Journal of Epidemiology & Community Health

Blakey, K; Feltbower, R G; Parslow, R C; James, P W; Pozo, B Gómez; Stiller, C; Vincent, T J; Norman, P; McKinney, P A; Murphy, M F; Craft, A W; McNally, R J Q

doi: 10.1136/jech.2010.120956.4pmid: N/A

ObjectiveTo analyse the putative association between incidence of primary bone cancer diagnosed in 0–49 year olds in Great Britain (GB) in 1980–2005 and fluoride in drinking water. The analyses focussed on osteosarcoma and Ewing sarcoma.DesignThe study accessed multiple data sources including population census, digital boundary, postcode directory and fluoride monitoring at water supply zone level data. Incidence data from all 10 regional cancer registries were accessed and analysed by census ward. Residential postcode was used as a proxy for population distribution and the basis for making all census data compatible with 2001 census geography. Postcode distributions were also used to link water supply zones to census wards for England and Wales and postcode sectors for Scotland and enabled a fluoride level to be assigned to each census small-area in GB.SettingGB.ParticipantsData from patients (0 to 49 years) diagnosed with a primary bone cancer between 1980 and 2005 and registered with one of the 10 regional cancer registries in GB.Main outcome measureNegative binomial regression was used to examine the relationship between incidence rates and census small-area fluoride levels. These models were fitted to census small-area data aggregated into four age bands (0–14; 15–29; 30–49 and 0–49 years) and by gender with the logarithm of the “at risk” population as an offset.ResultsThere were a total of 2566 osteosarcoma cases aged 0–49 years; 817 aged 0–14 years; 1315 aged 15–29 years and 434 aged 30–49 years. For Ewing sarcoma there were a total of 1650 cases aged 0–49 years; 659 aged 0–14 years; 800 aged 15–29 years and 191 aged 30–49 years. After adjustment for age and gender, no statistically significant association was found between osteosarcoma or Ewing sarcoma and fluoride levels in drinking water. For example, for osteosarcoma the RR for 1 ppm increase in fluoride level 0.993; 95% CI 0.843 to to 1.171 and for Ewing sarcoma RR 0.860; 95% CI 0.696 to to 1.064.ConclusionThis is the first time the relationship between fluoride and bone cancer has been studied across the whole of GB at census ward level. No statistically significant associations between Ewing sarcoma or osteosarcoma and fluoride in drinking water were found.

McNeill, G; Osei-Assibey, G; Dick, S; Macdiarmid, J; Semple, S; Reilly, J; Ellaway, A; Cowie, H

doi: 10.1136/jech.2010.120477.32pmid: N/A

ObjectiveTo use evidence from systematic reviews of environmental influences on childhood overweight to prioritise areas for development of public health interventions.DesignSystematic literature reviews of intervention and longitudinal studies of environmental factors which could influence overweight via diet and/or physical activity, followed by a questionnaire-based ranking exercise for (a) the strength of the evidence for a causal association between the environmental factor and childhood overweight and (b) the likely effect size of public health actions on each factor on the prevalence of overweight in children. Environmental factors for which there was both strong evidence of causality and a larger effect size were selected for detailed modelling of the likely impact of public health interventions in children in Scotland.SettingChildren up to 8 years in Scotland.ParticipantsAcademics and policy makers with experience of reviewing evidence of public health interventions on obesity.Main Outcome MeasureRanking of environmental factors to identify those which should be prioritised for future public health interventions.ResultsOf the twenty-four environmental factors initially identified at stakeholder workshops, no studies were found for three factors influencing physical activity and one factor affecting diet. For the remaining twenty factors a median of six (range 1–28) studies were identified and summarised in tabular form. Fourteen academics and policy makers were given the tables to complete the rating exercise, which took approximately 1 h. The strength of the evidence and the likely effect size of actions were rated on a scale of 0 (low) to 5 (high). Eight of the environmental factors obtained mean ratings >3 for both strength of evidence and likely effect size: six were factors related to diet (high energy-dense snacks, sugar-sweetened soft drinks, infant feeding, availability of high fat, sugar and salt foods and portion size of manufactured foods and of restaurant and cafeteria items) and two were related to physical activity (physical education in schools and sedentary leisure activity). The ratings were lowest for access to local amenities, safe routes to schools and provision of healthy foods in schools.ConclusionThe ranking exercise provided a structured approach for obtaining a consensus view on priorities for public health action using tables of evidence from a systematic review. Use of this approach with a larger number academics and policy makers from different sectors would be useful to assess whether the area of expertise and sector (academia vs policy) influences the rating of the evidence.

