness Practice and Organisational Care (EPOC)-defined study designs are eligible. Study quality will be assessed using the Cochrane 7-domain-based evaluation for randomised and clinical trials, and EPOC criteria for quasiexperimental studies. Data will be extracted by two reviewers and presented in tabular and narrative form. Meta-analysis will be undertaken using random-effects models, and generic inverse variance analysis for adjusted effect estimates. We will report sensitivity analyses according to study quality and design characteristics, and subgroup analyses according to coverage of ban, age group and parental/maternal smoking status. Publication bias will be assessed. Ethics and disseminationEthics assessment is not required. ResultsWill be presented in one manuscript. The protocol is registered with PROSPERO, registration number CRD42013003522.

A randomised controlled non-inferiority trial of primary care-based facilitated access to an alcohol reduction website (EFAR-FVG): the study protocol [PROTOCOL]

Tue, 12 Feb 2013 00:00:00 +0000

IntroductionThere is a strong body of evidence demonstrating the effectiveness of brief interventions by primary care professionals for risky drinkers. However, implementation levels remain low because of time constraints and other factors. Facilitated access to an alcohol reduction website offers primary care professionals a time-saving alternative to standard face-to-face intervention, but it is not known whether it is as effective. Methods and analysisA randomised controlled non-inferiority trial for risky drinkers comparing facilitated access to a dedicated website with standard face-to-face brief intervention to be conducted in primary care settings in the Region of Friuli Giulia Venezia, Italy. Adult patients will be given a leaflet inviting them to log on to a website to complete the Alcohol Use Disorders Identification Test (AUDIT-C) alcohol screening questionnaire. Screen positives will be requested to complete an online trial module including consent, baseline assessment and randomisation to either standard intervention by the practitioner or facilitated access to an alcohol reduction website. Follow-up assessment of risky drinking will be undertaken online at 1 month, 3 months and 1 year using the full AUDIT questionnaire. Proportions of risky drinkers in each group will be calculated and non-inferiority assessed against a specified margin of 10%. Assuming a reduction of 30% of risky drinkers receiving standard intervention, 1000 patients will be required to give 90% power to reject the null hypothesis. Ethics and disseminationThe protocol was approved by the Isontina Independent Local Ethics Committee on 14 June 2012. The findings of the trial will be disseminated through peer-reviewed journals, national and international conference presentations and public events involving the local administrations of the towns where the trial participants are resident. Registration detailsTrial registration number NCT: 01638338.

Specialty choice in times of economic crisis: a cross-sectional survey of Spanish medical students [RESEARCH]

Tue, 12 Feb 2013 00:00:00 +0000

ObjectiveTo investigate the determinants of specialty choice among graduating medical students in Spain, a country that entered into a severe, ongoing economic crisis in 2008. SettingSince 2008, the percentage of Spanish medical school graduates electing Family and Community Medicine (FCM) has experienced a reversal after more than a decade of decline. DesignA nationwide cross-sectional survey conducted online in April 2011. ParticipantsWe invited all students in their final year before graduation from each of Spain's 27 public and private medical schools to participate. Main outcome measuresRespondents' preferred specialty in relation to their perceptions of: (1) the probability of obtaining employment; (2) lifestyle and work hours; (3) recognition by patients; (4) prestige among colleagues; (5) opportunity for professional development; (6) annual remuneration and (7) the proportion of the physician's compensation from private practice. Results978 medical students (25% of the nationwide population of students in their final year) participated. Perceived job availability had the largest impact on specialty preference. Each 10% increment in the probability of obtaining employment increased the odds of preferring a specialty by 33.7% (95% CI 27.2% to 40.5%). Job availability was four times as important as compensation from private practice in determining specialty choice (95% CI 1.7 to 6.8). We observed considerable heterogeneity in the influence of lifestyle and work hours, with students who preferred such specialties as Cardiovascular Surgery and Obstetrics and Gynaecology valuing longer rather than shorter workdays. ConclusionsIn the midst of an ongoing economic crisis, job availability has assumed critical importance as a determinant of specialty preference among Spanish medical students. In view of the shortage of practitioners of FCM, public policies that take advantage of the enhanced perceived job availability of FCM may help steer medical school graduates into this specialty.

