Smoking cessation care during pregnancy: A qualitative exploration of midwives' challenging role.

PROBLEM: The majority of South Australian pregnant women who smoke do not quit during pregnancy. Additionally, the prevalence of smoking is higher among pregnant women living in socially disadvantaged areas. BACKGROUND: Understanding challenges in midwives' provision of smoking cessation care can elucidate opportunities to facilitate women's smoking cessation. AIM: We aimed to understand midwives' perspectives on current practices, perceived barriers and facilitators to delivery of smoking cessation care, and potential improvements to models of smoking cessation care. METHODS: An exploratory qualitative research methodology and thematic analysis was used to understand the perspectives of midwives in five focus groups. FINDINGS: Four themes were generated from the data on how midwives perceived their ability to provide smoking cessation care: Tensions between providing smoking cessation care and maternal care; Organisational barriers in the delivery of smoking cessation care; Scepticism and doubt in the provision of smoking cessation care; and Opportunities to enable midwives' ability to provide smoking cessation care. DISCUSSION: A combination of interpersonal, organisational and individual barriers impeded on midwives' capacities to approach, follow-up and prioritise smoking cessation care. Working with women living with disadvantage and high rates of smoking, the midwife's role was challenging as it balanced delivering smoking cessation care without jeopardising antenatal care. CONCLUSION: Providing midwives with resources and skills may alleviate the sense of futility that surrounds smoking cessation care. Provision of routine training and education could also improve understandings of the current practice guidelines.

Comparison of the Tree-Based Machine Learning Algorithms to Cox Regression in Predicting the Survival of Oral and Pharyngeal Cancers: Analyses Based on SEER Database.

This study aims to demonstrate the use of the tree-based machine learning algorithms to predict the 3- and 5-year disease-specific survival of oral and pharyngeal cancers (OPCs) and compare their performance with the traditional Cox regression. A total of 21,154 individuals diagnosed with OPCs between 2004 and 2009 were obtained from the Surveillance, Epidemiology, and End Results (SEER) database. Three tree-based machine learning algorithms (survival tree (ST), random forest (RF) and conditional inference forest (CF)), together with a reference technique (Cox proportional hazard models (Cox)), were used to develop the survival prediction models. To handle the missing values in predictors, we applied the substantive model compatible version of the fully conditional specification imputation approach to the Cox model, whereas we used RF to impute missing data for the ST, RF and CF models. For internal validation, we used 10-fold cross-validation with 50 iterations in the model development datasets. Following this, model performance was evaluated using the C-index, integrated Brier score (IBS) and calibration curves in the test datasets. For predicting the 3-year survival of OPCs with the complete cases, the C-index in the development sets were 0.77 (0.77, 0.77), 0.70 (0.70, 0.70), 0.83 (0.83, 0.84) and 0.83 (0.83, 0.86) for Cox, ST, RF and CF, respectively. Similar results were observed in the 5-year survival prediction models, with C-index for Cox, ST, RF and CF being 0.76 (0.76, 0.76), 0.69 (0.69, 0.70), 0.83 (0.83, 0.83) and 0.85 (0.84, 0.86), respectively, in development datasets. The prediction error curves based on IBS showed a similar pattern for these models. The predictive performance remained unchanged in the analyses with imputed data. Additionally, a free web-based calculator was developed for potential clinical use. In conclusion, compared to Cox regression, ST had a lower and RF and CF had a higher predictive accuracy in predicting the 3- and 5-year OPCs survival using SEER data. The RF and CF algorithms provide non-parametric alternatives to Cox regression to be of clinical use for estimating the survival probability of OPCs patients.

Effect of maternal smoking during pregnancy on childhood type 1 diabetes: a whole-of-population study.

