Young adults' work-family life courses and mental health trajectories from adolescence to young adulthood: a TRAILS study.

PURPOSE: Work-family life courses have been associated with mental health at various time points in life but little is known about how mental health develops during these work-family life courses. The aim of this study was to examine mental health trajectories from adolescence to young adulthood in women and men with different work-family life courses. METHODS: Data from 992 young adults participating in the 18-year follow-up TRacking Adolescents' Individual Lives Survey (TRAILS) were used. Work-family life courses from ages 18 to 28 years were previously constructed using sequence analysis. For each work-family life course, trajectories of internalising and externalising problems from ages 11 to 29 years were estimated using a multi-group random intercept growth model. Differences in mental health trajectories were examined across work-family life courses. RESULTS: For women, trajectories of internalising and externalising problems in young adulthood differed significantly between work-family life courses (p = 0.037 and p < 0.001, respectively). Women in the inactive work-family life course reported the highest scores of internalising and externalising problems during the entire young adulthood but the differences in mental health scores became most pronounced at age 29. Trajectories of internalising and externalising problems of men did not significantly differ between the work-family life courses. CONCLUSION: Mental health trajectories differed between women depending on their work-family life course. In men, differences between work-family life courses were less pronounced. Future studies should examine which work-family events and transitions captured in work-family life courses are associated with subsequent mental health problems during longer follow-up.

Cost-Effectiveness of a Multi-faceted Workplace Intervention to Reduce Musculoskeletal Pain in Nursing Staff: A Cluster-Randomized Controlled Trial (INTEVAL_Spain).

PURPOSE: To evaluate the cost-effectiveness of a multifaceted workplace intervention to reduce musculoskeletal pain (MSP) in nursing staff. METHODS: The study was a 1-year cluster-randomized controlled trial. The intervention combined participatory ergonomics, health promotion, and case management. The control group received usual care. Societal and health system perspectives were used. Costs included direct health and indirect costs. The effects were MSP and quality-adjusted life years (QALYs). MSP was measured using the Standardized Nordic Questionnaire at baseline and 6- and 12-month follow-up. QALYs were measured using the EuroQol-5D-3L at 6- and 12-month follow-up. Incremental costs and QALYs were modelled using generalized linear models. MSP was analysed through generalized logistic models. Incremental cost-effectiveness ratios (ICERs) were calculated, and cost-effectiveness planes and acceptability curves were constructed. RESULTS: Total mean costs per person were €614 and €216 for the intervention and control group, respectively, with a societal perspective. The intervention mean cost was €38/person. From the societal perspective, the ICER showed that overall additional €68 (€9 from a health system perspective) were required to achieve 1-extra-percentage-point reduction of MSP. ICERs were €34 from the societal and €4 from the health system perspectives for neck, shoulders and upper back pain; €53 and €7 for low back; €179 and €23 for hands; €39 and €5 for legs; €115 and €14 for the knees; €36 and €5 for feet For MSP in the elbows. For participants with pain in the elbow, and for QALYs, the ICER showed that the intervention group was dominated by the control group. CONCLUSION: This intervention was not cost-effective in terms of QALYs. However, in terms of MSP, with a willingness to pay of €100, the probability of the intervention being cost-effective was around 90%. Further studies incorporating our recommendations are needed to confirm these findings. STUDY REGISTRATION: ISRCTN15780649, retrospectively registered.

Impact of trajectories of maternal postpartum depression on infants' socioemotional development.