Ighomereho, A; Steel, N; Bachmann, M

doi: 10.1136/jech.2010.120477.68pmid: N/A

IntroductionVisual impairment is an important preventable cause of disability in the UK. Cataract, glaucoma, diabetic retinopathy and age related macular degeneration are the common causes of visual impairment in the blind register, but little is known about the prevalence of eye disease in the community. This study aims to estimate the community prevalence of eye disease.MethodsTwenty-five general practices in Norfolk and Waveney were invited, and seven practices from rural, urban and inner city areas agreed to participate. Anonymised data about age, sex, Read codes, ophthalmic prescription, and post codes were extracted from electronic records using MIQUEST data extraction programme. Patients with an ophthalmic diagnosis between 1st May 2008 and 30th April 2009 were identified. The prevalence of both minor eye conditions such as conjunctivitis and eyelid conditions, and major conditions leading to visual impairment (cataract, glaucoma, diabetic retinopathy and age related macular degeneration) was estimated.Results3089 (5.1%) people with ages ranging from 0 to 104 years (mean 49.9 years) had an eye condition, out of a total practice population of 60 739 had at least one eye condition. Of these 3089 people, 1707 (55.3%) were female, 1382 (44.7%) were male. 150(4.9%) of these had age related macular degeneration, 200 (6.5%) had glaucoma, 223 (7.2%) had cataract, 371 (12%) had diabetic retinopathy, 560 (18.1%) had eyelid conditions, 1211 (39.2%) had conjunctivitis and benign conjunctival conditions. Some patients had more than one eye condition. The overall prevalence of eye conditions was 5.1%. Prevalence for individual eye conditions were as follows: Age related macular degeneration was 0.2%, Cataract was 0.4%, Diabetic retinopathy was 0.6%, glaucoma was 0.3%, conjunctivitis including benign conjunctival conditions was 2% and eyelid conditions was 0.9%. A limitation of the study is that we relied on Read codes for identification of eye conditions. Eye conditions may not have been coded at all, and any errors in coding could have introduced misclassification bias.ConclusionsThe four eye conditions that are the major causes of preventable visual impairment are frequently encountered in general practice. Further research is needed into the management of these conditions in primary care, so that ways to further reduce avoidable visual impairment can be identified.

McCann, M; O'Reilly, D

doi: 10.1136/jech.2010.120956.64pmid: N/A

ObjectivesTo offer reasons for the gender difference in care home admission risk.DesignA prospective longitudinal study collecting information from 2001 census returns, death registration, and health card registration information for a 28% sample of the Northern Ireland population, along with information from the local care home inspectorate. Analyses were performed using Cox regression models with hazard of care home admission as the outcome.Participants55 440 people aged 65 years or older and not living in care homes at the time of the Census.Main outcome measuresPermanent admission to a care home for older people, identified by change of address (from health card registration information) to a registered nursing or residential home (from inspectorate information).ResultsIn unadjusted models, women were 80% more likely to be admitted to a care home than men (HR 1.80 95% CI 1.65 to 1.96), while in fully adjusted models, the risk averaging across all living arrangements was 10% higher (HR 1.10 95% CI 1.00 to 1.20). There was however variation in the risk by living arrangements. After controlling for age, there was no raised admission risk for females among people living alone (HR 1.05 95% CI 0.93 to 1.19), or with siblings (HR 1.04 95% CI 0.64 to 1.68), however there was a higher risk when looking at the 20 972 cohort members living with a partner (HR 1.34 CI 1.14 to 1.59). There was no evidence of variation with health status of coresidents.ConclusionsApart from age, the single biggest contribution to the raised admission risk is living arrangements. There are no apparent gender differences among people living alone or with siblings, whereas the risk is higher for women living with a partner. This suggests that the support provided within the home is different, and that women receive less support from their husbands than men receive from their wives. Further research should investigate the effect of coresident gender on living arrangements among people living with children.

