Social inequalities in low birth weight in England and Wales: trends and implications for future population health

STUDY OBJECTIVE: To examine social inequalities and trends in low birth weight in England and Wales. DESIGN: Analysis of routine birth data, comparing (a) couple and sole registered births, and (b) manual and non-manual occupational groups. SETTING: England and Wales, 1993-2000. MAIN RESULTS: Social inequalities in low birth weight were evident throughout 1993-2000: relative to the non-manual group, there is an increased risk for the manual group (range in RR 1.22-1.35) and sole registrations (RR 1.51-1.67). An estimated 6.5% (2979 births) of low birth weight in 2000 could have been avoided if risks associated with the manual group were absent, and 2.8% (1290 births) avoided if risks associated with sole registration were absent. Between 1993 and 2000, the low birthweight rate increased significantly with an estimated overall increase of 11%. Increases were evident in all social groups (15% in manual, 11% in sole registrations and 9% in non-manual); however relative to non-manual the increase in RRs were not statistically significant for manual or sole registrations. When multiple births are excluded, the rate of low birth weight is reduced but there is still a significant increase over time and social differentials are undiminished. CONCLUSIONS: There are social inequalities in low birth weight in England and Wales that have not narrowed over an eight year period, 1993-2000. These inequalities are likely to affect childhood and adult health inequalities in the future, hence strategies will need to address differences in low birth weight and further monitoring of trends is therefore desirable.     

Differential trends in alcohol-related mortality: a register-based follow-up study in Finland in 1987-2003

AIMS: To assess to what extent alcohol-related mortality has changed by age, sex and education in Finland in 1987-2003, a period which saw two periods of economic growth, separated by a severe depression (1991-1995). METHODS: A register-based follow-up study of all over 15-year-old Finnish men and women. Age, sex and education of the participants were measured at the time of the 1985, 1990, 1995 and 2000 censuses. Follow-up for mortality was for 1987-2003. The outcome measure was alcohol-related mortality, which was defined using information on the underlying and contributory causes of death. RESULTS: Among men and women aged 45 years and over, the trends in alcohol-related mortality were associated with economic cycles. Among those aged less than 45 years, alcohol-related mortality decreased from the early 1990s, but intoxication-related accidents and violence still contributed largely to premature mortality. The unfavourable trend for older men resulted from an increase in mortality due to directly alcohol-attributable diseases, alcohol-related diseases of the circulatory system and accidents and violence, and for older women from an increase due to intoxication-related accidents and violence, and alcohol-attributable diseases. Alcohol-related mortality was higher in lower educational groups, and among women the educational gap widened towards the end of the study period. CONCLUSIONS: This study shows that trends in both economic conditions and per capita consumption of alcohol are not associated with trends in alcohol-related mortality in all population subgroups. In health policy more attention should be paid to divergent trends in gender, age and education specific alcohol-related mortality.     

Occurrence of violence and violence-related injuries among 12-18 year-old Finns

AIMS: The aim of this study was to investigate the occurrence, nature, and severity of violence and violence-related injuries, and the occurrence of alcohol-related violence among Finnish adolescents. METHODS: A 12-page questionnaire was mailed to a nationwide representative sample of 12-, 14-, 16-, and 18-year-olds (n = 10,883). The response rate was 75%. RESULTS: Of the 8,135 respondents, 7.9% (646) reported violence occurrence and 1.7% violence-related injury during the past month. The male-female ratio for violence occurrence was 1.9 (95% CI 1.6-2.2) and for violence-related injury occurrence 0.8 (95% CI 0.6-1.2). Sixteen-year-old girls reported the highest injury rate (23/1,000). Most typically, the violent persons were individuals known by the victim before the incident. Girls were significantly (p < 0.001) more often (43%) in a fight with, or assailed by, a family member than boys (8%). Although boys' violent actions were related to leisure-time activities (64%), violence rarely took place during sports activities. Alcohol-related violence increased with age. Some 13% of 14-year-olds reported being under the influence of alcohol at the time of violence. The corresponding figures for 16- and 18-year-olds were 41% and 62%, respectively. Moreover, alcohol was closely associated with violence-related injuries. CONCLUSIONS: Violence is common among Finnish adolescents. While violence does not always lead to injury, related injuries are an important cause of adolescent morbidity. Alcohol seems to be strongly associated with adolescent violence and related injuries.     