BACKGROUND: We assessed (a) the effects of postpartum depression (PPD) trajectories until 6 months postpartum on infants' socioemotional development (SED) at age 12 months, and (b) the mediating role of maternal self-efficacy (MSE), and the additional effect of postpartum anxiety at age 12 months. METHODS: We used data from POST-UP trial (n = 1843). PPD was assessed using the Edinburgh Postnatal Depression Scale (EPDS) at 1, 3, and 6 months. Infants' SED was assessed at 12 months using the Ages and Stages Questionnaire-Social-Emotional (ASQ-SE). Structural equations were applied to estimate the effect of PPD trajectories on infants' SED and mediation by MSE. The additional effects of postpartum anxiety were assessed with conditional regression. RESULTS: Higher levels of PPD over time were associated with a lower SED (coefficient for log-EPDS 3.5, 95% confidence interval 2.8; 4.2, e.g., an increase in the EPDS score from 9 to 13 worsens the ASQ-SE by 1.3 points). About half of this relationship was mediated by MSE. Postpartum anxiety had an independent adverse effect on SED. CONCLUSIONS: PPD and postpartum anxiety have a negative impact on infants' SED. MSE as a mediator may be a potential target for preventive interventions to alleviate the negative effects of maternal psychopathology on infants' SED. IMPACT: The trajectories of postpartum depression (PPD) from 1 month to 6 months were negatively related to infants' socioemotional development (SED) at age 12 months, underlining the importance of repeated assessment of PPD. Maternal self-efficacy (MSE) mediated the association between PPD and SED, implying MSE could be a potential target for preventive interventions. An additional independent negative effect of postpartum anxiety was identified, implying the assessment of postpartum anxiety also has a surplus value to identify mothers at risk.

Multiple health risk behaviors and mental health from a life course perspective: The Dutch TRAILS study.

We examined trajectories of multiple health risk behavior (MHRB) patterns throughout adolescence, and changes in mental health from childhood to young adulthood. Further, we assessed how continuity or onset of MHRBs overall were associated with subsequent changes in mental health, and whether this varied by type of MHRBs. We used six waves of the prospective Dutch TRAILS study (2001-2016; n = 2229), covering ages 11 until 23. We measured MHRBs (substance use: alcohol misuse, cannabis use, smoking; and obesity-related: overweight, physical inactivity, irregular breakfast intake) at three time points during adolescence. We assessed mental health as Youth/Adult Self-report total problems at ages 11 and 23. Latent class growth analyses and ANOVA were used to examine longitudinal trajectories and associations. We identified six developmental trajectories for the total of MHRBs and mental health. Trajectories varied regarding likelihood of MHRBs throughout adolescence, mental health at baseline, and changes in mental health problems in young adulthood. We found no associations for the continuity of overall MHRBs throughout adolescence, and neither for early, mid- or late onset, with changes in mental health problems in young adulthood. However, continuity of MHRBs in the obesity-related subgroup was significantly associated with an increase in mental health problems. Adolescents with the same MHRB patterns may, when reaching adulthood, have different levels of mental health problems, with mental health at age 11 being an important predictor. Further, involvement with obesity-related MHRBs continuously throughout adolescence is associated with increased mental health problems in young adulthood.

Adolescents' mental health problems increase after parental divorce, not before, and persist until adulthood: a longitudinal TRAILS study.

Parental divorce is one of the most stressful life events for youth and is often associated with (long-lasting) emotional and behavioral problems (EBP). However, not much is known about the timing of the emergence of these EBP in adolescents relative to the moment of parental divorce, and its longitudinal effects. We therefore assessed this timing of EBP in adolescents of divorce and its longitudinal effects. We used the first four waves of the TRacking Adolescent's Individual Lives Survey (TRAILS) cohort, which included 2230 10-12 years olds at baseline. EBP were measured through the Youth Self-Report (YSR), as internalizing and externalizing problems. We applied multilevel analysis to assess the effect of divorce on EBP. The levels of both internalizing and externalizing problems were significantly higher in the period after parental divorce (ß = 0.03, and 0.03, respectively; p < 0.05), but not in the period before divorce, with a persistent and increasing effect over the follow-up periods compared to adolescents not experiencing divorce. Adolescents tend to develop more EBP in the period after parental divorce, not before. These effects are long-lasting and underline the need for better care for children with divorcing parents.

Care improves self-reported daily functioning of adolescents with emotional and behavioural problems.