AIMS/HYPOTHESIS: Evidence of an association between maternal smoking during pregnancy (prenatal smoking) and childhood type 1 diabetes is mixed. Previous studies have been small and potentially biased due to unmeasured confounding. The objectives of this study were to estimate the association between prenatal smoking and childhood type 1 diabetes, assess residual confounding with a negative control design and an E-value analysis, and summarise published effect estimates from a meta-analysis. METHODS: This whole-of-population study (births from 1999 to 2013, participants aged ≤15 years) used de-identified linked administrative data from the South Australian Early Childhood Data Project. Type 1 diabetes was diagnosed in 557 children (ICD, tenth edition, Australian Modification [ICD-10-AM] codes: E10, E101-E109) during hospitalisation (2001-2014). Families not given financial assistance for school fees was a negative control outcome. Adjusted Cox proportional HRs were calculated. Analyses were conducted on complete-case (n = 264,542, type 1 diabetes = 442) and imputed (n = 286,058, type 1 diabetes = 557) data. A random-effects meta-analysis was used to summarise the effects of prenatal smoking on type 1 diabetes. RESULTS: Compared with non-smokers, children exposed to maternal smoking only in the first or second half of pregnancy had a 6% higher type 1 diabetes incidence (adjusted HR 1.06 [95% CI 0.73, 1.55]). Type 1 diabetes incidence was 24% lower (adjusted HR 0.76 [95% CI 0.58, 0.99]) among children exposed to consistent prenatal smoking, and 16% lower for exposure to any maternal smoking in pregnancy (adjusted HR 0.84 [95% CI 0.67, 1.08]), compared with the unexposed group. Meta-analytic estimates showed 28-29% lower risk of type 1 diabetes among children exposed to prenatal smoking compared with those not exposed. The negative control outcome analysis indicated residual confounding in the prenatal smoking and type 1 diabetes association. E-value analysis indicated that unmeasured confounding associated with prenatal smoking and childhood type 1 diabetes, with a HR of 1.67, could negate the observed effect. CONCLUSIONS/INTERPRETATION: Our best estimate from the study is that maternal smoking in pregnancy was associated with 16% lower childhood type 1 diabetes incidence, and some of this effect was due to residual confounding.

A novel case-control design to estimate the extent of over-diagnosis of breast cancer due to organised population-based mammography screening.

Debate about the extent of breast cancer over-diagnosis due to mammography screening has continued for over a decade, without consensus. Estimates range from 0 to 54%, but many studies have been criticized for having flawed methodology. In this study we used a novel study design to estimate over-diagnosis due to organised mammography screening in South Australia (SA). To estimate breast cancer incidence at and following screening we used a population-based, age-matched case-control design involving 4,931 breast cancer cases and 22,914 controls to obtain OR for yearly time intervals since women's last screening mammogram. The level of over-diagnosis was estimated by comparing the cumulative breast cancer incidence with and without screening. The former was derived by applying ORs for each time window to incidence rates in the absence of screening, and the latter, by projecting pre-screening incidence rates. Sensitivity analyses were undertaken to assess potential biases. Over-diagnosis was estimated to be 8% (95%CI 2-14%) and 14% (95%CI 8-19%) among SA women aged 45 to 85 years from 2006-2010, for invasive breast cancer and all breast cancer respectively. These estimates were robust when applying various sensitivity analyses, except for adjustment for potential confounding assuming higher risk among screened than non-screened women, which reduced levels of over-diagnosis to 1% (95%CI 5-7%) and 8% (95%CI 2-14%) respectively when incidence rates for screening participants were adjusted by 10%. Our results indicate that the level of over-diagnosis due to mammography screening is modest and considerably lower than many previous estimates, including others for Australia.

Can screening 4-5 year olds accurately identify children who will have teacher-reported mental health problems when children are aged 6-7 years?

OBJECTIVE: To assess the screening accuracy of information obtained from parents of 4-5-year-old children for the purpose of identifying the children who have teacher-reported mental health problems when they are aged 6-7 years. METHOD: The study used data from the Longitudinal Study of Australian Children (LSAC) obtained when children were aged 4-5 years and 6-7 years. The level of children's mental health problems was assessed using the Strengths and Difficulties Questionnaire (SDQ) completed by parents when children were aged 4-5 years and by teachers when children were aged 6-7 years (n=2163). When children were aged 4-5 years, parenting skills were assessed using three questionnaires developed for the parent-completed LSAC questionnaire and maternal mental health was assessed using the Kessler Psychological Distress Scale (K6). RESULTS: When the level of parent-reported childhood mental health problems at 4-5 years old was used to identify children with teacher-reported mental health problems (i.e. a score in the "abnormal" range of the teacher-reported SDQ Total Difficulties Scale) when the children were aged 6-7 years, sensitivity was 26.8%, positive predictive value was 22.8%, and specificity was 92.9%. The addition of further information about the characteristics of children and their parents made only a small improvement to screening accuracy. CONCLUSIONS: Targeted interventions for preschool children may have the potential to play an important role in reducing the prevalence of mental health problems during the early school years. However, current capacity to accurately identify preschoolers who will experience teacher-reported mental health problems during the early school years is limited.