A population-level prediction tool for the incidence of first-episode psychosis: translational epidemiology based on cross-sectional data [RESEARCH]

Mon, 11 Feb 2013 00:00:00 +0000

ObjectivesSpecialist early intervention services (EIS) for people aged 14-35 years with first episodes of psychosis (FEP) have been commissioned throughout England since 2001. A single estimate of population need was used everywhere, but true incidence varies enormously according to sociodemographic factors. We sought to develop a realistically complex, population-based prediction tool for FEP, based on precise estimates of epidemiological risk. Design and participantsData from 1037 participants in two cross-sectional population-based FEP studies were fitted to several negative binomial regression models to estimate risk coefficients across combinations of different sociodemographic and socioenvironmental factors. We applied these coefficients to the population at-risk of a third, socioeconomically different region to predict expected caseload over 2.5 years, where the observed rates of ICD-10 F10-39 FEP had been concurrently ascertained via EIS. SettingEmpirical population-based epidemiological data from London, Nottingham and Bristol predicted counts in the population at-risk in the East Anglia region of England. Main outcome measuresObserved counts were compared with predicted counts (with 95% prediction intervals (PI)) at EIS and local authority district (LAD) levels in East Anglia to establish the predictive validity of each model. ResultsA model with age, sex, ethnicity and population density performed most strongly, predicting 508 FEP participants in EIS in East Anglia (95% PI 459, 559), compared with 522 observed participants. This model predicted correctly in 5/6 EIS and 19/21 LADs. All models performed better than the current gold standard for EIS commissioning in England (716 cases; 95% PI 664-769). ConclusionsWe have developed a prediction tool for the incidence of psychotic disorders in England and Wales, made freely available online (http://www.psymaptic.org), to provide healthcare commissioners with accurate forecasts of FEP based on robust epidemiology and anticipated local population need. The initial assessment of some people who do not require subsequent EIS care means additional service resources, not addressed here, will be required.

The relative incidence of fracture non-union in the Scottish population (5.17 million): a 5-year epidemiological study [RESEARCH]

Fri, 8 Feb 2013 00:00:00 +0000

ObjectivesIn the UK there are approximately 850 000 new fractures seen each year. Rates of non-union of 5-10% of fractures have been suggested, the cost to the National Health Service of treating non-union has been reported to range between {pound}7000 and {pound}79 000 per person yet there are little actual data available. The objective of this epidemiological study therefore is for the first time to report the rates of fracture non-union. DesignA cross-sectional epidemiological study. SettingThe population of Scotland. ParticipantsAll patient admissions to hospital in Scotland are coded according to diagnosis. These data are collected by (and were obtained from) Information Services Department Scotland. Those who have been coded for a bone non-union between 2005 and 2010 were included in the study. No patients were excluded. Population data were obtained from the Registrar General for Scotland. Outcome measureThe number of fracture non-unions per 100 000 population of Scotland according to age, sex and anatomical distribution of non-union. Results4895 non-unions were treated as inpatients in Scotland between 2005 and 2010, averaging 979 per year, with an overall incidence of 18.94 per 100 000 population per annum. The distribution according to gender was 57% male and 43% female. The overall peak incidence according to age was between 30 and 40 years. The mean population of Scotland between 2005 and 2010 was 5 169 140 people. ConclusionFracture non-union in the population as a whole remains low at less than 20 per 100 000 population and peaks in the fourth decade of life. Further research is required to determine the risk of non-union per fracture according to age/sex/anatomical distribution. .

Life-event stress induced by the Great East Japan Earthquake was associated with relapse in ulcerative colitis but not Crohn's disease: a retrospective cohort study [RESEARCH]