Emotional and behavioural problems (EBP) have a negative impact on various life domains of adolescents. Receiving care for EBP may improve the functioning of adolescents with EBP, but evidence on long-term outcomes in real-life settings is lacking. We, therefore, investigated self-reported functioning in different life domains of adolescents with various EBP, and the role of care during a three-year period. We used data from the TAKECARE study, which consist of a care and community cohort. We followed adolescents aged 12 and over (n = 733) during 3 years over five assessment rounds. Using the Strengths and Difficulties Questionnaire, self-reported functioning was measured in four life domains: home life, friendships, classroom learning and leisure activities. We categorized the respondents into four groups: (1) adolescents without emotional and behavioural problems (n = 298); (2) adolescents with emotional problems (n = 192); (3) adolescents with behavioural problems (n = 80); and (4) adolescents with both emotional and behavioural problems (n = 163). The development of functioning over time was analyzed using longitudinal ordinal (probit) regression analyses. Adolescents with both emotional and behavioural problems reported poorer functioning at baseline in all domains and adolescents who received care reported poorer functioning at baseline compared to adolescents who did not receive care. Regarding the change in functioning during the 3 years, adolescents who received care showed improved functioning in all domains. We found improved functioning after care, even if the problems may not have been solved. Psychosocial care can contribute to the functioning of adolescents with EBP, which can have major effects on their future life.

Respirable Crystalline Silica Exposure, Smoking, and Lung Cancer Subtype Risks. A Pooled Analysis of Case-Control Studies.

Rationale: Millions of workers around the world are exposed to respirable crystalline silica. Although silica is a confirmed human lung carcinogen, little is known regarding the cancer risks associated with low levels of exposure and risks by cancer subtype. However, little is known regarding the disease risks associated with low levels of exposure and risks by cancer subtype.Objectives: We aimed to address current knowledge gaps in lung cancer risks associated with low levels of occupational silica exposure and the joint effects of smoking and silica exposure on lung cancer risks.Methods: Subjects from 14 case-control studies from Europe and Canada with detailed smoking and occupational histories were pooled. A quantitative job-exposure matrix was used to estimate silica exposure by occupation, time period, and geographical region. Logistic regression models were used to estimate exposure-disease associations and the joint effects of silica exposure and smoking on risk of lung cancer. Stratified analyses by smoking history and cancer subtypes were also performed.Measurements and Main Results: Our study included 16,901 cases and 20,965 control subjects. Lung cancer odds ratios ranged from 1.15 (95% confidence interval, 1.04-1.27) to 1.45 (95% confidence interval, 1.31-1.60) for groups with the lowest and highest cumulative exposure, respectively. Increasing cumulative silica exposure was associated (P trend < 0.01) with increasing lung cancer risks in nonsilicotics and in current, former, and never-smokers. Increasing exposure was also associated (P trend ≤ 0.01) with increasing risks of lung adenocarcinoma, squamous cell carcinoma, and small cell carcinoma. Supermultiplicative interaction of silica exposure and smoking was observed on overall lung cancer risks; superadditive effects were observed in risks of lung cancer and all three included subtypes.Conclusions: Silica exposure is associated with lung cancer at low exposure levels. An exposure-response relationship was robust and present regardless of smoking, silicosis status, and cancer subtype.

Diesel Engine Exhaust Exposure, Smoking, and Lung Cancer Subtype Risks. A Pooled Exposure-Response Analysis of 14 Case-Control Studies.

