Do routinely measured risk factors for obesity explain the sex gap in its prevalence? Observations from Saudi Arabia.

BACKGROUND: The prevalence of adult obesity is higher in women than men in most countries. However, the pathways that link female sex with excess obesity are still not fully understood. We examine whether socioeconomic and behavioural factors may mediate the association between sex and obesity in the Saudi Arabian setting where there is female excess in obesity. METHODS: We performed a mediation analysis using a cross-sectional, national household survey from Saudi Arabia with 4758 participants (51% female). A series of multivariable regression models were fitted to test if socioeconomic position, physical activity, sedentary behaviour, diet, and smoking mediate the association between sex and obesity (BMI >=30). The findings were confirmed using causal mediation analysis. RESULTS: Women in this sample were roughly twice as likely as men to be obese (crude OR 1.9; 95% CI 1.6-2.3). The odds ratio remained significantly higher for women compared to men in models testing for mediation (OR range 1.95-2.06). Our data suggest that indicators of socio-economic position, physical activity, sedentary behaviour, diet, and smoking do not mediate the sex differences in obesity. CONCLUSIONS: Our analysis shows that most commonly measured risk factors for obesity do not explain the sex differences in its prevalence in the Saudi context. Further research is needed to understand what might explain the female excess in obesity prevalence. We discuss how data related to the lived experience of Saudi men and women may tap into underlying mechanisms by which the sex difference in obesity prevalence are produced

Socio-demographic determinants of the severity of locomotor disability among adults in Bangladesh: a cross-sectional study, December 2010-February 2011.

BACKGROUND: Socio-demographic variables are widely known to have an association with the presence of any disability. However, the association between the severity of locomotor disability and socio-demographic variables has never been investigated in Bangladesh. METHODS: A cross sectional survey of adults with locomotor disabilities was conducted between December 2010 and February 2011 at the Centre for the Rehabilitation of the Paralysed (CRP), Dhaka, Bangladesh. During the study period 328 adults with locomotor disabilities met our selection criteria, but 316 consented and participated in the study. The 55-item Locomotor Disability Scale was used to measure disability. This study investigated the socio-demographic determinants of the severity of locomotor disability: age, gender, marital status, educational attainment, occupation, income status, type of house, living in own/rented house, household monthly income, household population and area of residence. RESULTS: Participants' age was positively associated with the severity of their locomotor disability (β = 0.01; 95% CI: 0.004 to 0.02), adjusting for diagnosis and other socio-demographic variables studied. Individuals who had an income experienced 0.35 (95% CI: -0.63 to -0.07) points decrease in the severity of disability than those did not have an income, adjusting for diagnosis and rest of the socio-demographic variables studied. In comparison to the unemployed individuals, students, homemakers, and individuals in elementary occupation respectively experienced 0.75 (95% CI: -1.08 to -0.43), 0.51 (95% CI: -0.82 to -0.19) and 0.37 (95% CI: -0.66 to -0.08) points decrease in the severity of locomotor disability, adjusting for diagnosis and rest of the socio-demographic variables studied. CONCLUSIONS: The severity of locomotor disability has an association with individuals' age, income status and occupation of the adults with such disability in Bangladesh. No such association was evident with other socioeconomic position and demographic variables. This finding suggests that people with locomotor disabilities in Bangladesh experience similar disabling built and attitudinal environments irrespective of their socioeconomic positions and demographic characteristics. Further community-based studies are needed to confirm such conclusions