Fri, 8 Feb 2013 00:00:00 +0000

ObjectiveStress is thought to be one of the triggers of relapses in patients with inflammatory bowel disease (IBD). We examined the rate of relapse in IBD patients before and after the Great East Japan Earthquake. DesignA retrospective cohort study. Settings13 hospitals in Japan. Participants546 ulcerative colitis (UC) and 357 Crohn's disease (CD) patients who received outpatient and inpatient care at 13 hospitals located in the area that were seriously damaged by the earthquake. Data on patient's clinical characteristics, disease activity and deleterious effects of the earthquake were obtained from questionnaires and hospital records. Primary outcomeWe evaluated the relapse rate (from inactive to active) across two consecutive months before and two consecutive months after the earthquake. In this study, we defined active' as conditions with a partial Mayo score=2 or more (UC) or a Harvey-Bradshaw index=6 or more (CD). ResultsAmong the UC patients, disease was active in 167 patients and inactive in 379 patients before the earthquake. After the earthquake, the activity scores increased significantly (p<0.0001). A total of 86 patients relapsed (relapse rate=15.8%). The relapse rate was about twice that of the corresponding period in the previous year. Among the CD patients, 86 patients had active disease and 271 had inactive disease before the earthquake. After the earthquake, the activity indices changed little. A total of 25 patients experienced a relapse (relapse rate=7%). The relapse rate did not differ from that of the corresponding period in the previous year. Multivariate analyses revealed that UC, changes in dietary oral intake and anxiety about family finances were associated with the relapse. ConclusionsLife-event stress induced by the Great East Japan Earthquake was associated with relapse in UC but not CD.

Is socioeconomic status associated with dietary sodium intake in Australian children? A cross-sectional study [RESEARCH]

Fri, 8 Feb 2013 00:00:00 +0000

ObjectiveTo assess the association between socioeconomic status (SES) and dietary sodium intake, and to identify if the major dietary sources of sodium differ by socioeconomic group in a nationally representative sample of Australian children. DesignCross-sectional survey. Setting2007 Australian National Children's Nutrition and Physical Activity Survey. ParticipantsA total of 4487 children aged 2-16 years completed all components of the survey. Primary and secondary outcome measuresSodium intake was determined via one 24 h dietary recall. The population proportion formula was used to identify the major sources of dietary salt. SES was defined by the level of education attained by the primary carer. In addition, parental income was used as a secondary indicator of SES. ResultsDietary sodium intake of children of low SES background was 2576 (SEM 42) mg/day (salt equivalent 6.6 (0.1) g/day), which was greater than that of children of high SES background 2370 (35) mg/day (salt 6.1 (0.1) g/day; p<0.001). After adjustment for age, gender, energy intake and body mass index, low SES children consumed 195 mg/day (salt 0.5 g/day) more sodium than high SES children (p<0.001). Low SES children had a greater intake of sodium from processed meat, gravies/sauces, pastries, breakfast cereals, potatoes and potato snacks (all p<0.05). ConclusionsAustralian children from a low SES background have on average a 9% greater intake of sodium from food sources compared with those from a high SES background. Understanding the socioeconomic patterning of salt intake during childhood should be considered in interventions to reduce cardiovascular disease.

Diagnosis-specific disability pension predicts suicidal behaviour and mortality in young adults: a nationwide prospective cohort study [RESEARCH]

Fri, 8 Feb 2013 00:00:00 +0000

ObjectivesIncreasing rates of disability pension (DP), particularly owing to mental diagnoses, have been observed among young adults in Organisation for Economic Co-operation and Development (OECD) countries. There is a lack of knowledge about the health prognosis in this group. The aim of this study was to investigate whether DP in young adulthood owing to specific mental diagnoses or somatic diagnoses predicts suicidal behaviour and all-cause mortality. DesignA nationwide prospective cohort study. SettingA register study of all young adults who in 2005 were 19-23 years old and lived in Sweden. Registers held by the National Board of Health and Welfare, Statistics Sweden and the National Social Insurance Agency were used. Participants525 276 young adults. Those who in 2005 had DP with mental diagnoses (n=8070) or somatic diagnoses (n=3975) were compared to all the other young adults in the same age group (n=513 231). Outcome measuresHRs for suicide attempt, suicide and all-cause mortality in 2006-2010 were calculated by Cox proportionate hazard regression models, adjusted for sex, country of birth, parental education and parental and previous own suicidal behaviour. ResultsThe adjusted HR for suicide attempt was 3.32 (95% CI 2.98 to 3.69) among those on DP with mental diagnoses and 1.78 (95% CI 1.41 to 2.26) among those on DP with somatic diagnoses. For the specific mental diagnoses, the unadjusted HRs ranged between 2.42 (mental retardation) and 22.94 (personality disorders), while the adjusted HRs ranged between 2.03 (mental retardation) and 6.00 (bipolar disorder). There was an increased risk of mortality for young adults on DP in general, but only those with mental DP diagnoses had a significantly elevated HR of completed suicide with an adjusted HR of 3.92 (95% CI 2.83 to 5.43). ConclusionsYoung adults on DP are at increased risk of suicidal behaviour and preterm death, which emphasises the need for improved treatment and follow-up.