Do breast cancer risk factors differ among those who do and do not undertake mammography screening?

OBJECTIVES: There is considerable interest in whether mammography screening leads to over-diagnosis of breast cancer. However self-selection into screening programmes may lead to risk differences that affect estimates of over-diagnosis. This study compares the breast cancer risk profiles of participants and non-participants of population-based mammography screening. Risk profiles are also compared between those who have and have not used private screening services. SETTING: This study involved 1162 women aged 40-84 who participated in the 2012 Health Omnibus, an annual face-to-face interview-based survey of a representative sample of the population in the state of South Australia. METHODS: Data were collected on participation in mammography screening, demographic characteristics and breast cancer risk factors (including reproductive, familial and lifestyle factors). Missing data were multiply imputed. Factors independently associated with ever having been screened were identified using multivariable logistic regression, for population-based and ad hoc, private mammography screening separately. RESULTS: Compared with non-participants, participants of population-based screening were more likely to have used hormone replacement therapy (odds ratio [OR] = 3.72), experienced breast biopsy or surgery (OR = 2.22), and be overweight or obese (OR = 1.57). They were less likely to be sufficiently active (OR = 0.57) or be born in a non-English speaking country (OR = 0.50) or aged under 50 (OR = 0.09). Women who were screened privately were more likely to have a family history of breast cancer (OR = 1.66) and have experienced breast biopsy or surgery (OR = 3.17) than those who had not. CONCLUSIONS: South Australian women who participated in the population-based mammography screening have a slightly higher prevalence of breast cancer risk factors. This also applies to those who undertook private screening.

Impact of hormone replacement therapy use on mammographic screening outcomes.

PURPOSE: This study aims to measure the impact of HRT use at the time of screening on rates of screen-detected invasive breast cancer (IBC) and ductal carcinoma in situ (DCIS), interval cancers and investigative procedures, within a well-established population-based mammography screening program. METHODS: Using South Australian BreastScreen data from 1998 to 2009 pertaining to 819,722 screening episodes, Poisson regression models were undertaken to estimate the incidence risk ratios (IRR) for various screening outcomes at both the first and subsequent screening rounds, among women who had been using HRT in the 6 months prior to screening compared with those who had not. RESULTS: Current HRT use was associated with increased risk of recall for assessment, biopsy procedures, and breast cancer diagnosis among BreastScreen participants. Risk of screen-detected breast cancer was increased at subsequent screening rounds (IRR = 1.30, 95% confidence interval 1.18-1.34), but not at women's first screening round (1.05, 0.88-1.25). This increased risk applied to IBC (1.35, 1.27-1.45), but not to DCIS (1.04, 0.89-1.23). Interval cancer risk was elevated among HRT users following both the first screen (1.77, 1.33-2.37) and subsequent screening episodes (1.92, 1.72-2.15). CONCLUSIONS: Increased risks of recall, biopsy rates, screen-detected, and interval cancers among HRT users have important implications for population-based breast cancer screening programs. Our findings support the concept that HRT use may increase the growth of preexisting cancers. Lack of effect on DCIS could imply different etiology or time frames for DCIS and IBC development or increased transition from preinvasive to invasive disease due to HRT use.

Inequalities in non-communicable diseases and effective responses.

In most countries, people who have a low socioeconomic status and those who live in poor or marginalised communities have a higher risk of dying from non-communicable diseases (NCDs) than do more advantaged groups and communities. Smoking rates, blood pressure, and several other NCD risk factors are often higher in groups with low socioeconomic status than in those with high socioeconomic status; the social gradient also depends on the country's stage of economic development, cultural factors, and social and health policies. Social inequalities in risk factors account for more than half of inequalities in major NCDs, especially for cardiovascular diseases and lung cancer. People in low-income countries and those with low socioeconomic status also have worse access to health care for timely diagnosis and treatment of NCDs than do those in high-income countries or those with higher socioeconomic status. Reduction of NCDs in disadvantaged groups is necessary to achieve substantial decreases in the total NCD burden, making them mutually reinforcing priorities. Effective actions to reduce NCD inequalities include equitable early childhood development programmes and education; removal of barriers to secure employment in disadvantaged groups; comprehensive strategies for tobacco and alcohol control and for dietary salt reduction that target low socioeconomic status groups; universal, financially and physically accessible, high-quality primary care for delivery of preventive interventions and for early detection and treatment of NCDs; and universal insurance and other mechanisms to remove financial barriers to health care.

