Obesity and other health determinants across Europe: the EURALIM project

STUDY OBJECTIVE: EURALIM (EURope ALIMentation), a European collaborative study, aimed to determine and describe the extent to which European data on risk factor distributions from different populations could be pooled and harmonised in a common database for international comparisons. SETTING: Seven independent population-based surveys from six European countries (France, Italy, Northern Ireland/United Kingdom, Spain, Switzerland, the Netherlands). METHODS: Data for 18 381 women and 12 908 men aged 40-59 were pooled in a common database. Central statistical analyses on major cardiovascular risk factors were conducted with careful consideration of methodological issues, including differences in study designs, data assessment tools, and analytic techniques used. MAIN RESULTS: Because of the detected variability among methods used, direct comparisons of risk factor distributions and prevalences between studies were problematic. None the less, comparisons of within population contrasts by sex, age group, and other health determinants were considered to be meaningful and apt, as illustrated here for obesity. Results were targeted and disseminated to both the general public and public health professionals and framed in the context of a European information campaign. CONCLUSIONS: International and national comparisons between existing locally run studies are feasible and useful, but harmonisation methods need improvement. Development of an international risk factor surveillance programme based on decentralised data collection is warranted. In the meantime, risk factor contrasts across populations can be used as a basis for targeting needed public health intervention programmes.     

深圳市福田区中小学生健康状况3年动态分析

目的 分析深圳福田区中小学生健康状况的变化。方法 对该区6所监测点中小学1997－1999年学生体检资料进行对比分析。结果 中学生健康问题明显多于小学生,3年间中学生视力不良、龋齿肥胖以及小学生的营养不良和肥胖患病率均有不同程度上升（P＜0.005）,小学生龋齿患病率1998年上升,1999年下降,中小学生的沙眼患病率均明显降低（P＜0.005）。中学女生视力不和龋患率高于男生,小学女生患率高于男生（P＜0.005）。结论 中小学生健康状况尚存在许多问题,减轻学习负担,加强健康教育有助于提高中小学生健康水平。     

The global activity limitation indicator and self-rated health: two complementary predictors of mortality

Background

The purpose of this study is to compare the ability of the Global Activity Limitation Indicator (GALI) and self-rated health (SRH) to predict all-cause mortality in the general adult population.

Methods

We linked the 2001 Belgian Health Interview Survey with mortality and migration registers 2001–2010. The baseline sample included 8,583 individuals aged 15 years and older. Poisson regression models were used to estimate the effect of the GALI and SRH on mortality rate during follow-up. We investigated the impact of gender, age, education and follow-up period on the association between the GALI/SRH and mortality.

Results

The GALI and SRH were strong and complementary predictors of mortality in the Belgian adult population. Although the two global instruments shared some traits, they predicted mortality concurrently, with some indication of a somewhat stronger effect for SRH. We found neither significant differences between men and women, nor between education groups. The predictive effect of the GALI and SRH slightly decreased over time and the predictive effect of SRH slightly decreased with age.

Conclusions

Our findings suggest that the GALI and SRH are useful and complementary measures for assessing the health and functional status of adults in population surveys.     

Regions, hospitals and health outcomes over time: A multi-level analysis of repeat prevalence among a cohort of health-care workers

BackgroundThe relative importance of region, workplace, and individual determinants of health burden is debated.ObjectiveTo model the contribution of hospital characteristics to employee mental and musculoskeletal disorders.MethodsWe linked employment records of nurses and support services’ staff with health records, neighbourhood census, and hospital administrative data. We conducted multi-level logistic regression analyses with three levels: year (I), employee characteristics (II), and hospital characteristics (III).ResultsNorthern region hospitals experienced lower disorder prevalences (odds ratios (OR) 0.58, 95% confidence intervals (0.40, 0.82) for mental and 0.56 (0.44, 0.73) for musculoskeletal disorders). Hospitals with yearly workloads of the highest versus lowest quintiles of inpatient days/1000 employee hours (>86.0 vs. <42.6) and surgical cases/1000 employee hours (>10.5 vs. <3.9) had greater odds of mental (1.29 (1.05, 1.57); 1.22 (1.05, 1.42)) and musculoskeletal (1.38 (1.21, 1.58); 1.21 (1.09, 1.34)) disorders.ConclusionOpportunities exist for reduction in burden with hospital workload reduction. Further exploration of regional effects is needed.     