Internalised homonegativity predicts HIV-associated risk behavior in European men who have sex with men in a 38-country cross-sectional study: some public health implications of homophobia [RESEARCH]

Mon, 4 Feb 2013 00:00:00 +0000

ObjectivesInternalised homonegativity (IH) is hypothesised to be associated with HIV risk behaviour and HIV testing in men who have sex with men (MSM). We sought to determine the social and individual variables associated with IH and the associations between IH and HIV-related behaviours. Design and settingWe examined IH and its predictors as part of a larger Internet-delivered, cross-sectional study on HIV and health in MSM in 38 European countries. Participants181 495 MSM, IH data analysis subsample 144 177. All participants were male, over the age of consent for homosexual activity in their country of domicile, and have had at least one homosexual contact in the past 6 months. MethodologyAn anonymous Internet-based questionnaire was disseminated in 25 languages through MSM social media, websites and organisations and responses saved to a UK-based server. IH was measured using a standardised, cross-culturally appropriate scale. ResultsThree clusters of European countries based on the level of experienced discrimination emerged. IH was predicted by country LGB (lesbian, gay and bisexual) legal climate, Gini coefficient and size of place of settlement. Lower IH was associated with degree the respondent was out' as gay to others and older age. Outness' was associated with ever having an HIV test and age, education and number of gay friends, while IH (controlling for the number of non-steady unprotected sex partners and perceived lack of control over safe sex) was associated with condom use for anal intercourse. ConclusionsIH is associated with LGB legal climate, economic development indices and urbanisation. It is also associated with outness' and with HIV risk and preventive behaviours including HIV testing, perceived control over sexual risk and condom use. Homonegative climate is associated with IH and higher levels of HIV-associated risk in MSM. Reducing IH through attention to LGB human rights may be appropriate HIV reduction intervention for MSM.

A cross-sectional study on socioeconomic status and health-related quality of life among elderly Chinese [RESEARCH]

Fri, 1 Feb 2013 00:00:00 +0000

ObjectivesTo examine the association between socioeconomic status (SES) and health-related quality of life (HRQOL) in a sample of elderly Chinese people in Hong Kong. Study DesignCross-sectional study. Setting18 elderly health centers in Hong Kong. ParticipantsThis study was based on a cohort aged 65 years or above who were enrolled in the Elderly Health Services from 1998 to 2005 in Hong Kong. Initially, 3324 individuals were randomly sampled from the baseline database. In the end, 2441 successful cases were obtained for the telephone survey. After excluding cases with missing SES or HRQOL information and the cases whose questionnaires were answered by their family members, 2347 individuals were included in the final analysis. ResultsElderly Chinese with less subjective economic hardship reported much better self-rated health (SRH) (OR 1.57-4.70, all p<0.01)< and higher Medical Outcomes Study short form (SF)12 scores ({beta} 2.56-10.26, all p<0.01) than those with economic hardship. Male individuals in the highest education and occupation subgroup reported better HRQOL comparing with the baseline subgroup (OR for SRH 1.91-3.26, p<0.01; {beta} 2.63-4.96, p<0.05). Two economic indicators, income and expenditure, only showed significant positive associations with physical SF12 scores for men ({beta} 2.91-5.42, all p<0.05). Housing tenure was associated with SRH (OR 1.34 for men and 1.27 for women, p<0.05) but not SF12 scores. ConclusionsEconomic hardship showed the strongest association with HRQOL among all SES indicators. Educational level, occupational level and economic indicators tended to associate with physical HRQOL only among elderly Chinese men. More attention should be placed on subjective SES indicators when investigating influences on HRQOL among elderly Chinese people.