Rationale: Although the carcinogenicity of diesel engine exhaust has been demonstrated in multiple studies, little is known regarding exposure-response relationships associated with different exposure subgroups and different lung cancer subtypes.Objectives: We expanded on a previous pooled case-control analysis on diesel engine exhaust and lung cancer by including three additional studies and quantitative exposure assessment to evaluate lung cancer and subtype risks associated with occupational exposure to diesel exhaust characterized by elemental carbon (EC) concentrations.Methods: We used a quantitative EC job-exposure matrix for exposure assessment. Unconditional logistic regression models were used to calculate lung cancer odds ratios and 95% confidence intervals (CIs) associated with various metrics of EC exposure. Lung cancer excess lifetime risks (ELR) were calculated using life tables accounting for all-cause mortality. Additional stratified analyses by smoking history and lung cancer subtypes were performed in men.Measurements and Main Results: Our study included 16,901 lung cancer cases and 20,965 control subjects. In men, exposure response between EC and lung cancer was observed: odds ratios ranged from 1.09 (95% CI, 1.00-1.18) to 1.41 (95% CI, 1.30-1.52) for the lowest and highest cumulative exposure groups, respectively. EC-exposed men had elevated risks in all lung cancer subtypes investigated; associations were strongest for squamous and small cell carcinomas and weaker for adenocarcinoma. EC lung cancer exposure response was observed in men regardless of smoking history, including in never-smokers. ELR associated with 45 years of EC exposure at 50, 20, and 1 µg/m3 were 3.0%, 0.99%, and 0.04%, respectively, for both sexes combined.Conclusions: We observed a consistent exposure-response relationship between EC exposure and lung cancer in men. Reduction of workplace EC levels to background environmental levels will further reduce lung cancer ELR in exposed workers.

Trajectories of care for children and adolescents with psychosocial problems: a 3-year prospective cohort study.

BACKGROUND: Care for children and adolescents with psychosocial problems is aimed at reducing problems. There may be a relationship between the intensity and duration of care provision and improvement of these outcomes, but evidence on this issue is lacking. We therefore examined the association between care trajectories based on duration and intensity of care for children, and the reduction in psychosocial problems after 3 years. METHODS: We obtained a cohort of all children entering psychosocial care in one region (n = 1,378), the TAKECARE cohort, and followed it for 3 years, with five assessment rounds. Retention in the final round was 85.8%. Psychosocial problems were measured using the parent report of the Total Difficulty Score of the Strength and Difficulties Questionnaire (SDQ-TDS). We constructed trajectories for intensity of care using growth mixture modelling and assessed the association between duration and intensity of care trajectories and SDQ-TDS after 3 years. RESULTS: After 3 months 60.6% of children and adolescents were receiving care, after 1 year 38.7% were receiving care and after 3 years 26.0%. Regarding intensity of care, three trajectories were found: one with minimal intensity during all 3 years, a second with initially medium intensity and strong reduction within 1 year, and a third with high intensity and a reduction after 1 year. Although the psychosocial problems of children and adolescents were reduced during the 3-year period, the rate of decline was relatively less marked for children and adolescents with longer care trajectories. CONCLUSION: Overall, children and adolescents with psychosocial problems who received care had improved outcomes at follow-up. However, increased provision of care does not automatically lead to reduction of problems, and although overall psychosocial problems are reduced, a substantial subgroup has longer lasting problems.

Variance constraints strongly influenced model performance in growth mixture modeling: a simulation and empirical study.

BACKGROUND: Growth Mixture Modeling (GMM) is commonly used to group individuals on their development over time, but convergence issues and impossible values are common. This can result in unreliable model estimates. Constraining variance parameters across classes or over time can solve these issues, but can also seriously bias estimates if variances differ. We aimed to determine which variance parameters can best be constrained in Growth Mixture Modeling. METHODS: To identify the variance constraints that lead to the best performance for different sample sizes, we conducted a simulation study and next verified our results with the TRacking Adolescent Individuals' Lives Survey (TRAILS) cohort. RESULTS: If variance parameters differed across classes and over time, fitting a model without constraints led to the best results. No constrained model consistently performed well. However, the model that constrained the random effect variance and residual variances across classes consistently performed very poorly. For a small sample size (N = 100) all models showed issues. In TRAILS, the same model showed substantially different results from the other models and performed poorly in terms of model fit. CONCLUSIONS: If possible, a Growth Mixture Model should be fit without any constraints on variance parameters. If not, we recommend to try different variance specifications and to not solely rely on the default model, which constrains random effect variances and residual variances across classes. The variance structure must always be reported Researchers should carefully follow the GRoLTS-Checklist when analyzing and reporting trajectory analyses.