A longitudinal analysis of the relationship between changes in socio-economic status and changes in health

In this paper we contribute to discussion on the relationship between different aspects of socio-economic status (SES) and health. Separating different aspects of SES facilitates the specification of a structural relationship between SES indicators and morbidity. Longitudinal data and the utilization of growth curve modelling enable an empirical analysis of the direct relationship between changes over time in SES indicators and changes in morbidity. Our empirical analysis is based on panel data (N = 2976) derived from the annual Swedish Survey of Living Conditions. The panel, which consists of respondents that at the first panel wave were between 31 and 47 years old, is followed for 16 years, starting in 1979. Data are gathered at three points of time. A growth curve model is set up using structural equation modelling. The structural relationship and changes over time are simultaneously estimated. It is shown that in relation to health occupational position is crucial, canalising the effects of class of origin and education. More prestigious jobs are related to initially good health and to a less rapid deterioration in health. At the same time initial health affects occupational mobility, confirming a health selection into less prestigious jobs. It is also shown that change of occupation and income are related to change in health. The analysis confirms a strong relationship between SES and morbidity and shows that initial SES affects later changes in morbidity, i.e., a causal relationship exists between SES and morbidity. But, the analysis also demonstrates the existence of selection effects, meaning that initial morbidity causes less favourable changes in SES. It is finally revealed that changes in occupational prestige and income changes co-vary with changes in morbidity. Hence, the analysis provides basic information necessary to make any assumption about causality and selection in relation to SES and health.     

Change in income and change in self-rated health: Systematic review of studies using repeated measures to control for confounding bias

It is generally assumed that income is strongly and positively associated with health. However, much of the evidence supporting this assumption comes from cross-sectional data or analyses that have not fully accounted for biases from confounding and health selection (the reverse pathway from health to income). This paper reports results of a systematic review of panel and longitudinal studies investigating whether changes in income led to changes in self-rated health (SRH) in adults. A variety of electronic databases were searched, up until January 2010, and thirteen studies were included, using data from five different panel or longitudinal studies. The majority of studies found a small, positive and statistically significant association of income with SRH, which was much reduced after controlling for unmeasured confounders and/or health selection. Residual bias, particularly from measurement error, probably reduced this association to the null. Most studies investigated short-term associations between income and SRH or the effect of temporary (usually one year) income changes or shocks, so did not rule out possibly stronger associations between health and longer-term average income or income lagged over longer time periods. Nevertheless, the true causal short-term relationship between income and health, estimated by longitudinal studies of income change and SRH that control for confounding, may be much smaller than that suggested by previous, mostly cross-sectional, research.     

A multilevel analysis of social capital and self-rated health: Evidence from the British Household Panel Survey

Social capital is often described as a collective benefit engendered by generalised trust, civic participation, and mutual reciprocity. This feature of communities has been shown to associate with an assortment of health outcomes at several levels of analysis. The current study assesses the evidence for an association between area-level social capital and individual-level subjective health. Respondents participating in waves 8 (1998) and 9 (1999) of the British Household Panel Survey were identified and followed-up 5 years later in wave 13 (2003). Area social capital was measured by two aggregated survey items: social trust and civic participation. Multilevel logistic regression models were fitted to examine the association between area social capital indicators and individual poor self-rated health. Evidence for a protective association with current self-rated health was found for area social trust after controlling for individual characteristics, baseline self-rated health and individual social trust. There was no evidence for an association between area civic participation and self-rated health after adjustment. The findings of this study expand the literature on social capital and health through the use of longitudinal data and multilevel modelling techniques.     