Active transportation to school in Canadian youth: should injury be a concern? [BRIEF REPORTS]

Fri, 1 Feb 2013 00:00:00 +0000

Active transportation to school provides a means for youth to incorporate physical activity into their daily routines, and this has obvious benefits for child health. Studies of active transportation have rarely focused on the negative health effects in terms of injury. This cross-sectional study is based on the 2009/10 Canadian Health Behaviour in School-Aged Children survey. A sample of children aged 11-15 years (n=20 076) was studied. Multi-level logistic regression was used to examine associations between walking or bicycling to school and related injury. Regular active transportation to school at larger distances (approximately >1.6 km; 1.0 miles) was associated with higher relative odds of active transportation injury (OR: 1.52; 95% CI 1.08 to 2.15), with a suggestion of a dose-response relationship between longer travel distances and injury (p=0.02). Physical activity interventions for youth should encourage participation in active transportation to school, while also recognising the potential for unintentional injury.

Can we update the Summary Hospital Mortality Index (SHMI) to make a useful measure of the quality of hospital care? An observational study [RESEARCH]

Wed, 30 Jan 2013 00:00:00 +0000

ObjectiveTo advance methods for the estimation of hospital performance based upon mortality ratios. DesignObservational study estimating trust performance in a year derived according to comparative standards from a 3-year period, accounting for patient-level case-mix and overdispersion (unexplained variability). Participants23 363 630 admissions to the English National Health Service (NHS) by NHS Trust. Main outcome measuresNumber of SDs (QUality and Outcomes Research Unit Measure, QUORUM banding) and comparative odds of hospital mortality difference from mean performance by trust compared for 2010/2011, 2008/2009 and 2009/2010, accounting for patient-level case-mix. ResultsThe model was highly predictive of mortality (C statistic=0.93), and well calibrated by risk stratum. There was substantial overdispersion. No trusts were more than 3 SDs above the mean, and only one trust was more than 2 SDs above the mean for 2010/2011. ConclusionsQUORUM is highly predictive of patient mortality in hospital or up to 30 days after admission. However, like the Summary Hospital Mortality Indicator (SHMI), QUORUM is subjected to considerable remaining legitimate but unexplained variation. It is unlikely that measures like QUORUM and SHMI will be useful beyond identifying a very small number of trusts as potential outliers.

The relationship between employment and social participation among Australians with a disabling chronic health condition: a cross-sectional analysis [RESEARCH]

Wed, 30 Jan 2013 00:00:00 +0000

ObjectivesSocial interaction may be particularly important for people with chronic health conditions, due to the numerous benefits to an individual's health. This paper aims to determine if labour force participation is a factor that influences individuals with chronic health conditions partaking in social or cultural events. Design and settingThe study undertakes a cross-sectional analysis of the 2009 Survey of Disability, Ageing and Carers, a nationally representative survey of the Australian population. Participants33 376 records of persons aged 25-64years. Outcome measuresParticipation in social and community activities. ResultsIt was found that after controlling for age, sex, level of highest education, income unit type and severity of disability, people with a chronic health condition that were in the labour force were more than twice as likely to be participating in social or community events (OR 2.54, 95% CI 1.95 to 3.29, p<0.0001), and in cultural events (OR 2.57, 95% CI 2.21 to 3.00, p<0.0001) as their counterparts who were out of the labour force. The results were then repeated, with the addition of income as a confounding variable. People with a chronic health condition that were in the labour force were still a little more than twice as likely to be participating in social or community events (OR 2.25, 95% CI 1.69 to 3.00, p<0.0001), and to be participating in cultural events (OR 2.08, 95% CI 1.76 to 2.45, p<0.0001) as their counterparts who were out of the labour force. ConclusionsParticipating in the labour force may be an important driver of social participation among those with chronic health conditions, independent of income. People with chronic health conditions who are not in the labour force and do not participate in social or cultural activities may have a compounding disadvantage.