Health literacy among older adults is associated with their 10-years' cognitive functioning and decline - the Doetinchem Cohort Study.

BACKGROUND: Many older adults have low levels of health literacy which affects their ability to participate optimally in healthcare. It is unclear how cognitive decline contributes to health literacy. To study this, longitudinal data are needed. The aim of this study was therefore to assess the associations of cognitive functioning and 10-years' cognitive decline with health literacy in older adults. METHODS: Data from 988 participants (mean age = 65.3) of the Doetinchem Cohort Study were analyzed. Health literacy was measured by the Brief Health Literacy Screening. Memory, mental flexibility, information processing speed, and global cognitive functioning were assessed at the same time as health literacy and also 10 years earlier. Logistic regression analyses were performed, adjusted for age, gender, and educational level. RESULTS: Higher scores on tests in all cognitive domains were associated with a lower likelihood of having low health literacy after adjustment for confounders (all ORs < 0.70, p-values<.001). Similar associations were found for past cognitive functioning (all ORs < 0.75, p-values<.05). Before adjustment, stronger cognitive decline was associated with a greater likelihood of having low health literacy (all ORs > 1.37, p-values<.05). These associations lost significance after adjustment for educational level, except for the association of memory decline (OR = 1.40, p = .023, 95% CI: 1.05 to 1.88). CONCLUSION: Older adults with poorer cognitive functioning and stronger cognitive decline are at risk for having low health literacy, which can affect their abilities to promote health and self-manage disease. Low health literacy and declining cognitive functioning might be a barrier for person-centered care, even in relatively young older adults.

Exposure-Response Analyses of Asbestos and Lung Cancer Subtypes in a Pooled Analysis of Case-Control Studies.

BACKGROUND: Evidence is limited regarding risk and the shape of the exposure-response curve at low asbestos exposure levels. We estimated the exposure-response for occupational asbestos exposure and assessed the joint effect of asbestos exposure and smoking by sex and lung cancer subtype in general population studies. METHODS: We pooled 14 case-control studies conducted in 1985-2010 in Europe and Canada, including 17,705 lung cancer cases and 21,813 controls with detailed information on tobacco habits and lifetime occupations. We developed a quantitative job-exposure-matrix to estimate job-, time period-, and region-specific exposure levels. Fiber-years (ff/ml-years) were calculated for each subject by linking the matrix with individual occupational histories. We fit unconditional logistic regression models to estimate odds ratios (ORs), 95% confidence intervals (CIs), and trends. RESULTS: The fully adjusted OR for ever-exposure to asbestos was 1.24 (95% CI, 1.18, 1.31) in men and 1.12 (95% CI, 0.95, 1.31) in women. In men, increasing lung cancer risk was observed with increasing exposure in all smoking categories and for all three major lung cancer subtypes. In women, lung cancer risk for all subtypes was increased in current smokers (ORs ~two-fold). The joint effect of asbestos exposure and smoking did not deviate from multiplicativity among men, and was more than additive among women. CONCLUSIONS: Our results in men showed an excess risk of lung cancer and its subtypes at low cumulative exposure levels, with a steeper exposure-response slope in this exposure range than at higher, previously studied levels. (See video abstract at, http://links.lww.com/EDE/B161.).

Co-morbidity of depression, anxiety and fatigue in cancer patients receiving psychological care.