Maternal psychological distress and child decision-making

Background: There is much research to suggest that maternal psychological distress is associated with many adverse outcomes in children. This study examined, for the first time, if it is related to children's affective decision-making. Methods: Using data from 12,080 families of the Millennium Cohort Study, we modelled the effect of trajectories of maternal psychological distress in early-to-middle childhood (3–11 years) on child affective decision-making, measured with a gambling task at age 11. Results: Latent class analysis showed four longitudinal types of maternal psychological distress (chronically high, consistently low, moderate-accelerating and moderate-decelerating). Maternal distress typology predicted decision-making but only in girls. Specifically, compared to girls growing up in families with never-distressed mothers, those exposed to chronically high maternal psychological distress showed more risk-taking, bet more and exhibited poorer risk-adjustment, even after correction for confounding. Most of these effects on girls’ decision-making were not robust to additional controls for concurrent internalising and externalising problems, but chronically high maternal psychological distress was associated positively with risk-taking even after this adjustment. Importantly, this association was similar for those who had reached puberty and those who had not. Limitations: Given the study design, causality cannot be inferred. Therefore, we cannot propose that treating chronic maternal psychological distress will reduce decision-making pathology in young females. Conclusions: Our study suggests that young daughters of chronically distressed mothers tend to be particularly reckless decision-makers

Trends in catastrophic health expenditure in India: 1993 to 2014

OBJECTIVE: To investigate trends in out-of-pocket health-care payments and catastrophic health expenditure in India by household age composition. METHODS: We obtained data from four national consumer expenditure surveys and three health-care utilization surveys conducted between 1993 and 2014. Households were divided into five groups by age composition. We defined catastrophic health expenditure as out-ofpocket payments equalling or exceeding 10% of household expenditure. Factors associated with catastrophic expenditure were identified by multivariable analysis. FINDINGS: Overall, the proportion of catastrophic health expenditure increased 1.47-fold between the 1993–1994 expenditure survey (12.4%) and the 2011–2012 expenditure survey (18.2%) and 2.24-fold between the 1995–1996 utilization survey (11.1%) and the 2014 utilization survey (24.9%). The proportion increased more in the poorest than the richest quintile: 3.00-fold versus 1.74-fold, respectively, across the utilization surveys. Catastrophic expenditure was commonest among households comprising only people aged 60 years or older: the adjusted odds ratio (aOR) was 3.26 (95% confidence interval, CI: 2.76–3.84) compared with households with no older people or children younger than 5 years. The risk was also increased among households with both older people and children (aOR: 2.58; 95% CI: 2.31–2.89), with a female head (aOR: 1.32; 95% CI: 1.19–1.47) and with a rural location (aOR: 1.27; 95% CI: 1.20–1.35). CONCLUSION: The proportion of households experiencing catastrophic health expenditure in India increased over the past two decades. Such expenditure was highest among households with older people. Financial protection mechanisms are needed for population groups at risk for catastrophic health expenditure

Association of nursery and early school attendance with later health behaviours, biomedical risk factors, and mortality: evidence from four decades of follow-up of participants in the 1958 birth cohort study.

BACKGROUND: Although early life education for improved long-term health and the amelioration of socioeconomically generated inequalities in chronic disease is advocated in influential policy statements, the evidence base is very modest. AIMS: To address this dearth of evidence using data from a representative UK national birth cohort study. METHODS: The analytical sample comprised men and women in the 1958 birth cohort study with prospectively gathered data on attendance at nursery or primary school before the age of 5 years who had gone on to participate in social survey at 42 years (n=11 374), or a biomedical survey at 44/5 years of age (n=9210), or had data on vital status from 18 to 55 years (n=17 657). RESULTS: Relative to study members who had not attended nursery, in those who had, there was in fact a higher prevalence of smoking and high alcohol intake in middle age. Conversely, nursery attenders had more favourable levels of lung function and systolic blood pressure in middle age. This apparent association between nursery attendance and lower systolic blood pressure was confined to study members from more deprived social backgrounds of origin (P value for interaction 0.030). There was no apparent link between early school attendance and any behavioural or biological risk factor. Neither nursery nor early school attendance was clearly related to mortality risk. CONCLUSIONS: We found no clear evidence for an association of either attendance at nursery or primary school before the age of 5 years and health outcomes around four decades later

Socio-economic inequalities in curative health-seeking for children in Egypt: analysis of the 2008 Demographic and Health Survey.