Lifetime risk of developing coronary heart disease in Aboriginal Australians: a cohort study [RESEARCH]

Wed, 30 Jan 2013 00:00:00 +0000

ObjectivesLifetime risk of coronary heart disease (CHD) is an important yardstick by which policy makers, clinicians and the general public can assess and promote the awareness and prevention of CHD. The lifetime risk in Aboriginal people is not known. Using a cohort with up to 20 years of follow-up, we estimated the lifetime risk of CHD in Aboriginal people. DesignA cohort study. SettingA remote Aboriginal region. Participants1115 Aboriginal people from one remote tribal group who were free from CHD at baseline were followed for up to 20 years. Main outcome measuresDuring the follow-up period, new CHD incident cases were identified through hospital and death records. We estimated the lifetime risks of CHD with and without adjusting for the presence of competing risk of death from non-CHD causes. ResultsParticipants were followed up for 17 126 person-years, during which 185 developed CHD and 144 died from non-CHD causes. The average age at which the first CHD event occurred was 48 years for men and 49 years for women. The risk of developing CHD increased with age until 60 years and then decreased with age. Lifetime cumulative risk without adjusting for competing risk was 70.7% for men and 63.8% for women. Adjusting for the presence of competing risk of death from non-CHD causes, the lifetime risk of CHD was 52.6% for men and 49.2% for women. ConclusionsLifetime risk of CHD is as high as one in two in both Aboriginal men and women. The average age of having first CHD events was under 50 years, much younger than that reported in non-Aboriginal populations. Our data provide useful knowledge for health education, screening and prevention of CHD in Aboriginal people.

Disparities in fatal and non-fatal injuries between Irish travellers and the Irish general population are similar to those of other indigenous minorities: a cross-sectional population-based comparative study [RESEARCH]

Mon, 28 Jan 2013 00:00:00 +0000

ObjectivesTo assess recent disparities in fatal and non-fatal injury between travellers and the general population in Ireland. DesignA cross-sectional population-based comparative study. SettingRepublic of Ireland. ParticipantsPopulation census and retrospective mortality data were collected from 7042 traveller families, travellers being those identified by themselves and others as members of the traveller community. Retrospective injury incidence was estimated from a survey of a random sample of travellers in private households, aged 15 years or over (702 men and 961 women). Comparable general population data were obtained from official statistical reports, while retrospective incidence was estimated from the Survey of Lifestyle, Attitude and Nutrition 2002, a random sample of 5992 adults in private households aged 18 years or over. Outcome measuresPotential Years of Life Lost (PYLL), Standardised Mortality Ratios (SMR), Standardised Incidence Ratios (SIR) and Case Fatality Ratios (CFR). ResultsInjury accounted for 36% of PYLL among travellers, compared with 13% in the general population. travellers were more likely to die of unintentional injury than the general population (SMR=454 (95% CI 279 to 690) in men and 460 (95% CI 177 to 905) in women), with a similar pattern for intentional injury (SMR=637 (95% CI 367 to 993) in men and 464 (95% CI 107 to 1204 in women). They had a lower incidence of unintentional injury but those aged 65 years or over were about twice as likely to report an injury. Travellers had a higher incidence of intentional injuries (SIR=181 (95% CI 116 to 269) in men and 268 (95% CI 187 to 373) in women). Injury CFR were consistently higher among travellers. ConclusionsIrish travellers continue to bear a disproportionate burden of injury, which calls for scaling up injury prevention efforts in this group. Prevention and further research should focus on suicide, alcohol misuse and elderly injury among Irish travellers.

Characteristics of people with low health literacy on coronary heart disease GP registers in South London: a cross-sectional study [RESEARCH]

Mon, 28 Jan 2013 00:00:00 +0000

ObjectiveTo explore characteristics associated with, and prevalence of, low health literacy in patients recruited to investigate the role of depression in patients on General Practice (GP) Coronary Heart Disease (CHD) registers (the Up-Beat UK study). DesignCross-sectional cohort. The health literacy measure was the Rapid Estimate of Health Literacy in Medicine (REALM). Univariable analyses identified characteristics associated with low health literacy and compared health service use between health literacy statuses. Those variables where there was a statistically significant/borderline significant difference between health literacy statuses were entered into a multivariable model. Setting16 General Practices in South London, UK. ParticipantsInclusion: patients >18 years, registered with a GP and on a GP CHD register. Exclusion: patients temporarily registered. Primary outcome measureREALM. ResultsOf the 803 Up-Beat cohort participants, 687 (85.55%) completed the REALM of whom 106 (15.43%) had low health literacy. Twenty-eight participants could not be included in the multivariable analysis due to missing predictor variable data, leaving a sample of 659. The variables remaining in the final model were age, gender, ethnicity, Indices of Multiple Deprivation score, years of education, employment; body mass index and alcohol intake, and anxiety scores (Hospital Anxiety and Depression Scale). Univariable analysis also showed that people with low health literacy may have more, and longer, practice nurse consultations than people with adequate health literacy. ConclusionsThere is a disadvantaged group of people on GP CHD registers with low health literacy. The multivariable model showed that patients with low health literacy have significantly higher anxiety levels than people with adequate health literacy. In addition, the univariable analyses show that such patients have more, and longer, consultations with practice nurses. We will collect 4-year longitudinal cohort data to explore the impact of health literacy in people on GP CHD registers and the impact of health literacy on health service use.