Socioeconomic and behavioral risk factors for mortality in a national 19-year prospective study of U.S. adults

Many demographic, socioeconomic, and behavioral risk factors predict mortality in the United States. However, very few population-based longitudinal studies are able to investigate simultaneously the impact of a variety of social factors on mortality. We investigated the degree to which demographic characteristics, socioeconomic variables and major health risk factors were associated with mortality in a nationally-representative sample of 3617 U.S. adults from 1986 to 2005, using data from the 4 waves of the Americans' Changing Lives study. Cox proportional hazard models with time-varying covariates were employed to predict all-cause mortality verified through the National Death Index and death certificate review. The results revealed that low educational attainment was not associated with mortality when income and health risk behaviors were included in the model. The association of low income with mortality remained after controlling for major behavioral risks. Compared to those in the “normal” weight category, neither overweight nor obesity was significantly associated with the risk of mortality. Among adults age 55 and older at baseline, the risk of mortality was actually reduced for those were overweight (hazard rate ratio = 0.83) and those who were obese (hazard rate ratio = 0.68), controlling for other health risk behaviors and health status. Having a low level of physical activity was a significant risk factor for mortality (hazard rate ratio = 1.58). The results from this national longitudinal study underscore the need for health policies and clinical interventions focusing on the social and behavioral determinants of health, with a particular focus on income security, smoking prevention/cessation, and physical activity.     

Patient experiences with information in a hospital setting: Associations with coping and self-rated health in chronic illness

The structural relations between patient experiences with information provided by hospital staff, coping behaviour and changes in self-rated health were studied in a cohort of people with chronic illness (n = 556) over a period of 2 years. A structural equation approach was applied to model cross-sectional and longitudinal effects. Positive experiences with information were cross-sectionally but not longitudinally associated with improved self-rated health. Patient experiences with information are not related to avoidance coping, but positive experiences contribute to more frequent use of supportant coping. The findings in the present study indicate that measures of patient experiences with information are not merely a reflection of patients’ health or coping behaviour. More theoretical work is required to describe the relationships between different patient reported outcomes. The insight into mechanisms underlying changes in physical and mental health in chronic illness could be further improved by evaluating the effects of specific educational and psychosocial interventions in a longitudinal design.     

The role of geographic scale in testing the income inequality hypothesis as an explanation of health disparities

This study re-examined the role of geographic scale in measuring income inequality and testing the income inequality hypothesis (IIH) as an explanation of health disparities. We merged Behavioral Risk Factor Surveillance System (BRFSS) 2000 data with income inequality indices constructed at different geographic scales to test the association between income inequality and four different health indicators, i.e., self-assessed health status as a morbidity measure, vaccination against influenza as a measure of use of preventive healthcare, having any kind of health insurance as a measure of access, and obesity as a modifiable health risk factor measure. Multilevel models are used in our regression of the health indicators on measures of income inequalities and control variables. Our analysis suggests that because income inequality is a contextual variable, income inequalities measured at different geographic scales have different interpretations and relate to societal characteristics at different levels. Therefore, a rejection of the IIH at one level does not necessarily negate the possibility that income inequality affects health at another level. Assessment across a variety of scales is needed to have a comprehensive picture of the IIH in any given study. Empirical results also show that whether the IIH holds could depend on the sex group examined and the health indicator used, which implies different mechanisms of IIH exist for different sex groups and health indicators, in addition to the geographic scale. The role of geographic scale should be more rigorously considered in social determinants of health research.     