BACKGROUND: The existence and magnitude of socio-economic inequalities in health-seeking behaviours for child curative care in Egypt and mechanisms underlying these associations have not been comprehensively assessed. This study examined whether socio-economic position (SEP) was associated with health-seeking behaviours for diarrhoea and acute respiratory infection (ARI) in children and explored potential mechanisms underlying these associations using mediation analysis. METHODS: Children aged under-five years living with their mothers sampled by the 2008 Egypt Demographic and Health Survey were used to estimate the prevalence of diarrhoea and ARI in the two-week period preceding the survey. If either illness was reported, three dimensions of health-seeking were examined in adjusted mediation models, separately by illness: whether medical care was sought, whether such care was timely (within one day of symptom onset), and whether it was sought from private providers. Latent variables of parental socio-cultural capital and household-level economic capital were the main exposures of interest. RESULTS: In the sample of 10,006 children, 8.4% had diarrhoea and 7.6% had ARI. Care was sought for 62.0% of children with diarrhoea and 78.5% with ARI; two-thirds of care-seeking for both illnesses was timely. More than 7 in 10 children who sought care were taken to private providers. Socio-cultural capital or economic capital were not independently associated with seeking care for either illness. Socio-cultural capital was positively associated with timely care-seeking, and economic capital was positively associated with private provider use in adjusted analyses for both illnesses. CONCLUSIONS: SEP was not a strong determinant of care-seeking for diarrhoea or ARI, but there was a modest positive effect of SEP on timely receipt of care and private provider use. Further research is needed to explore perceptions of illness severity and the availability and quality of care from public and private providers

Levels of disability in the older population of England: Comparing binary and ordinal classifications.

BACKGROUND: Recent studies suggest the importance of distinguishing severity levels of disability. Nevertheless, there is not yet a consensus with regards to an optimal classification. OBJECTIVE: Our study seeks to advance the existing binary definitions towards categorical/ordinal manifestations of disability. METHODS: We define disability according to the WHO's International Classification of Functioning, Disability and Health (ICF) using data collected at the baseline wave of the English Longitudinal Study of Aging, a longitudinal study of the non-institutionalized population, living in England. First, we identify cut-off points in the continuous disability score derived from ICF to distinguish disabled from no-disabled participants. Then, we fit latent class models to the same data to find the optimal number of disability classes according to: (i) model fit indicators; (ii) estimated probabilities of each disability item; (iii) association of the predicted disability classes with observed health and mortality. RESULTS: According to the binary classification criteria, about 32% of both men and women are classified disabled. No optimal number of classes emerged from the latent class models according to model fit indicators. However, the other two criteria suggest that the best-fitting model of disability severity has four classes. CONCLUSIONS: Our findings contribute to the debate on the usefulness and relevance of adopting a finer categorization of disability, by showing that binary indicators of disability averaged the burden of disability and masked the very strong effect experienced by individuals having severe disability, and were not informative for low levels of disability

Hospitalisation trends in India from serial cross-sectional nationwide surveys: 1995 to 2014.