OBJECTIVES: This study aimed to examine (1) subgroups of cancer patients with distinct co-morbidity patterns of depression, anxiety and fatigue; (2) how individuals transitioned between these patterns; and (3) whether socio-demographic, clinical and psychological care characteristics distinguished patients' transitions. METHOD: This naturalistic, longitudinal study focused on 241 cancer patients receiving psycho-oncological care in the Netherlands. Data were collected before initiation of psychological care (T1), 3 months (T2), and 9 months thereafter (T3). Latent transition analysis was performed examining research questions. RESULTS: Three distinct co-morbidity patterns were identified: class 1 ('mood disturbances and fatigue'), class 2 ('mood disturbances') and class 3 ('few symptoms of mood disturbances and fatigue'). Half of those in class 1 remained in this group from T1 to T3, a quarter transitioned to class 2 and another quarter to class 3. Baseline physical symptoms distinguished these transitions: those with more physical symptoms tended to remain stable. Half of patients in class 2 remained stable from T1 to T3, 46% moved into class 3 and 8% into class 1. Baseline physical symptoms and years after cancer diagnosis significantly distinguished these transitions: the 8% moving to class 1 had more physical symptoms and were longer after cancer diagnosis. Most patients in class 3 remained stable from T1 to T3, and predictors of transitions could not be examined. CONCLUSIONS: Three distinct co-morbidity patterns of depression, anxiety and fatigue were identified and exhibited different symptom courses longitudinally. Those with poor physical health tended to report elevated mood disturbances and fatigue during psychological care. Copyright © 2016 John Wiley & Sons, Ltd.

Stability and relative validity of the Neuromuscular Disease Impact Profile (NMDIP).

BACKGROUND: The aim of this study was to examine the stability and relative validity (RV) of the Neuromuscular Disease Impact Profile (NMDIP) using criterion-related groups. In a previous study the NMDIP-scales showed good internal consistency, convergent and discriminant validity. Known-groups analysis showed that the NMDIP discriminates between categories of extent of limitations. METHODS: A cross-sectional postal survey study was performed on patients diagnosed with a NMD and registered at the Department of Neurology, University Medical Center Groningen, the Netherlands. Participants were asked to complete the preliminary NMDIP, the Medical Outcome study Short Form Questionnaire (SF-36), the World Health Organization Quality Of Life-abbreviation version (WHOQOL-bref), and two generic domain specific measures: the Groningen Activity Restriction Scale (GARS) and the Impact on Participation and Autonomy Questionnaire (IPAQ). The variables 'Extent of Limitations' and 'Quality of Life' were used to create criterion-related groups. Stability over time was tested using the Wilcoxon Signed Rank Test for paired samples and the intraclass correlation coefficients for repeated measures. RV was examined by comparing the ability of NMDIP with generic multidimensional health impact measures, and domain specific measures in discriminating between criterion-related subgroups using the Kruskal-Wallis H-test. RESULTS: Response rate was 70% (n = 702). The NMDIP-scales showed sufficient stability over time, and satisfactory or strong RV. In general, the NMDIP scales performed as well as or better than the concurrent measurement instruments. CONCLUSIONS: The NMDIP proved to be a valid and reliable disease-targeted measure with a broad scope on physical, psychological and social functioning.

Less reduction of psychosocial problems among adolescents with unmet communication needs.

Patient-professional communication has been suggested to be a major determinant of treatment outcomes in psychosocial care for children and adolescents. However, the mechanisms involved are largely unknown and no longitudinal studies have been performed. Our aim was, therefore, to assess over the course of 1 year, the impact of patient-centered communication on psychosocial problems of adolescents in psychosocial care, including the routes mediating this impact. We obtained data on 315 adolescents, aged 12-18 years, enrolled in child and adolescent social or mental health care. We assessed patient-centered communication by comparing the needs and experiences of adolescents with regard to three aspects of communication: affective quality, information provision, and shared decision-making. Changes in psychosocial problems comprised those reported by adolescents and their parents between baseline and 1 year thereafter. Potential mediators were treatment adherence, improvement of understanding, and improvement in self-confidence. We found a relationship between unmet needs for affective quality, information provision, and shared decision-making and less reduction of psychosocial problems. The association between the unmet need to share in decision-making and less reduction of psychosocial problems were partially mediated by less improvement in self-confidence (30 %). We found no mediators regarding affective quality and information provision. Our findings confirm that patient-centered communication is a major determinant of treatment outcomes in psychosocial care for adolescents. Professionals should be aware that tailoring their communication to individual patients' needs is vital to the effectiveness of psychosocial care.