Evans, C E L; Greenwood, D C; Cade, J E

doi: 10.1136/jech.2010.120956.68pmid: N/A

ObjectiveThe aims of the review were to identify school-based randomised and non-randomised controlled trials to increase daily or lunchtime fruit and vegetable intake in children and to determine the impact of school-based interventions to change fruit and vegetable consumption at lunchtime and over the whole day.DesignA systematic literature review was carried out to identify appropriate trials. This was followed by meta-analysis techniques to determine the pooled estimate of the difference in daily fruit and vegetable intake in the intervention group compared with the control group.ParticipantsTrials carried out in schools where children were aged 5 to 11 years were included. All trials reported in English language journals were eligible.Results28 randomised and non-randomised controlled trials were identified that reported daily fruit and/or vegetable intake. A median intake of 0.4 portions more fruit and vegetables was consumed in the intervention group compared to the control group. The qualitative review of 7 studies reporting lunchtime intake, either in addition to daily intake or independently in studies concentrating solely on lunchtime intake, revealed a median difference of 0.2 portions more fruit and vegetables in the intervention group at lunchtime. The meta-analysis of daily intake included 13 studies classified into one of two groups: behavioural change studies with a school and/or home component that relied on families improving eating behaviour; and free school fruit and vegetable scheme where fruit and vegetables are distributed to children. The short term impact of both type of programme was determined using the follow up data collected within 3 months of the end of the intervention. This was the longest follow-up period in most cases. The pooled estimates (95% CI) for behavioural change studies and free fruit and vegetable schemes were 0.43 (0.21 to 0.65) and 0.44 (0.20 to 0.67) portions respectively. The pooled estimate (95% CI) for all studies was 0.42 (95% CI 0.27 to 0.58) portions more in the intervention group. The majority of the difference was due to fruit not vegetables. Heterogeneity was high for the meta-analysis with lunchtime intake but reasonable for daily intake.ConclusionSchool-based interventions have the potential to moderately improve fruit and vegetable intake in children, with approximately half of the increase attributable to improvements in lunchtime intake.

Goodman, A; Gisselmann, M D; Koupil, I

doi: 10.1136/jech.2010.120956.27pmid: N/A

ObjectiveTo investigate early-life biological and social predictors of educational outcomes, and compare the nature and magnitude of these effects across twentieth century Sweden.DesignMulti-generational data from a representative, population-based birth cohort, with linkage to routinely collected data.SettingSweden.Participants9829 Swedish male and females born 1915–1929 and 9465 of their grandchildren born 1973-1980, restricting participants to those who remained alive and in Sweden until age 20.Characteristics measured at birthSex, birthweight for gestational age, preterm birth, birth multiplicity, birth order, mother's age, mother's marital status and family social class.Educational outcomesSchool achievement was measured using standardised schoolmarks in elementary school. Education continuation was measured as a) senior school attendance and b) entrance to higher education.ResultsThe predictors of both school achievement and education continuation were very similar in the two cohorts, and effect sizes were usually at least as large in the younger cohort. In both cohorts, the independent predictors of better schoolmarks were: female gender (adjusted effect size 0.35 standard deviations (SD) in 1915–1929, 0.41SD in 1979-1980); higher birthweight for gestational age (0.09SD in 1915–1929, 0.23SD in 1979–1980 for highest vs lowest quintile); lower birth order (eg, 0.33SD in 1915–1925, 0.65SD in 1973–1980 for birth order 1 vs 4–5); older mother (eg, 0.12SD in 1915–1929, 0.34SD in 1973–1980 for 35–39 years vs 20–24 years); married mother (0.14SD in 1915–1929, 0.15SD in 1973–1980 for married vs unmarried); and higher family social class (eg, 0.39SD in 1915–1929, 0.66SD in 1973–1980 for high/mediate non-manual vs semi/unskilled manual). There were no independent effects of preterm or twin status. The same characteristics predicted education continuation, except that for this outcome the older cohort now showed a marked male advantage and no birthweight effect. Even after adjusting for school achievement, education continuation was still predicted by lower birth order, older mother, married mother and higher social class.ConclusionsMultiple early-life characteristics predicted educational outcomes across the lifecourse. These included size at birth (foetal growth rate) and family composition effects which typically receive far less attention than socio-economic influences. A range of pathways including impaired cognitive development, are likely to mediate these effects. Most effects were remarkably stable across the half-century separating our cohorts, indicating their potential relevance for understanding educational inequalities in populations around the world. Greater understanding of educational inequalities would, in turn, shed light onto a major mechanism whereby health inequalities are created and recreated across generations.

