On the measurement of inequalities in health

This paper offers a critical appraisal of the various methods employed to date to measure inequalities in health. It suggests that only two of these—the slope index of inequality and the concentration index—are likely to present an accurate picture of socioeconomic inequalities in health. The paper also presents several empirical examples to illustrate of the dangers of using other measures such as the range, the Lorenz curve and the index of dissimilarity

Population Projections and Demographic Knowledge in France and Great Britain in the Postwar Period

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/111965/1/padr47.pd

"Getting sicker quicker": does living in a more deprived neighbourhood mean your health deteriorates faster?

Data from the longitudinal West of Scotland Twenty-07 Study: Health in the Community was used to examine whether, over a 20 year period, the self-reported health of people living in deprived areas became poorer faster compared to those living in more affluent areas. Three cohorts (born in the early 1930s, 1950s and 1970s) are included, covering 60 years of the life span. Using multilevel growth curve models, a 40% probability of reporting poor health was predicted among residents of more deprived areas at an earlier age (66) compared to those living in more affluent areas (83). Wider area differences were seen for men than for women. Our findings indicate that attempts to reduce area differences in health should start young but also continue throughout the lifespan

Exploring differential item functioning in the SF-36 by demographic, clinical, psychological and social factors in an osteoarthritis population

The SF-36 is a very commonly used generic measure of health outcome in osteoarthritis (OA). An important, but frequently overlooked, aspect of validating health outcome measures is to establish if items work in the same way across subgroup of a population. That is, if respondents have the same 'true' level of outcome, does the item give the same score in different subgroups or is it biased towards one subgroup or another. Differential item functioning (DIF) can identify items that may be biased for one group or another and has been applied to measuring patient reported outcomes. Items may show DIF for different conditions and between cultures, however the SF-36 has not been specifically examined in an osteoarthritis population nor in a UK population. Hence, the aim of the study was to apply the DIF method to the SF-36 for a UK OA population. The sample comprised a community sample of 763 people with OA who participated in the Somerset and Avon Survey of Health. The SF-36 was explored for DIF with respect to demographic, social, clinical and psychological factors. Well developed ordinal regression models were used to identify DIF items. Results: DIF items were found by age (6 items), employment status (6 items), social class (2 items), mood (2 items), hip v knee (2 items), social deprivation (1 item) and body mass index (1 item). Although the impact of the DIF items rarely had a significant effect on the conclusions of group comparisons, in most cases there was a significant change in effect size. Overall, the SF-36 performed well with only a small number of DIF items identified, a reassuring finding in view of the frequent use of the SF-36 in OA. Nevertheless, where DIF items were identified it would be advisable to analyse data taking account of DIF items, especially when age effects are the focus of interest

The importance of both setting and intensity of physical activity in relation to non-clinical anxiety and depression

Physical activity is associated with good physical and mental health. Current recommendations suggest that people should achieve 30 minutes of moderate-intensity activity most days of the week to gain health benefits. This activity may be accumulated in leisure time, in active commuting, at work or in the home. Here we look at the cross-sectional relationship between physical activity and mental health as measured by the HADS anxiety and depression scores in a sample of 1,742 participants from a Scottish general population survey. The participants were men and women in three age cohorts aged around 24, 44 and 64 years who, in 1995, were interviewed face to face and also self-completed the HADS depression and anxiety scale. Respondents reported their levels of physical activity at work, in the home and in leisure time; the intensities of activity were also determined. Physical activity was related to depression scores but not to anxiety scores. There was no relationship between work physical activity and depression score. Among women, depression score increased with each additional episode of vigorous home activity. In both sexes, depression score decreased with each additional episode of vigorous leisure activity, but among men the decrease in depression score with moderate leisure activity was reversed if a lot of moderate activity was undertaken. We have found a variable relationship between depression scores and various settings for physical activity. Researchers, policymakers and practitioners who are interested in the relationship between physical activity and mental health should take into account the setting for activity as well as frequency, duration and intensity of activity

Increased blood pressure reactions to acute mental stress are associated with 16-year cardiovascular disease mortality