Population-based characteristics of fatal and hospital admissions for poisoning in Fiji: TRIP Project-11 [BRIEF REPORT]

Fri, 25 Jan 2013 00:00:00 +0000

This study investigated the incidence and characteristics of poisoning fatalities and hospital admissions among indigenous Fijians and Indians in Viti Levu, Fiji. Individuals with a mechanism of injury classified as poisoning were identified using the Fiji injury surveillance in hospitals system, a population-based registry established for 12 months in Viti Levu, and analysed using population-based denominators. The mean annual rates of fatalities and hospitalisations were 2.3 and 26.0 per 100 000, respectively. Over two-thirds of poisonings occurred among people of Indian ethnicity. Most intentional poisoning admissions occurred among women (58.3%) and in 15-29-year-old individuals (73.8%). Unintentional poisoning admission rates were highest among Indian boys aged 0-14 years. While over 75% of events occurred at home, the substances involved were not systematically identified. The findings indicate the need for a strategy that addresses the differing contexts across age group, gender and ethnicity, and a lead agency responsible for implementing and monitoring its effectiveness.

Determinants of self-reported smoking and misclassification during pregnancy, and analysis of optimal cut-off points for urinary cotinine: a cross-sectional study [RESEARCH]

Thu, 24 Jan 2013 00:00:00 +0000

ObjectivesTo estimate the prevalence and factors associated with smoking and misclassification in pregnant women from INMA (INfancia y Medio Ambiente, Environment and Childhood) project, Spain, and to assess the optimal cut-offs for urinary cotinine (UC) that best distinguish daily and occasional smokers with varying levels of second-hand smoke (SHS) exposure. DesignWe used logistic regression models to study the relationship between sociodemographic variables and self-reported smoking and misclassification (self-reported non-smokers with UC >50 ng/ml). Receiver operating characteristic (ROC) curves were used to calculate the optimal cut-off point for discriminating smokers. The cut-offs were also calculated after stratification among non-smokers by the number of sources of SHS exposure. The cut-off points used to discriminate smoking status were the level of UC given by Youden's index and for 50 and 100 ng/ml for daily smokers, or 25 and 50 ng/ml for occasional smokers. ParticipantsAt the third trimester of pregnancy, 2263 pregnant women of the INMA Project were interviewed between 2004 and 2008 and a urine sample was collected. ResultsPrevalence of self-reported smokers at the third trimester of pregnancy was 18.5%, and another 3.9% misreported their smoking status. Variables associated with self-reported smoking and misreporting were similar, including born in Europe, educational level and exposure to SHS. The optimal cut-off was 82 ng/ml (95% CI 42 to 133), sensitivity 95.2% and specificity 96.6%. The area under the ROC curve was 0.986 (95% CI 0.982 to 0.990). The cut-offs varied according to the SHS exposure level being 42 (95% CI 27 to 57), 82 (95% CI 46 to 136) and 106 ng/ml (95% CI 58 to 227) for not being SHS exposed, exposed to one, and to two or more sources of SHS, respectively. The optimal cut-off for discriminating occasional smokers from non-smokers was 27 ng/ml (95% CI 11 to 43). ConclusionsPrevalence of smoking during pregnancy in Spain remains high. UC is a reliable biomarker for classifying pregnant women according to their smoking status. However, cut-offs would differ based on baseline exposure to SHS.