Does the liberalisation of abortion laws increase the number of abortions? The case study of Spain.

BACKGROUND: Over the course of the 1980s a public debate on abortion took place in Spain culminating in a more permissive social climate and, in 1985, the partial decriminalisation of abortion. Before this, women were forced to abort illegally or abroad in countries which had decriminalised abortions. The aim of this study is to present jointly the evolution of abortions in Spanish women in England and Wales between 1974 and 1995, The Netherlands between 1980 and 1995 and Spain since the start of the register in 1987 through to 1995 and to compare trends both before and after the law in Spain. METHODS: Incidence rates were calculated in each of the countries studied and the slopes of the curves for 1974-1984 and 1987-1995 were compared. Data were obtained from reports published by the offices of abortion surveillance in England and Wales, The Netherlands and Spain. RESULTS: The rates increased constantly throughout the study period. From 1974 to 1985, a total of 204,736 Spanish women aborted in England and Wales and The Netherlands. After the law was passed, 34,895 Spanish women had abortions in those countries over the period 1986-1995. During 1987-1995, 340,214 Spanish women terminated their pregnancies in Spain. The regression coefficients before and after the passing of the law were beta = 0.3538 (0.307-0.400) and beta = 0.319 (0.243-0.394) respectively; no difference was observed. CONCLUSIONS: During the study period a significant proportion of reproductive-aged Spanish women had abortions in England and Wales and The Netherlands. Decriminalisation has had no observed effect on the trends in abortion, but rather it has benefited Spanish women by making abortion available locally and, therefore, reducing the inequalities implied by lack of access to proper health care services. These data demonstrate the impact of the liberalisation of abortion on the trends of procedures performed in other countries.     

Impact of paracetamol pack size restrictions on poisoning from paracetamol in England and Wales: an observational study

BACKGROUND: About 500 drug poisoning deaths involving paracetamol (acetaminophen) occur every year in England and Wales. To reduce the number of deaths, regulations were introduced in 1998 to restrict the sale of paracetamol. In this paper, we evaluate the impact of these regulations. METHODS: Mortality data for England and Wales were provided by the Office for National Statistics. Deaths were defined as due to compound paracetamol (paracetamol in combination with another analgesic, a low dose opioid or other ingredients) or paracetamol only, with or without alcohol or other drugs. The Department of Health provided data on all hospital admissions with a primary diagnosis of paracetamol poisoning. RESULTS: Mortality rates for paracetamol only were similar for males and females, and decreased from about 4.5 to 2.8 per million between 1997 and 1999 and again from about 3.1 to 2.2 per million between 2001 and 2002. These falls may be attributable to random variation in the rates. Deaths involving compound paracetamol, which were not subject to the 1998 regulations, remained relatively constant over the study period. There was evidence of a decreasing trend in paracetamol only mortality rates and this followed overall trends for other drug poisoning excluding opioids and drugs of misuse. Hospital admissions due to paracetamol poisoning increased from about 27 000 to 33 000 between 1995/1996 and 1997/1998 and then decreased to 25 000 in 2001/2002. There were almost 50 per cent more admissions for females than males, with the highest admission rates amongst females aged 15-24 years old. CONCLUSIONS: Between 1993 and 2002, mortality rates and hospital admissions due to paracetamol poisoning declined. However, the contribution of the 1998 regulations to this decline is not clear. Paracetamol poisoning continues to be an important public health issue in England and Wales and represents significant workload for the NHS in England.     