An index measuring adherence to complementary feeding guidelines has convergent validity as a measure of infant diet quality.

The complementary feeding period is an important stage of child development. The study aim was to develop an index reflecting the degree of adherence to complementary feeding guidelines, evaluate its convergent validity, and explore associations with socio-demographic factors and dietary pattern scores in childhood. Data were analyzed from the Avon Longitudinal Study of Parents and Children (n = 6065) using parent-completed dietary questionnaires at 6 mo of age, socio-demographic information, and dietary patterns derived by principal component analysis at age 3 y. The Complementary Feeding Utility Index (CFUI) consists of 14 components: breastfeeding duration, feeding to appetite, timing of introduction to solids, exposure to iron-rich cereals, fruit and vegetable intake, exposure to high-fat/-salt/-sugar foods including sugary drinks, food texture, and meal/snack frequency. Regression analyses were undertaken to investigate associations between index scores, socio-demographic factors, food and nutrient intakes, and dietary pattern scores at age 3 y. Milk and food intake at 6 mo and nutrient intake at 8 mo of age varied across quintiles of index score in largely the expected directions. Associations were found among index score, maternal age, education, social class, maternal smoking history, and prepregnancy BMI. After adjustment for socio-demographic factors, the index score was associated with "processed" [ß = -0.234 (95% CI = -0.260, -0.209)] and "healthy" [ß = 0.185 (95% CI = 0.155, 0.215)] dietary pattern scores at age 3 y. The CFUI is able to discriminate across food intake, nutrient intake, and socio-demographic factors and is associated with later dietary patterns.

Prenatal prediction of poor maternal and offspring outcomes: implications for selection into intensive parent support programs.

This study examined the predictive ability of mother's age, antenatal depression, education, financial difficulties, partner status, and smoking for a range of poor maternal and offspring outcomes assessed up to 61 months postnatally. Outcomes obtained from the Avon Longitudinal Study of Parents and Children (ALSPAC) were maternal postnatal depression at 8 weeks (n = 10,070), never breastfeeding (n = 7,976), feelings of poor attachment (n = 8,253) and hostility (n = 8,159) at 47 months, and not in employment, education or training (NEET, n = 8,265) at 61 months. Only a small proportion of women with each outcome were aged less than 20 years when they were pregnant. At least half of the women experiencing these outcomes, and up to 74.7% of women with postnatal depression, could be identified if they had at least one of the predictors measured during pregnancy (age < 20, depression, education less than O level, financial difficulties, no partner, or smoking). Model discrimination was poor using maternal age only (area under the receiver operator characteristic (AUROC) curve approximately 0.52), except for never breastfeeding (0.63). Discrimination improved (AUROC: 0.80, 0.69, 0.62, 0.60, 0.66 for depression, never breastfeeding, poor attachment, hostility and NEET, respectively) when all six predictors were included in the model. Calibration improved for all outcomes with the model including all six predictors, except never breastfeeding where even age alone demonstrated good calibration. Factors other than young maternal age, including education, smoking and depression during pregnancy should be considered in identifying women and their offspring likely to benefit from parenting support interventions.

Exploring determinants of secular decreases in childhood blood pressure and hypertension.

BACKGROUND: Childhood blood pressure is largely uninfluenced by medical treatment and behavioral changes associated with hypertension diagnosis. Examining secular trends in childhood blood pressure and its contributing factors will help us better understand population-level determinants of blood pressure and hypertension. METHODS AND RESULTS: Data were from 4 waves of the Korean National Health and Nutrition Examination Survey between 1998 and 2008, including a total of 5909 boys and girls 10 to 19 years of age. Over the past 10 years, age- and height-adjusted mean systolic blood pressure decreased substantially from 115.6 to 106.9 mm Hg (by 8.7 mm Hg) among boys and from 111.8 to 101.8 mm Hg (by 10.0 mm Hg) among girls. Associated childhood hypertension and prehypertension/hypertension prevalences decreased by 52% to 86%. These remarkable decreases were found among all age and socioeconomic groups and were not explained by secular changes in childhood obesity (body mass index and waist circumferences), health behaviors (cigarette smoking and physical activity), nutritional factors (sodium, potassium, total energy, protein, and fat intake), psychological factors (perceived stress and sleep duration), and sociodemographic factors (annual household income and family size). CONCLUSIONS: We observed important population declines in blood pressure in Korea over a 10-year period in children 10 to 19 years of age, but the likely causes for these secular trends remain to be determined.