Do return-to-work trajectories differ by mental disorder diagnosis? A register study among 37 523 Dutch workers.

OBJECTIVES: Return to work (RTW) of workers with mental disorders is often a process of gradually increasing work hours over time, resulting in a RTW trajectory. This study aimed to investigate 2-year RTW trajectories by mental disorder diagnosis, examining the distribution of age, sex and contracted work hours across the diagnosis-specific RTW trajectories. METHODS: Sickness absence episodes diagnosed within the ICD-10 chapter V (mental and behavioral disorders) and ICD-10 Z73.0 (burnout) were retrieved from a Dutch occupational health service register, together with age, sex and contracted work hours. Sickness absence episodes due to adjustment disorders (N=25 075), anxiety disorders (N=1335), burnout (N=3644), mood disorders (N=5076), and post-traumatic stress disorders (N=2393) were most prevalent and included in latent class growth analysis (LCGA) to estimate 23-month RTW trajectories. RESULTS: Four main RTW trajectories were identified for all mental disorder diagnoses: fast full RTW [range 82.4% (mood disorders) to 92.0% (adjustment disorders) of the study population], slow full RTW [3.5% (burnout) to 6.1% (mood disorders)], slow partial RTW [0.6% (adjustment disorders) to 1.6% (mood disorders)] and no RTW [2.2% (adjustment disorders) to 9.7% (mood disorders)]. Trajectories with a late onset of fast full RTW included higher percentages of women and lower percentages of full-time workers. CONCLUSIONS: RTW trajectories were similar for different mental disorder diagnoses although the distribution differed across diagnoses, with more partial and no RTW trajectories among workers with mood disorders. To better guide workers back to work, more knowledge is needed of factors associated with late, partial, or no RTW.

Diverging death risks: Mortality as a corollary of economic, social, cultural and person capital.

Introduction: Diverging death risks are associated with a wide range of social factors, including not only education and income but also other economic and non-economic resources. The aim of this study was to assess the association of mortality risks with four types of resources: economic, social, cultural and person capital. Methods: We used data of 2,952 participants from the Disparities in the Netherlands survey and annual mortality data from Statistics Netherlands for the period 2014 to 2021. Economic capital was measured through education, income, occupation, home equity, and liquid assets. Social capital was measured by the strength of social ties, the size of the core discussion network, and access to people in resourceful positions; cultural capital by lifestyle, digital skills, and mastery of English, and person capital by self-rated health, impediments to climbing stairs, self-confidence, self-image, people's appearance, and body mass index. To accommodate the fact that each capital was derived from several indicators, we used Partial Least Squares (PLS) Cox Regression. Results: In multiple regression, higher economic, cultural, and person capital were associated with lower mortality (hazard ratio, 0.77; 95% confidence interval [CI, 0.65 to 0.90], 0.77 [0.64-0.93] and 0.80; [0.70-0.92]), adjusted for all capital measures and sex. Conclusion: The finding that more economic, cultural and person capital is associated with lower mortality provides empirical support for an approach that uses a broad spectrum of capital measures - hitherto rarely included simultaneously in epidemiological research - in order to understand diverging death risks. By integrating sociological concepts, cohort data, and epidemiological research methods, our study highlights the need for further research on the interplay between different forms of resources in shaping health inequalities. In designing public health interventions, we advocate the adoption of a multidimensional capital-based framework for tackling social disparities in mortality.

The impact of accredited social health activists in India on uptake of modern contraception: A nationally representative multilevel modelling study.