Abdalla, S; Quirke, B; Daly, L; Fitzpatrick, P; Kelleher, C

doi: 10.1136/jech.2010.120956.57pmid: N/A

BackgroundIrish Travellers are a distinct minority group characterised by a nomadic lifestyle, specific culture and substantial socio-economic and health disadvantage. When examined in 1987 the Traveller community in the Republic of Ireland (ROI) were shown to have a higher mortality than the general population. Updated information was needed to inform policy action in this area.ObjectiveTo examine the current mortality experience of Irish Travellers in the ROI and to contrast it with that of the general population.Design, setting and participantsWe conducted a retrospective mortality count as part of a wider Traveller Census (The All Ireland Traveller Health Study). In ROI 9056 Traveller families were surveyed. Census respondents were asked to identify all immediate and extended family members who died over an exact 12 month period preceding the census date. Information obtained was corroborated with and supplemented by reports from the Traveller health networks, Public Health Nurses and General Registrar death records.Main outcome measuresStandardised mortality ratios (SMR) with 95% CI using the 2008 ROI general population mortality rates as standard.ResultsThere were 188 Traveller deaths in the year preceding the census date of October 14th 2008. Traveller mortality in ROI is nearly three and a half times higher than that of the general population (SMR 348; 95% CI 298 to 397). This compares with a corresponding SMR of 254 calculated in 1987. Though general population mortality (age-adjusted) has declined by 35% over the past 20 years, Traveller mortality has only dropped by 13%, thus widening the mortality gap. Males have a significantly higher mortality than females with an SMR of 469 (95% CI 387 to 552) compared to a female SMR of 232 (95% CI 175 to 289). With a standard set of general population mortality rates in those aged 15 years and over, Travellers had an SMR of 277 (95% CI 235 to 319) compared to an SMR of 232 (95% CI 227 to 237) in the lower socio-economic group of the general population.ConclusionMortality among Irish Travellers has declined over the past 20 years but at a slower rate than that of the general population; the gap between Travellers and the general population has widened, particularly in males. The current gap is larger than that between the lower socio-economic group and the general ROI population. The results highlight the value of mortality measurement in uncovering health trends and health inequalities.

Mc Carthy, V J C; Perry, I J; Greiner, B A

doi: 10.1136/jech.2010.120956.13pmid: N/A

ObjectiveIn the present paper, we examine the association between manual work, resultant functional limitations and reduced ability to carry out daily activities of living (ADL), in older age. We hypothesise that manual workers as opposed to non-manual workers suffer, in older age, functional limitations and reduced ability to carry out ADL. This study is of great importance owing to our ageing Irish population and an ailing health service.MethodsA 10 year follow up study was conducted on a cohort of the general population (59–80 year olds) in the Republic of Ireland. Specific data on physical measurements, marital status, educational attainment, work history, functional status and ADL was collected on 357 study participants. Work history data focused on the job the participant had done for the longest period of time, paid or unpaid. Each participant was then asked if they described this work as manual or non-manual. Functional limitations and ADL were assessed using validated scales.ResultsJust over half the sample were female (53%) with 44% (n=150) retired (median=9 (5.14) years). Over 60% of the participants were, or had been engaged in manual work with this percentage higher in males, albeit non-significant (68% vs 58%, p=0.08). 20% of the total sample had complete function with a higher proportion of non-manual as opposed to manual workers (p=0.07) with no limitations. Almost three quarters of the sample had functional limitations and less than one fifth were classified as having an ADL disability.Using linear regression, manual workers were significantly more likely to have functional limitations even after adjustment (B=0.85, SE=0.30, p=0.01) for socio-demographic factors. When stratified by age, manual work remained significantly associated with functional limitations in the 60–69 year olds (B=0.66, SE=0.34, p=0.05) and in the 70–80 year olds (B=1.13, SE=0.50, p=0.03). For the older age group, males had a decreased risk of functional limitations independent of work type (B=−1.06, SE=0.47, p=0.03).There was no significant association between manual work and reduced activities of daily living either in the unadjusted or adjusted model.DiscussionFunctional limitations, in an older population, are related to the type of work they carried out. Good health surveillance for manual workers at a young age can identify limitations early. Initiatives such as work organisation, education and promotion of best work practices with regard to manual work can reduce functional limitations in older age.