The beneficial effects of preschool attendance on adult cardiovascular disease risk.

OBJECTIVE: To assess the effect of South Australian Kindergarten Union participation on adult cardiovascular behavioural risk factors. METHODS: Using a retrospective cohort design, this study examined the effect of attendance at a Kindergarten Union preschool from 1940 to 1972 on behavioural risk factors for cardiovascular disease in adults 34-67 years. Dichotomous outcomes were analysed using a generalised linear model (Poisson distribution) with robust variance estimates. Outcomes with more than two categories were analysed with a multinomial logistic model. RESULTS: There was a beneficial effect of preschool on high physical activity relative to sedentary and on ever smoking, but a negative effect on fruit consumption. Preschool attendance was not associated with alcohol risk or vegetable consumption under traditional criteria, however the point estimate for vegetable consumption was in the beneficial direction. The point estimates from the multinomial model suggested a step-wise decreasing risk for preschool attendees to have less risk of experiencing multiple behavioural risk factors (e.g. risk of five risk factors for preschool participants compared with non-participants). CONCLUSIONS AND IMPLICATIONS: Attendance at a Kindergarten Union preschool was associated with a reduced risk of two and an indication of benefit in a third behavioural risk factor in adulthood. This study provides some evidence for the potential health benefit of interventions outside of the health sector to prevent cardiovascular diseases, which are strongly associated with lifelong social disadvantage.

Young maternal age and poor child development: predictive validity from a birth cohort.

OBJECTIVE: We aimed to examine the ability of mother's age, and other factors measured during pregnancy (education, financial difficulties, partner status, smoking, and depression), to predict child development outcomes up to age 5 years. METHODS: Data were obtained from the Avon Longitudinal Study of Parents and Children (ALSPAC). Poor child development was defined as scoring in the worst 10% of a parent-reported ALSPAC developmental scale (ADS) at 18 months (n = 7546), the Strengths and Difficulties Questionnaire (SDQ) at 47 months (n = 8328), or teacher-reported School Entry Assessment (SEA) scores at 4 to 5 years (n = 7345). RESULTS: Only a small proportion of children with poor development had mothers aged younger than 20 years at their birth (3.3%, 6.4%, and 9.2%, for the ADS, SDQ, and SEA, respectively). A greater proportion with each measure of poor development would be identified (48.9%, 63.6%, and 74.4%, respectively) if all 6 predictors were used and a woman had at least 1 of these. Model discrimination was poor using maternal age only (area under the receiver operator characteristic curve ~ 0.5 for all 3 outcomes). This improved when all 6 predictors were included in the model (ADS: 0.56; SDQ: 0.66; SEA: 0.67). Calibration also improved with the model including all 6 predictors. CONCLUSIONS: Even if programs targeted at teen-aged mothers are successful in improving child development, they will have little impact on population levels of poor child development if young maternal age is the sole or main means of identifying eligibility for the program.

Associations of education with 30 year life course blood pressure trajectories: Framingham Offspring Study.