OBJECTIVES: We report hospitalisation trends for different age groups across the states of India and for various disease groups, compare the hospitalisation trends among the older (aged 60 years or more) and the younger (aged under 60 years) population and quantify the factors that contribute to the change in hospitalisation rates of the older population over two decades. DESIGN: Serial cross-sectional study. SETTING: Nationally representative sample, India. DATA SOURCES: Three consecutive National Sample Surveys (NSS) on healthcare utilisation in 1995-1996, 2004 and 2014. PARTICIPANTS: Six hundred and thirty-three thousand four hundred and five individuals in NSS 1995-1996, 385 055 in NSS 2004 and 335 499 in NSS 2014. METHODS: Descriptive statistics, multivariable analyses and a regression decomposition technique were used to attain the study objectives. RESULT: The annual hospitalisation rate per 1000 increased from 16.6 to 37.0 in India from 1995-1996 to 2014. The hospitalisation rate was about half in the less developed than the more developed states in 2014 (26.1 vs 48.6 per 1000). Poor people used more public than private hospitals; this differential was higher in the more developed (40.7% vs 22.9%) than the less developed (54.3% vs 40.1%) states in 2014. When compared with the younger population, the older population had a 3.6 times higher hospitalisation rate (109.9 vs 30.7) and a greater proportion of hospitalisation for non-communicable diseases (80.5% vs 56.7%) in 2014. Among the older population, hospitalisation rates were comparatively lower for females, poor and rural residents. Propensity change contributed to 86.5% of the increase in hospitalisation among the older population and compositional change contributed 9.3%. CONCLUSION: The older population in India has a much higher hospitalisation rate and has continuing greater socioeconomic differentials in hospitalisation rates. Specific policy focus on the requirements of the older population for hospital care in India is needed in light of the anticipated increase in their proportion in the population

Testing Comparability Between Retrospective Life History Data and Prospective Birth Cohort Study Data

Objectives: To determine whether comparable prospective and retrospective data present the same association between childhood and life course exposures and mid-life wellbeing. Method: Prospective data is taken from the 1958 UK National Child Development Study at age 50 in 2008 and earlier sweeps (n = 8,033). Retrospective data is taken from the English Longitudinal Study of Ageing at ages 50-55 from a life history interview in 2007 (n = 921). Results: There is a high degree of similarity in the direction of association between childhood exposures that have been prospectively collected in National Child Development Study and retrospectively collected in English Longitudinal Study of Ageing and wellbeing outcomes in mid-life. However, the magnitude of these associations is attenuated substantially by the inclusion of measurements, which are difficult or impossible to capture retrospectively, and are only available in prospective data, such as childhood poverty, cognitive ability, and indices of social and emotional adjustment. Discussion: The findings on the one hand provide some reassurance to the growing literature using life history data to determine life course associations with later life wellbeing. On the other hand, the findings show an overestimation in the retrospective data, in part, arising from the absence in life history data of childhood measures that are not well suited to retrospective collection

Horizontal inequity in outpatient care use and untreated morbidity: evidence from nationwide surveys in India between 1995 and 2014.

Equity in healthcare has been a long-term guiding principle of health policy in India. We estimate the change in horizontal inequities in healthcare use over two decades comparing the older population (60 years or more) with the younger population (under 60 years). We used data from the nationwide healthcare surveys conducted in India by the National Sample Survey Organization in 1995-96 and 2014 with sample sizes 633 405 and 335 499, respectively. Bivariate and multivariate logit regression analyses were used to study the socioeconomic differentials in self-reported morbidity (SRM), outpatient care and untreated morbidity. Deviations in the degree to which healthcare was distributed according to need were measured by horizontal inequity index (HI). In each consumption quintile the older population had four times higher SRM and outpatient care rate than the younger population in 2014. In 1995-96, the pro-rich inequity in outpatient care was higher for the older (HI: 0.085; 95% CI: 0.066, 0.103) than the younger population (0.039; 0.034, 0.043), but by 2014 this inequity became similar. Untreated morbidity was concentrated among the poor; more so for the older (-0.320; -0.391, -0.249) than the younger (-0.176; -0.211, -0.141) population in 2014. The use of public facilities increased most in the poorest and poor quintiles; the increase was higher for the older than the younger population in the poorest (1.19 times) and poor (1.71 times) quintiles. The use of public facilities was disproportionately higher for the poor in 2014 than in 1995-96 for the older (-0.189; -0.234, -0.145 vs - 0.065; -0.129, -0.001) and the younger (-0.145; -0.175, -0.115 vs - 0.056; -0.086, -0.026) population. The older population has much higher morbidity and is often more disadvantaged in obtaining treatment. Health policy in India should pay special attention to equity in access to healthcare for the older population