Exaggerated cardiovascular reactions to acute psychological stress may be involved in the aetiology of cardiovascular pathology. The present analysis examined the association between the magnitude of systolic and diastolic blood pressure reactions to stress and cardiovascular disease mortality. Participants were 431 (229 women) from the West of Scotland Twenty-07 Study, aged 63 years at the time of stress testing, where blood pressure was measured during resting baseline and mental arithmetic stress. Participants’ vital status was tracked for the next 16 years, during which time 38 had died of cardiovascular disease. Both systolic and diastolic blood pressure reactions were positively associated with cardiovascular disease mortality. This association could reflect the long term erosive effects of exaggerated reactivity on the vasculature as well as its short term capacity to trigger acute cardiovascular events

PRImary care Streptococcal Management (PRISM) study:In vitro study, diagnostic cohorts and a pragmatic adaptive randomised controlled trial with nested qualitative study and cost-effectiveness study

Background: Antibiotics are still prescribed to most patients attending primary care with acute sore throat, despite evidence that there is modest benefit overall from antibiotics. Targeting antibiotics using either clinical scoring methods or rapid antigen detection tests (RADTs) could help. However, there is debate about which groups of streptococci are important (particularly Lancefield groups C and G), and uncertainty about the variables that most clearly predict the presence of streptococci. Objective: This study aimed to compare clinical scores or RADTs with delayed antibiotic prescribing. Design: The study comprised a RADT in vitro study; two diagnostic cohorts to develop streptococcal scores (score 1; score 2); and, finally, an open pragmatic randomised controlled trial with nested qualitative and cost-effectiveness studies. Setting: The setting was UK primary care general practices. Participants: Participants were patients aged ≥ 3 years with acute sore throat. Interventions: An internet program randomised patients to targeted antibiotic use according to (1) delayed antibiotics (control group), (2) clinical score or (3) RADT used according to clinical score. Main outcome measures: The main outcome measures were self-reported antibiotic use and symptom duration and severity on seven-point Likert scales (primary outcome: mean sore throat/difficulty swallowing score in the first 2-4 days). Results: The IMI TestPack Plus Strep A (Inverness Medical, Bedford, UK) was sensitive, specific and easy to use. Lancefield group A/C/G streptococci were found in 40% of cohort 2 and 34% of cohort 1. A five-point score predicting the presence of A/C/G streptococci [FeverPAIN: Fever; Purulence; Attend rapidly (≤ 3 days); severe Inflammation; and No cough or coryza] had moderate predictive value (bootstrapped estimates of area under receiver operating characteristic curve: 0.73 cohort 1, 0.71 cohort 2) and identified a substantial number of participants at low risk of streptococcal infection. In total, 38% of cohort 1 and 36% of cohort 2 scored ≤ 1 for FeverPAIN, associated with streptococcal percentages of 13% and 18%, respectively. In an adaptive trial design, the preliminary score (score 1; n = 1129) was replaced by FeverPAIN (n = 631). For score 1, there were no significant differences between groups. For FeverPAIN, symptom severity was documented in 80% of patients, and was lower in the clinical score group than in the delayed prescribing group (-0.33; 95% confidence interval -0.64 to -0.02; p = 0.039; equivalent to one in three rating sore throat a slight rather than moderately bad problem), and a similar reduction was observed for the RADT group (-0.30; -0.61 to 0.00; p = 0.053). Moderately bad or worse symptoms resolved significantly faster (30%) in the clinical score group (hazard ratio 1.30; 1.03 to 1.63) but not the RADT group (1.11; 0.88 to 1.40). In the delayed group, 75/164 (46%) used antibiotics, and 29% fewer used antibiotics in the clinical score group (risk ratio 0.71; 0.50 to 0.95; p = 0.018) and 27% fewer in the RADT group (0.73; 0.52 to 0.98; p = 0.033). No significant differences in complications or reconsultations were found. The clinical score group dominated both other groups for both the cost/quality-adjusted life-years and cost/change in symptom severity analyses, being both less costly and more effective, and cost-effectiveness acceptability curves indicated the clinical score to be the most likely to be cost-effective from an NHS perspective. Patients were positive about RADTs. Health professionals' concerns about test validity, the time the test took and medicalising self-limiting illness lessened after using the tests. For both RADTs and clinical scores, there were tensions with established clinical experience. Conclusions: Targeting antibiotics using a clinical score (FeverPAIN) efficiently improves symptoms and reduces antibiotic use. RADTs used in combination with FeverPAIN provide no clear advantages over FeverPAIN alone, and RADTs are unlikely to be incorporated into practice until health professionals' concerns are met and they have experience of using them. Clinical scores also face barriers related to clinicians' perceptions of their utility in the face of experience. This study has demonstrated the limitation of using one data set to develop a clinical score. FeverPAIN, derived from two data sets, appears to be valid and its use improves outcomes, but diagnostic studies to confirm the validity of FeverPAIN in other data sets and settings are needed. Experienced clinicians need to identify barriers to the use of clinical scoring methods. Implementation studies that address perceived barriers in the use of FeverPAIN are needed