BACKGROUND: Education is inversely associated with cardiovascular disease incidence in developed countries. Blood pressure may be an explanatory biological mechanism. However few studies have investigated educational gradients in longitudinal blood pressure trajectories, particularly over substantial proportions of the life course. Study objectives were to determine whether low education was associated with increased blood pressure from multiple longitudinal assessments over 30 years. Furthermore, we aimed to separate antecedent effects of education, and other related factors, that might have caused baseline differences in blood pressure, from potential long-term effects of education on post-baseline blood pressure changes. METHODS: The study examined 3890 participants of the Framingham Offspring Study (mean age 36.7 years, 52.0% females at baseline) from 1971 through 2001 at up to 7 separate examinations using multivariable mixed linear models. RESULTS: Mixed linear models demonstrated that mean systolic blood pressure (SBP) over 30 years was higher for participants with ≤12 vs. ≥17 years education after adjusting for age (3.26 mmHg, 95% CI: 1.46, 5.05 in females, 2.26 mmHg, 95% CI: 0.87, 3.66 in males). Further adjustment for conventional covariates (antihypertensive medication, smoking, body mass index and alcohol) reduced differences in females and males (2.86, 95% CI: 1.13, 4.59, and 1.25, 95% CI: -0.16, 2.66 mmHg, respectively). Additional analyses adjusted for baseline SBP, to evaluate if there may be educational contributions to post-baseline SBP. In analyses adjusted for age and baseline SBP, females with ≤12 years education had 2.69 (95% CI: 1.09, 4.30) mmHg higher SBP over follow-up compared with ≥17 years education. Further adjustment for aforementioned covariates slightly reduced effect strength (2.53 mmHg, 95% CI: 0.93, 4.14). Associations were weaker in males, where those with ≤12 years education had 1.20 (95% CI: -0.07, 2.46) mmHg higher SBP over follow-up compared to males with ≥17 years of education, after adjustment for age and baseline blood pressure; effects were substantially reduced after adjusting for aforementioned covariates (0.34 mmHg, 95% CI: -0.90, 1.68). Sex-by-education interaction was marginally significant (p = 0.046). CONCLUSION: Education was inversely associated with higher systolic blood pressure throughout a 30-year life course span, and associations may be stronger in females than males.

Life course socioeconomic position is associated with inflammatory markers: the Framingham Offspring Study.

Associations between life course socioeconomic position (SEP) and novel biological risk markers for coronary heart disease such as inflammatory markers are not well understood. Most studies demonstrate inverse associations of life course SEP with C-reactive protein (CRP), interleukin-6 (IL-6) and fibrinogen, however little is known about associations between life course SEP and other inflammatory markers including intercellular adhesion molecule-1 (ICAM-1), tumor necrosis factor II (TNFR2), lipoprotein phospholipase A2 (Lp-PLA2) activity, monocyte chemoattractant protein-1 (MCP-1) or P-selectin. The objectives of this analysis were to determine whether three life course SEP frameworks ("accumulation of risk", "social mobility" and "sensitive periods") are associated with the aforementioned inflammatory markers. We examined 1413 Framingham Offspring Study participants (mean age 61.2+/-8.6 years, 54% women), using multivariable regression analyses. In age- and sex-adjusted regression analyses, cumulative SEP ("accumulation of risk" SEP framework), for low vs. high SEP, was inversely associated with CRP, IL-6, ICAM-1, TNFR2, Lp-PLA2 activity, MCP-1 and fibrinogen. We found that there were few consistent trends between social mobility trajectories and most inflammatory markers. Own educational attainment was inversely associated with 7 of 8 studied inflammatory markers, while father's education, father's occupation and own occupation were inversely associated with 4, 5 and 4 inflammatory markers, respectively, in age- and sex-adjusted analyses. The strengths of association between SEP and inflammatory markers were typically substantially accounted for by CHD risk markers (smoking, body mass index, systolic blood pressure, total:HDL cholesterol ratio, fasting glucose, medications, depressive symptomatology) suggesting these may be important mechanisms that explain associations between SEP and the studied inflammatory markers.

The contribution of material, psychosocial, and behavioral factors in explaining educational and occupational mortality inequalities in a nationally representative sample of South Koreans: relative and absolute perspectives.

The contributions of material, psychosocial, and behavioral factors in explaining socioeconomic inequalities in health have been explored in many Western studies. Most prior investigations have looked at relative abilities to explain such inequalities. In addition, little research focuses on Asian countries, despite the fact that the prevalence and socioeconomic distribution of risk factors for mortality are different there. This study examined relative and absolute abilities of material, psychosocial, and behavioral pathways to explain educational and occupational inequalities in mortality in a nationally representative sample from South Korea. The 1998 and 2001 National Health and Nutrition Examination Survey data were pooled and linked to national mortality data. Of 8366 men and women over 30 years of age, 310 died between 1999 and 2005. Nine pathway variables were examined: three material factors (income, health insurance, and car ownership status), three psychosocial factors (depression, stress, and marital status), and three behavioral factors (smoking, alcohol consumption, and physical exercise). The relative risk and relative index of inequality were used as measures of relative inequality, and risk differences and the slope index of inequality were used as measures of absolute inequality. Material factors explained a total of 29.0% of the excess in relative risk for education and 50.0% of the excess in relative risk for occupational class. Material factors explained 78.6% of the excess in absolute mortality difference for education and 41.1% for occupational class. Psychosocial factors for both education and occupational class had a relative and absolute explanatory power of less than 15%. Behavioral factors showed a relative explanatory power of about 15%, but absolute explanatory power reached 84.0% for education and 105.4% for occupational class. However, the number of deaths used to calculate the absolute explanatory power was small. Results of this study suggest that absolute socioeconomic mortality inequalities could be substantially reduced if behavioral risk factors were reduced in the whole population.