Why some generations are more violent than others: assessment of age, period, and cohort effects

Empirical longitudinal studies assessing why community-level violence rates change over time are lacking. Despite a wide-ranging literature, questions remain as to whether changes over time are due to factors occurring in specific periods (period effects) or individuals in successive cohorts (cohort effect). The objective was to assess the relative contribution of age, period, and cohort effects on violence trends. The authors assessed differences in self-reported violence between two cohorts of males (n = 1,009) from the Pittsburgh Youth Study, which tracked delinquency and risk factors from 1987 to 2000. The youngest cohort were aged 7-19 years, and the oldest cohort were aged 13-25 years. Yearly measures of violence were examined through generalized estimating equations. The oldest cohort reported higher levels of violence even after adjustment for age and major individual-level risk factors (odds ratio (OR) = 1.45, 95% confidence interval (CI): 1.17, 1.81) such as gang participation and drug dealing, as well as community-level factors (OR = 2.16, 95% CI: 1.65, 2.82). However, when period effects were included, cohort differences were rendered insignificant (OR = 1.23, 95% CI: 0.78, 1.94). The authors conclude that differences in the rates of violence over time may be attributed to changing social factors (period effects) and not to differences between the individuals (cohort effect) of cohorts.     

Comparison of trends in method-specific suicide rates in Australia and England & Wales, 1968-97

OBJECTIVE: To compare secular trends in method-specific suicide rates among young people in Australia and England & Wales between 1968 and 1997. METHODS: Australian data were obtained from the Australian Bureau of Statistics, and for England & Wales from the Office for National Statistics. Overall and method-specific suicide rates for 15-34 year old males and females were calculated using ICD codes E950-9 and E980-9 except E988.8. RESULTS: In both settings, suicide rates have almost doubled in young males over the past 30 years (from 16.8 to 32.9 per 100,000 in Australia and from 10.1 to 19.0 in England & Wales). Overall rates have changed little in young females. In both sexes and in both settings there have been substantial increases in suicide by hanging (5-7 fold increase in Australia and four-fold increase in England & Wales). There have also been smaller increases in gassing in the 1980s and '90s. In females, the impact of these increases on overall rates has been offset by a decline in drug overdose, the most common method in females. CONCLUSIONS: Rates of male suicide have increased substantially in both settings in recent years, and hanging has become an increasingly common method of suicide. The similarity in observed trends in both settings supports the view that such changes may have common causes. Research should focus on understanding why hanging has increased in popularity and what measures may be taken to diminish it.     

The incidence of molluscum contagiosum, scabies and lichen planus

We aimed to describe the incidence of new episodes of molluscum contagiosum, scabies and lichen planus presenting to general practitioners in England and Wales. We examined data collected in a sentinel practice network (the Weekly Returns Service of the Royal College of General Practitioners) in which about half a million persons were observed each year over the period 1994-2003. The incidence of molluscum contagiosum in males was 243/100,000 person-years and in females 231; of scabies, males 351, females 437; of lichen planus, males 32, females 37. Incidence varied by year and age. Ninety per cent of molluscum contagiosum episodes were reported in children aged 0-14 years, where incidence in 2000 (midpoint of a 6-year period of stable incidence) was 1265/100,000 (95% CI 1240-1290). Scabies affected all ages and annual incidence ranged between 233 (95% CI 220-246) in 2003 and 470 (95% CI 452-488) in 2000. Lichen planus occurred chiefly in persons aged over 45 years: incidence (all ages) ranged between 27 (95% CI 23-31) in 2003 and 43 (95% CI 37-49) in 1998. The relative risk of female to male incidence (all ages) of molluscum contagiosum was 0.95 (95% CI 0.91-0.99); of scabies 1.25 (95% CI 1.21-1.28); and of lichen planus 1.19 (95% CI 1.08-1.13).     

Relationships between child, family and neighbourhood characteristics and childhood injury: a cohort study

There has been little research into the role of neighbourhood effects in childhood injury. We report results from a cohort study, comprising 1717 families (2357 children aged 0-7 years) registered at 47 general practices in Nottingham, UK. Multi-level Poisson regression examined relationships between electoral ward (neighbourhood), family and child characteristics and medically attended injury rates. Primary care attendance rates were higher for children in rented accommodation and those aged 2-3 years. An n-shaped relationship was found between geographical access to services and the primary care attendance rate. Accident and Emergency (A&E) department attendance rates were higher amongst boys, children in rented accommodation, with a teenage mother, aged 2-5 years and living in wards with a higher number of parks and play areas. They were lower for children whose families had a smoke alarm. Hospital admission rates were higher amongst children living in more deprived wards and wards with higher violent crime rates. They were lower in children whose families had smoke alarms, stair gates and stored sharp objects safely. Primary care and A&E attendance rates varied significantly between families. Variation between wards in the A&E attendance rate was explained by family characteristics. We conclude that characteristics of wards, families and children are associated with medically attended childhood injury rates. This study did not find a neighbourhood effect for A&E attendances that could not be explained by family level characteristics. Studies with greater power and a measure of injury severity independent of health service utilisation are needed to explore the relationship between neighbourhood effects and more severe injuries. The greater variation in injury rates vary between families than between neighbourhoods suggests reducing inequalities in injury rates may be achieved more effectively by focussing prevention at families rather than neighbourhoods, but in practice interventions at both levels are likely to be necessary.     