Socioeconomic status and health status: A study of males in the Canada health survey

The relationships between education/occupation/income and health status have been well documented in the international epidemiological and sociological literature for many years, however, specific studies on the subject are scarce in Canada. Even when relationships have been demonstrated, the reasons for these relationships are much debated. This study presents an analysis of the relationship between socioeconomic status (SES) and health status. The study is based on analysis of data from a sample of nearly 2000 male principal income earners from the 1978 Canada Health Survey. Firstly, is there a relationship between an individual's SES and health status in Canada? Secondly, what aspects of SES--education, occupational status, and/or income--are most important? Thirdly, what are the possible explanations of the observed relationship? That is, is it possible to disaggregate the relationship and thereby infer possible causal mechanisms? The findings indicated a direct positive relationship between SES and health status, i.e. the higher an individual's SES, the better that person's health. The major exception to this was the SES/fitness relationship. In this instance, the higher the SES, the lower the level of fitness. Though age was an important control variable as SES, fitness and illness are age related, the findings relating SES to the health measures remained even when age was controlled for. Of the three SES measures, income was consistently the best correlate of health status. Occupational status showed the most inconsistent relationships with health status. The findings supported both the social causation and social selection hypotheses. That is, social position can have an effect on health status (social causation), while health status can affect one's social position (social selection).     

Work stress and reduced health in young physicians: prospective evidence from Swiss residents

OBJECTIVES: Job stress, investigated by the effort-reward model in various working environments in different countries, has been widely reported, yet studies addressing physicians are lacking. The present study investigated the perceived job stress, its association with the amount of working hours, and its impact on young physicians' self-reported health and their satisfaction with life during residency. METHODS: In a prospective study design, a cohort of Swiss medical school graduates was followed up, beginning in 2001. In their second and fourth years of residency, 433 physicians assessed their effort-reward imbalance, overcommitment, physical and mental well-being and satisfaction in life. Taking the longitudinal design into account, four categories of stressed residents were defined: (1) subjects not reporting high work stress at either measurement, (2) subjects reporting high work stress in the second but not in the fourth year of residency, (3) subjects with onset of high work stress in fourth year and (4) residents reporting high work stress at both measurements. RESULTS: All components of the perceived stress at work were significantly correlated with the amount of working hours, effort showing the highest correlation. While two-thirds of the participants do not report high work stress, assessed by the extrinsic part of the effort-reward imbalance model (the ratio between effort and reward) and 12% show a decrease of stress over time, there are 15% with an increase of stress over time, and 10% with persistently high stress experience. In terms of the intrinsic stress component (overcommitment), 71% show low values, 12% show a decrease, 9% an increase and 8% constantly high values. The groups with constant and increasing extrinsic and intrinsic stress experience exhibit significantly worse health and life satisfaction compared to the remaining groups, after controlling for gender and baseline health. CONCLUSIONS: Stress at work in young physicians, especially when being experienced over a longer period in postgraduate training, has to be a matter of concern because of its negative impact on health and life satisfaction and the risk of developing symptoms of burnout in the long run.     

Income inequality and self-rated health in US metropolitan areas: A multi-level analysis

Income inequality has been found to affect health in a number of international and cross-national studies. Using data from a telephone survey of adults in the United States, this study analyzed the effect of metropolitan level income inequality on self-rated health. It combined individual data from the 2000 Behavioral Risk Factor Surveillance System with metropolitan level income data from the 2000 Census. After controlling for smoking, age, education, Black race, Hispanic ethnicity, sex, household income, and metropolitan area per capita income, this study found that for each 1 point rise in the GINI index (on a hundred point scale) the risk of reporting Fair or Poor self-rated health increased by 4.0% (95% confidence interval 1.6–6.5%). Given that self-rated health is a good predictor of morbidity and mortality, this suggests that metropolitan area income inequality is affecting the health of US adults.     

Change in health status and mortality as indicators of outcomes: comparison between the Medicare Advantage Program and the Veterans Health Administration

Background

Comparing health outcomes with adequate methodology is central to performance assessments of health care systems. We compared the Medicare Advantage Program (MAP) and the Veterans Health Administration (VHA) with regard to changes in health status and mortality.