Chronic lower respiratory diseases among demolition and cement workers: a population-based register study [RESEARCH]

Thu, 24 Jan 2013 00:00:00 +0000

ObjectiveTo estimate standardised hospitalisation ratios (SHR) for chronic lower respiratory diseases among demolition and cement workers in Denmark, 1995-2009. DesignThis is a population-based register study on data from the Occupational Hospitalisation Register'. SHR of chronic obstructive pulmonary disease (COPD) was calculated for both demolition and cement workers. SettingsRegister study with data from all hospitals in Denmark. Participants895 demolition workers and 5633 cement and concrete workers were included in the study and all economical active men were used as reference group. ResultsWe found a statistically significant high SHR for the cement workers, SHR=134 (95% CI 117 to 153). The SHR for demolition workers was 131 (95% CI 87 to 188). ConclusionsWe find a higher risk of being hospitalised due to COPD in cement and concrete workers (significant) and demolition workers (insignificant) compared to gainfully employed men.

Does implementation of the IMCI strategy have an impact on child mortality? A retrospective analysis of routine data from Egypt [RESEARCH]

Thu, 24 Jan 2013 00:00:00 +0000

BackgroundBetween 1999 and 2007, the Ministry of Health and Population in Egypt scaled up the Integrated Management of Childhood Illness (IMCI) strategy in 84% of public health facilities. ObjectivesThis retrospective analysis, using routinely available data from vital registration, aimed to assess the impact of IMCI implementation between 2000 and 2006 on child mortality. It also presents a systematic and comprehensive approach to scaling-up IMCI interventions and information on quality of child health services, using programme data from supervision and surveys. MethodsWe compared annual levels of under-five mortality in districts before and after they had started implementing IMCI. Mortality data were obtained from the National Bureau for Statistics for 254 districts for the years 2000-2006, 41 districts of which were excluded. For assessment of programme activities, we used information from the central IMCI data base, annual progress reports, follow-up after training visits and four studies on quality of child care in public health facilities. ResultsAcross 213 districts retained in the analysis, the estimated average annual rate of decline in under-five mortality was 3.3% before compared with 6.3% after IMCI implementation (p=0.0001). In 127 districts which started implementing IMCI between 2002 and 2005, the average annual rate of decline of under-five mortality was 2.6% (95% CI 1.1% to 4.1%) before compared with 7.3% (95% CI 5.8% to 8.7%) after IMCI implementation (p<0.0001). IMCI implementation also led to marked improvements in the quality of child health services. InterpretationIMCI implementation was associated with a doubling in the annual rate of under-five mortality reduction (3.3% vs 6.3%). This mortality impact is plausible, since substantial improvements occurred in quality of care provided to sick children in health facilities implementing IMCI.

A clustered randomised trial examining the effect of social marketing and community mobilisation on the age of uptake and levels of alcohol consumption by Australian adolescents [PROTOCOL]

Thu, 24 Jan 2013 00:00:00 +0000

IntroductionThroughout the world, alcohol consumption is common among adolescents. Adolescent alcohol use and misuse have prognostic significance for several adverse long-term outcomes, including alcohol problems, alcohol dependence, school disengagement and illicit drug use. The aim of this study was to evaluate whether randomisation to a community mobilisation and social marketing intervention reduces the proportion of adolescents who initiate alcohol use before the Australian legal age of 18, and the frequency and amount of underage adolescent alcohol consumption. Method and analysisThe study comprises 14 communities matched with 14 non-contiguous communities on socioeconomic status (SES), location and size. One of each pair was randomly allocated to the intervention. Baseline levels of adolescent alcohol use were estimated through school surveys initiated in 2006 (N=8500). Community mobilisation and social marketing interventions were initiated in 2011 to reduce underage alcohol supply and demand. The setting is communities in three Australian states (Victoria, Queensland and Western Australia). Students (N=2576) will complete school surveys in year 8 in 2013 (average age 12). Primary outcomes: (1) lifetime initiation and (2) monthly frequency of alcohol use. Reports of social marketing and family and community alcohol supply sources will also be assessed. Point estimates with 95% CIs will be compared for student alcohol use in intervention and control communities. Changes from 2006 to 2013 will be examined; multilevel modelling will assess whether random assignment of communities to the intervention reduced 2013 alcohol use, after accounting for community level differences. Analyses will also assess whether exposure to social marketing activities increased the intervention target of reducing alcohol supply by parents and community members. Trial registrationACTRN12612000384853.