The public health context of violence in Colombia.

OBJECTIVE: Among the countries of the Americas, Colombia has the highest level of deaths due to homicides and armed conflict. The objective of this research was to combine and contrast information from various sources on deaths due to violence in Colombia in order to identify major trends in violence in the country and to compare those trends with those in other nations of the Americas.METHODS: We drew together information from a wide array of sources, including the Government of Colombia, Colombian forensic institutions, nongovernmental organizations, and international research centers. We considered the impact of the violence on mortality as well as in such areas as nonfatal injuries, displacement of persons, and kidnappings.RESULTS: While there have been many deaths in Colombia directly related to military conflict, there have been many more deaths and injuries as an indirect result of war. The highest levels of deaths directly related to violence occurred during the 1990-1995 period. Although deaths due directly to armed conflict declined in the late 1990s, the related events of kidnappings and displacement did not.CONCLUSIONS: Efforts to reduce the violence-related suffering in Colombia must consider both direct and indirect causes of mortality as well as nonfatal outcomes such as kidnappings and displacement.     

Recent trends in mortality due to testicular cancer in Ireland: a comparison with England and Wales.

In the period 1961-84, the number of deaths in Ireland due to the testis cancer rose by 64%. This was due both to significant male population expansion (25.3%) and to an increased mortality rate. In the 25-34 years age group, one of the groups at highest risk, the mortality rate rose by 123%. In contrast, in England and Wales, although the male population has risen by 8.5% since 1961, the number of deaths has decreased by 17%. This is due to falling mortality rates, for example an 18% decrease in those aged 25-34 years. The highest rate of all occurred in those Irish over 75 years old. The changing Irish trends appear to lag behind those in England and Wales by some decades, and this raises important aetiological considerations.     

Health care expenditures and ageing: an international comparison

This study examines national health expenditure trends for Japan, Canada, Australia, and England and Wales (combined) to assess the impact of changing demographics and changing age-specific per capita expenditure on national health expenditure. Age-specific expenditure data were obtained from each country's department of health. We calculated changes in age-specific per capita expenditure, population demographics and the share of expenditures used by the different age groups over time. We then determined the extent to which isolated changes in population growth, demographic shifts and changes in age-specific per capita expenditure could predict observed increases in health expenditure. For Japan, Canada and Australia per capita health expenditure increased fastest among those aged 65 and over, at up to twice the increase of those aged 45-64. In England and Wales, on the other hand, those aged 65 and over experienced one-third of the cost increase of those aged 45-64. Hence, the proportion of national health expenditures used by the population aged 65 and over decreased from 40% to 35% in England and Wales, while increasing in the other countries by up to 10 percentage points. Demographic shifts and population growth predicted only 18% of the observed increases in health care expenditures in England and Wales, compared to 68%, 44% and 34% for Japan, Canada and Australia respectively. These differential changes in costs for older age groups over time invite future research into the driving forces behind these costs.     

Economic growth and health progress in England and Wales: 160 years of a changing relation

Using data for England and Wales during the years 1840-2000, a negative relation is found between economic growth--measured by the rate of growth of gross domestic product (GDP)--and health progress--as indexed by the annual increase in life expectancy at birth (LEB). That is, the lower is the rate of growth of the economy, the greater is the annual increase in LEB for both males and females. This effect is much stronger, however, in 1900-1950 than in 1950-2000, and is very weak in the 19th century. It appears basically at lag zero, though some short-lag effects of the same negative sign are found. In the other direction of causality, there are very small effects of the change in LEB on economic growth. These results add to an emerging consensus that in the context of long-term declining trends, mortality oscillates procyclically during the business cycle, declining faster in recessions. Therefore, LEB increases faster during recessions than during expansions. The investigation also shows how the relation between economic growth and health progress changed in England and Wales during the study period. No evidence of cointegration between income--as indexed by GDP or GDP per capita--and health--as indexed by LEB--is found.     