Cause-specific mortality time series analysis: a general method to detect and correct for abrupt data production changes

<p>Abstract</p> <p>Background</p> <p>Monitoring the time course of mortality by cause is a key public health issue. However, several mortality data production changes may affect cause-specific time trends, thus altering the interpretation. This paper proposes a statistical method that detects abrupt changes ("jumps") and estimates correction factors that may be used for further analysis.</p> <p>Methods</p> <p>The method was applied to a subset of the AMIEHS (Avoidable Mortality in the European Union, toward better Indicators for the Effectiveness of Health Systems) project mortality database and considered for six European countries and 13 selected causes of deaths. For each country and cause of death, an automated jump detection method called Polydect was applied to the log mortality rate time series. The plausibility of a data production change associated with each detected jump was evaluated through literature search or feedback obtained from the national data producers.</p> <p>For each plausible jump position, the statistical significance of the between-age and between-gender jump amplitude heterogeneity was evaluated by means of a generalized additive regression model, and correction factors were deduced from the results.</p> <p>Results</p> <p>Forty-nine jumps were detected by the Polydect method from 1970 to 2005. Most of the detected jumps were found to be plausible. The age- and gender-specific amplitudes of the jumps were estimated when they were statistically heterogeneous, and they showed greater by-age heterogeneity than by-gender heterogeneity.</p> <p>Conclusion</p> <p>The method presented in this paper was successfully applied to a large set of causes of death and countries. The method appears to be an alternative to bridge coding methods when the latter are not systematically implemented because they are time- and resource-consuming.</p

The role of material, psychosocial and behavioral factors in mediating the association between socioeconomic position and allostatic load (measured by cardiovascular, metabolic and inflammatory markers)

Lower socioeconomic position (SEP), both accumulated across the life course and at different life-stages, has been found to be associated with higher cumulative physiological burden, as measured by allostatic load. This study aimed to identify what factors mediate the association between SEP and allostatic load, as measured through combining cardiovascular, metabolic and inflammatory markers. We explored the role of material, psychological and behavioral factors, accumulated across two periods in time, in mediating the association between SEP and allostatic load. Data are from the West of Scotland Twenty-07 Study, with respondents followed over five waves of data collection from ages 35 to 55 (n=999). Allostatic load was measured by summing nine binary biomarker scores ('1'= in the highest-risk quartile) measured when respondents were 55. years old (wave 5). SEP was measured by a person's accumulated social class over two periods All mediators and SEP were measured at baseline in 1987 and 20. years later and combined to form accumulated measures of risk. Material mediators included car and home ownership, and having low income. The General Health Questionnaire (GHQ-12) was used as the psychosocial mediator. Behavioral mediators included smoking, alcohol consumption, physical activity and diet. Path analysis using linear regressions adjusting for sex were performed for each of the potential mediators to assess evidence of attenuation in the association between lower SEP and higher allostatic load. Analyses by mediator type revealed that renting one's home (approximately 78% attenuation) and having low income (approx. 62% attenuation) largely attenuated the SEP-allostatic load association. GHQ did not attenuate the association. Smoking had the strongest attenuating effect of all health behaviors (by 33%) with no other health behaviors attenuating the association substantially. Material factors, namely home tenure and income status, and smoking have important roles in explaining socioeconomic disparities in allostatic load, particularly when accumulated over time

Adoptive gay father families: parent-child relationships and children's psychological adjustment

Findings are presented on a U.K. study of 41 gay father families, 40 lesbian mother families, and 49 heterosexual parent families with an adopted child aged 3–9 years. Standardized interview and observational and questionnaire measures of parental well-being, quality of parent–child relationships, child adjustment, and child sex-typed behavior were administered to parents, children, and teachers. The findings indicated more positive parental well-being and parenting in gay father families compared to heterosexual parent families. Child externalizing problems were greater among children in heterosexual families. Family process variables, particularly parenting stress, rather than family type were found to be predictive of child externalizing problems. The findings contribute to theoretical understanding of the role of parental gender and parental sexual orientation in child development