Landy, R; Hardy, R; Head, J; Richards, M

doi: 10.1136/jech.2010.120956.30pmid: N/A

ObjectiveTo compare the effects of accounting for different missing data mechanisms in an investigation of the role of lifecourse socio-economic position (SEP) on later-life verbal cognitive ability.DesignTwo UK prospective cohort studies.ParticipantsA nationally representative sample born in 1946 (NSHD) (original N=5362), and a sample of British civil servants (Whitehall II) (original N=10 308).MethodsLinear regression models were used to test associations between SEP at different life stages and verbal ability. Results from complete case analysis (assuming missing completely at random) were compared with those using multiple imputation (assuming missing at random) and a Heckman selection model (assuming missing not at random) for each cohort.Main outcome measureVerbal cognitive ability in adulthood; the National Adult Reading Test at age 53 years (NSHD), and the Mill Hill Test at ages 55–79 years (Whitehall II).ResultsNSHD: Educational qualifications and head of household occupational SEP at age 53 were significantly related to verbal ability using all missing data methods, after adjusting for sex and cognitive function at age 8. The effect of childhood SEP was not significant at the 5% level when using Heckman selection (regression coefficient 0.51 (95% CI −0.25 to 1.27)) but was significant for complete case analysis (regression coefficient 0.83 (95% CI 0.11 to 1.54)). Compared with complete case analysis, the coefficients for SEP were generally higher when multiple imputation was used, but the overall conclusions remained the same. The coefficients using Heckman selection differed from those for the complete case and multiple imputation analyses, with lower coefficients for all SEP variables. Whitehall II: Educational qualifications and current occupational SEP were significantly associated with verbal ability for all missing data methods, after adjusting for age, sex, marital status, employment status (working/retired/long-term sick) and number of times the cognitive tests had been taken. The effect of childhood SEP was not significant. The coefficients were generally higher for multiple imputation than complete case analysis, whereas the Heckman selection coefficients were lower for educational qualifications and adult SEP (regression coefficient (95% CI) −4.46 (−5.12 to −3.78) for Heckman selection vs −5.15 (−5.75 to −4.55) for complete case).ConclusionEducational qualifications and adult SEP were significant predictors of verbal ability in middle to older age, but results for childhood SEP were inconclusive. Greater differences exist between the results from different missing data methods in the older Whitehall II sample, which may be due to greater selective dropout, which is better accounted for by Heckman selection.

Nieminen, T; Martelin, T; Koskinen, S; Prättälä, R; Alanen, E; Hyyppä, M T

doi: 10.1136/jech.2010.120477.31pmid: N/A

ObjectiveTo examine how different dimensions of social capital and health behaviour are associated.DesignCross-sectional data of the Health 2000 Health Examination Survey including a personal interview and self-administered questionnaires.SettingRepresentative sample (N=8028) of the Finnish adult population.Participants6986 (87%) adults aged 30 years or over.Main Outcome MeasuresNon-smoking, non-excessive drinking, leisure-time physical activity, daily use of vegetables, adequate duration of sleep.ResultsSocial capital was found to be associated with health behaviour. The dimension of social participation and networks was positively associated with every type of health behaviour. High levels of trust and reciprocity were related to non-smoking and adequate duration of sleep, and high levels of social support to adequate duration of sleep and daily use of vegetables. These associations persisted after controlling for age, gender, education and living arrangements. According to our findings, structural social capital seems to be associated with health behaviour more strongly than cognitive social capital.ConclusionIrrespective of their social status, people with higher levels of social capital—especially in social participation and networks—engage in healthier behaviour. When trying to reduce health inequalities, one strategy could be to promote social participation especially among people in danger of social exclusion.