Income related inequalities in self assessed health in Britain: 1979-1995

STUDY OBJECTIVE: To measure and decompose income related inequalities in self assessed health in England, Scotland, and Wales, 1979-1995. DESIGN: The relation between individual health and a non-linear transformation of equivalised income, allowing for sex, age, country, and year effects, was estimated by multiple regression. The share of health attributable to transformed income and the Gini coefficient for transformed income were calculated. Inequality in health was measured by the partial concentration index, which is the product of the Gini coefficient and the share of health attributable to transformed income. Participants and setting: Representative annual samples of the adult population living in private households in Great Britain 1979-1995. The total analysed sample was 299,968 people. MAIN RESULTS: Pro-rich health inequality was largest in Wales and smallest in England over the period because the effect of increased income on health was greatest in Wales and least in England. In all three countries, pro-rich health inequality increased throughout the period. In the early 1980s this was primarily attributable to increases in income inequality. Thereafter the increased share of health attributable to income was the principal cause. CONCLUSIONS: Reductions in pro-rich health inequality can be achieved by reducing income inequality, reducing the effect of income on health, or both.     

An aging population — Some demographic and health trends

This article reports information on the demographic changes that have occurred in England and Wales in this century, with particular emphasis on aspects related to the elderly. What is known about the major diseases killing the elderly and trends in these diseases is also reported. Projections of the elderly population over the next 40 years and attempts to identify the possible degree of handicap in these elderly are discussed. Since the beginning of the century the population of England and Wales has grown from about 32.5 million to over 49 million. Age-specific mortality trends throughout the century indicate that there has been an appreciable decline at younger ages, but less of a decrease with advancing age in males. The fluctuation in the birth rate, different trends in the age-specific mortality, and differences between mortality for the sexes has resulted in a change in the age structure of the population. The main cause of death in the age range 60-84 years for both males and females is ischaemic heart disease--responsible for 1/3 of all deaths in males and 1/4 of all deaths in females. As with mortality, the statistics for hospital in-patient care show a marked rise with advancing age. About 8% of the male and 11% of the female population aged 75 years and over were receiving care from health and welfare service facilities day by day during 1981. In the oldest age group of 90 years and over, there are at present about 25 males for every 100 females; by 2023 this is projected to increase to about 35 males for every 100 females. What is not clear from the basic projection is whether the improvement in mortality is associated with an increasing number of healthy survivors, or an increasing number of survivors who have a chronic disease.     

Tetanus in England and Wales, 1984-2000

A review of national tetanus surveillance in England and Wales during 1984-2000 was undertaken to evaluate the surveillance system and national vaccination policy. Hospital Episode Statistics for tetanus in England for fiscal years 1989/90-1995/6 were also examined to estimate under-reporting. A total of 175 cases of tetanus were reported, giving an annual incidence of 0.20 per million, the lowest levels ever recorded. The highest incidence was in those aged over 64 years (0.66 per million) with no significant sex difference. Twenty (11%) cases were reported in people who were eligible for routine childhood vaccination. Outdoor injuries were the commonest reported exposure risk. Tetanus case under-reporting was estimated as 54-64%. We conclude that GPs should ensure that all their patients are fully vaccinated, targeting those born before 1961. High childhood tetanus vaccination coverage remains a priority. As the disease becomes rarer, enhanced tetanus case surveillance is essential for tetanus immunization policy evaluation.     