Methods

We used the Death-Master-File for vital status and the Short-Form 36 to determine physical (PCS) and mental (MCS) health at baseline and at 2 years. We compared the probability of being alive with the same or better (than would be expected by chance) PCS (or MCS) at 2 years and mortality, while adjusting for case-mix. Given the geographic variations in MAP enrollment, we did a regional sub-analysis.

Results

There were no significant differences in the probability of being alive with the same or better PCS except for the South (VHA 65.8% vs. MAP 62.5%, P = .0014). VHA patients had a slightly higher probability than MAP patients of being alive with the same or better MCS (71.8% vs. 70.1%, P = .002) but no significant regional variations. The hazard ratios for mortality in the MAP were higher than in the VHA across all regions.

Conclusion

With the use of appropriate methodology, we found small differences in 2-year health outcomes that favor the VHA.

     

Distinguishing between quality of life and health status in quality of life research: A meta-analysis

Despite the increasing acceptance of quality of life (QOL) as a critical endpoint in medical research, there is little consensus regarding the definition of this construct or how it differs from perceived health status. The objective of this analysis was to understand how patients make determinations of QOL and whether QOL can be differentiated from health status. We conducted a meta-analysis of the relationships among two constructs (QOL and perceived health status) and three functioning domains (mental, physical, and social functioning) in 12 chronic disease studies. Instruments used in these studies included the RAND-36, MOS SF-20, EORTC QLQ-30, MILQ and MQOL-HIV. A single, synthesized correlation matrix combining the data from all 12 studies was estimated by generalized least squares. The synthesized matrix was then used to estimate structural equation models. The meta-analysis results indicate that, from the perspective of patients, QOL and health status are distinct constructs. When rating QOL, patients give greater emphasis to mental health than to physical functioning. This pattern is reversed for appraisals of health status, for which physical functioning is more important than mental health. Social functioning did not have a major impact on either construct. We conclude that quality of life and health status are distinct constructs, and that the two terms should not be used interchangeably. Many prominent health status instruments, including utility-based questionnaires and health perception indexes, may be inappropriate for measuring QOL. Evaluations of the effectiveness of medical treatment may differ depending on whether QOL or health status is the study outcome.     

Change in household income and risk for attention deficit hyperactivity disorder during childhood: A nationwide population-based cohort study

Background

Childhood attention deficit hyperactivity disorder (ADHD) is reported to be more prevalent among socioeconomically disadvantaged groups in various countries. The effect of poverty on child development appears to depend on how long poverty lasts. The timing of poverty also seems to be important for childhood outcomes. Lifetime socioeconomic status may shape current health. Thus, we investigated the effects of household income changes from birth to 4 years on the occurrence of ADHD.

A multilevel analysis of urban neighborhood socioeconomic disadvantage and health in late life

The associations between neighborhood context and various indicators of health are receiving growing empirical attention, but much of this research is regionally circumscribed or assumes similar effects across the life course. This study utilizes a U.S. national sample to investigate the association between urban neighborhood socioeconomic disadvantage and health specifically among older adults. Data are from 3442 participants aged 70 years and older in the 1993 Asset and Health Dynamics Among the Oldest Old (AHEAD) Study, and the 1990 U.S. Census. Our approach underscores the importance of multiple dimensions of health (self-reported physician-diagnosed cardiovascular disease [CVD], functional status, and self-rated health) as well as multiple dimensions of neighborhood disadvantage, which are conceptualized as environmental hazards that may lead to a physiologically consequential stress response. We find that individual-level factors attenuate the association between neighborhood disadvantage and both CVD and functional status, but not self-rated health. Net of covariates, high neighborhood socioeconomic disadvantage is significantly associated with reporting poor health. In late life, neighborhood socioeconomic disadvantage is more consequential to subjective appraisals of health than diagnosed CVD or functional limitations.