The government of India introduced the Accredited Social Health Activist (ASHA) programme in 2006 to connect marginalised communities to the health system. ASHAs are mandated to increase the uptake of modern contraception through the doorstep provision of services. There is currently no evidence on the impact of ASHAs on the uptake of contraception at the national level. This paper examines the impact of ASHAs on the uptake of modern contraception using nationally representative National and Family Health Survey data collected in 2019-21 in India. A multilevel logistic regression analysis was performed to determine the effect of contact with ASHAs on the uptake of modern contraception, controlling for regional variability and socio-demographic variables. The data provide strong evidence that ASHAs have succeeded in increasing modern contraceptive use. Women exposed to ASHAs had twice the odds of being current users of modern contraception compared to those with no contact, even after controlling for household and individual characteristics. However, only 28.1% of women nationally reported recent contact with ASHA workers. The ASHA programme should remain central to the strategy of the government of India and should be strengthened to achieve universal access to modern contraception and meet sustainable development goals by 2030.

Effectiveness of a health literacy intervention targeting both chronic kidney disease patients and health care professionals in primary and secondary care: a quasi-experimental study.

BACKGROUND: Chronic kidney disease (CKD) patients with limited health literacy are at risk for faster disease progression. To counteract this problem, we developed 'Grip on your Kidneys' (GoYK), an intervention targeting patients and health care professionals. We assessed the effect on self-management, patient activation, clinical parameters, consultation quality, and the professionals' use of health literacy strategies. We further evaluated the process. METHODS: A quasi-experimental study included 147 patients with CKD and 48 professionals from Dutch general practices and nephrology clinics. Patients and professionals in the intervention group (IG) received GoYK. Control patients received care-as-usual from the participating professionals. Data were collected with questionnaires and from patient records at baseline (T0), 4 months (T1) and 9 months (T2). RESULTS: No effects on self-management and patient activation were found. Conversely, at T2, the proportion of patients with hypertension decreased in the intervention group (odds ratio = 0.45, 95% confidence interval (95%CI) [0.20, 0.99]). In the intervention group, more lifestyle topics were discussed, at T1 (difference = 0.80, 95%CI [0.28, 1.31]) and T2 (difference = 0.69, 95%CI [0.14, 1.25]). Furthermore, several outcomes related to consultation quality improved. Professionals in the intervention group improved the use of health literacy strategies more, at T1 (difference = 0.64, 95%CI [0.33, 0.95]) and T2 (difference = 0.56, 95%CI [0.19, 0.93]). In general, patients and professionals considered GoYK to be useful. CONCLUSIONS: GoYK is promising, and offers a blueprint to optimize care for patients with limited health literacy. Researchers should develop and test interventions like GoYK, focusing on patients at risk for CKD, and with very low health literacy.

Evidence on the global measurement model of the Minnesota Living with Heart Failure Questionnaire.

PURPOSE: The Minnesota Living with Heart Failure Questionnaire (MLHFQ) is the most widely used health-related quality of life measure in both clinical and research settings. Nevertheless, its measurement model has never been confirmed. This study aims to fill that gap with a large international sample. METHODS: Data from eight studies (3,847 patients with heart failure) from 21 countries were merged and analysed. Common variables included MLHFQ scores, functional capacity, cardiovascular risk factors and the socio-demographic characteristics of the patient. The measurement model of the MLHFQ was assessed by means of exploratory and confirmatory factor analyses (EFA-CFA). The reliability of MLHFQ scores was evaluated using Cronbach's alpha coefficient and the MLHFQ's ability to differentiate among known groups was assessed through severity levels. RESULTS: Findings from the EFA and CFA suggest that the MLHFQ total and domain-specific scores fall within a bifactor model. The physical and emotional scores were supported within the sample, as was the original total score. Furthermore, a third factor was revealed regarding social environment. The reliability coefficient reached 0.9 for almost all physical and total scores. All the MLHFQ mean scores showed the ability to differentiate among functional capacity groups, with most of the effect size coefficients reaching 0.8. CONCLUSIONS: Beyond the suitable degree of reliability and validity displayed by the MLHFQ scores in the different country-specific versions, our results confirmed for the first time the unidimensionality of the most commonly used score in HF patients: the total MLHFQ score. Moreover, the social environment domain identified in this study can now be considered when assessing these patients' HRQL, especially as a relevant outcome with regard to disease management.