Assessing the burden of injury in six European countries

OBJECTIVE: To assess injury-related mortality, disability and disability-adjusted life years (DALYs) in six European countries. METHODS: Epidemiological data (hospital discharge registers, emergency department registers, mortality databases) were obtained for Austria, Denmark, Ireland, Netherlands, Norway, and the United Kingdom (England and Wales). For each country, the burden of injury was estimated in years lost due to premature mortality (YLL), years lived with disability (YLD), and DALYs (per 1000 persons). FINDINGS: We observed marked differences in the burden of injury between countries. Austria lost the largest number of DALYs (25 per 1000 persons), followed by Denmark, Norway and Ireland (17-20 per 1000 persons). In the Netherlands and United Kingdom, the total burden due to injuries was relatively low (12 per 1000 persons). The variation between countries was attributable to a high variation in premature mortality (YLL varied from 9-17 per 1000 persons) and disability (YLD varied from 2-8 per 1000 persons). In all countries, males aged 25-44 years represented one third of the total injury burden, mainly due to traffic and intentional injuries. Spinal cord injury and skull-brain injury resulted in the highest burden due to permanent disability. CONCLUSION: The burden of injury varies considerably among the six participating European countries, but males aged 15-24 years are responsible for a disproportionate share of the assessed burden of injury in all countries. Consistent injury control policy is supported by high-quality summary measures of population health. There is an urgent need for standardized data on the incidence and functional consequences of injury.     

Socioeconomic differentials in mortality among men within Great Britain: time trends and contributory causes

STUDY OBJECTIVE: To assess the size of mortality differentials in men by social class in Scotland as compared with England and Wales, and to analyse the time trends in these differentials. SUBJECTS: Men from England and Wales and Scotland around each census from 1951 to 1981. METHODS: Poisson regression analysis was used to calculate relative indices of inequality for disease specific and all cause mortality as a measure of mortality differentials between social classes. This measure is not dependent on the size of the social class groups, so it can be used to compare the magnitude of differentials over time periods during which the relative sizes of social class groups change. MAIN RESULTS: While overall death rates were higher in Scotland than in England and Wales around the 1951, 1961, and 1971 censuses the relative indices of inequality indicated smaller mortality differences between social classes in Scotland. Inequality, as indexed by the relative index of inequality, increased over time in both Scotland and England and Wales, but to a greater degree in Scotland, resulting in greater social class mortality differentials for Scotland in 1981 (the relative index of inequality increased from 1.40 to 2.43 for England and Wales, and from 1.22 to 2.57 for Scotland between 1951 and 1981). This greater increase in the magnitude of inequalities in all cause mortality in Scotland seemed to result from increasing social class differentials in cardiovascular disease, accidents and external causes, and "all other causes of death". Examining the trends in overall death rates, it seems that the greater increase in social class differences in Scotland occurred because of the greater decrease in death rates among the privileged social groups, in combination with a smaller decrease (or a greater increase) in the death rates in the lower social class groups. CONCLUSIONS: This study has shown that trends in mortality and in inequalities in mortality differ within Great Britain. Although death rates were higher in Scotland than in England and Wales, smaller mortality differentials by social class were found in Scotland over the period 1951 to 1971. By 1981, however, social class mortality differentials were greater in Scotland than in England and Wales. The greater increase in the social class differentials over time in Scotland, may have contributed to the worsening overall mortality profile in Scotland as compared with England and Wales that occurred between 1971 and 1981.       

Baseline indicators for measuring progress in preventing falls injury in older people

Objective: Over recent years, there has been increasing attention given to preventing falls and falls injury in older people through policy and other initiatives. This paper presents a baseline set of fall injury outcome indicators against which these preventive efforts can be assessed in terms of monitoring the rate of fall-related deaths and hospitalisations.
Methods: ICD-10-AM coded hospital separations, Australian Bureau of Statistics (ABS) mortality and ABS population data were used to determine the rate of fall-related injury mortality and hospitalisations occurring in people aged 65+ years in New South Wales (NSW), Australia, over the six-year period from 1998/99 to 2003/04, inclusive.
Results: Baseline trends for one fatality and five separations-based metrics are presented. Overall, fall mortality rates increased over the six years, with higher rates in males. Falls hospitalisation rates also increased slightly, with higher rates in females. The rates of hip fracture and pelvic fracture hospital separations generally declined over the six years and were highest in females. The level of unspecified and missing information about the place where falls occur increased by 1.5%.
Conclusion: Baseline trends in fall injury outcome metrics highlight the severity and frequency of fall injuries before wide scale implementation of the Management Policy to Reduce Fall Injury Among Older People in NSW.
Implications: Future use of these metrics will help to evaluate and monitor the progress of falls prevention in older people in NSW. They could also be adopted in other jurisdictions.