Childhood socioeconomic position, gender, adult body mass index, and incidence of type 2 diabetes mellitus over 34 years in the Alameda County Study.

OBJECTIVES: We examined the association between childhood socioeconomic position and incidence of type 2 diabetes and the effects of gender and adult body mass index (BMI). METHODS: We studied 5913 participants in the Alameda County Study from 1965 to 1999 who were diabetes free at baseline (1965). Cox proportional hazards models estimated diabetes risk associated with childhood socioeconomic position and combined childhood socioeconomic position-adult BMI categories in pooled and gender-stratified samples. Demographic confounders and potential pathway components (physical inactivity, smoking, alcohol consumption, hypertension, depression, health care access) were included as covariates. RESULTS: Low childhood socioeconomic position was associated with excess diabetes risk, especially among women. Race and body composition accounted for some of this excess risk. The association between childhood socioeconomic position and diabetes incidence differed by adult BMI category in the pooled and women-only groups. Adjustment for race and behaviors attenuated the risk attributable to low childhood socioeconomic position among the obese group only. CONCLUSIONS: Childhood socioeconomic position was a robust predictor of incident diabetes, especially among women. A cumulative risk effect was observed for both childhood socioeconomic position and adult BMI, especially among women.

Monitoring trends in socioeconomic health inequalities: it matters how you measure.

BACKGROUND: Odds ratio (OR), a relative measure for health inequality, has frequently been used in prior studies for presenting inequality trends in health and health behaviors. Since OR is not a good approximation of prevalence ratio (PR) when the outcome prevalence is quite high, an important problem may arise when OR trends are used in data in which the outcome variable (e.g., smoking or ill-health) is of relatively high prevalence and varies significantly over time. This study is to compare time trends of odds ratio (OR) and prevalence ratio (PR) for examining time trends in socioeconomic inequality in smoking. METHODS: A total of 147,805 subjects (71,793 men and 76,017 women) aged 25-64 from three Social Statistics Surveys of Korea from 1999 to 2006 were analyzed. Socioeconomic position indicators were occupational class and education. RESULTS: While there were no significant p values for trend in ORs of occupational class among men, trends for PRs were significant. In women, p values for OR trends were similar to those for PR trends. In males, RII by log-binomial regression showed a significant increasing tendency while RII by logistic regression was stable between years. In females, trends of RIIs by logistic regression and log-binomial regression produced a similar level of p values. CONCLUSION: Different methods of measuring trends in socioeconomic health inequalities may lead to different conclusions about whether relative inequalities are increasing or decreasing. Trends in ORs may overstate or understate trends in relative inequality in health when the outcome is of relatively high prevalence and that prevalence varies significantly with time.

Consistency between education reported in health survey and recorded in death certificate.

BACKGROUND: Education level is one indicator of socioeconomic position which, in several countries including South Korea, is provided though death certificate data. Its validity determines the usefulness of death certificate data for exploring the association between socioeconomic position and mortality. This study was to compare education recorded on the death certificate with that reported before death in a nationally representative cohort of participants in the National Health and Nutrition Examination Survey (NHANES). METHODS: The 1998/2001 NHANES data contained unique 13-digit personal identification numbers that were individually linked to death certificate data from the Korean National Statistical Office. Duration of mortality follow-up was 7.1 years. The data from 513 deaths were used to determine sensitivity and specificity of education in death certificate and estimate agreement rates of education level between NHANES data and death certificate data. Odds ratios for agreement in education were also estimated. Covariates considered in the analyses were gender, age, duration between NHANES and death, and cause of death. RESULTS: The proportion of deaths without recorded education in death certificate was very low (0.2%). A total of 29.4% discordant pairs were found. Sensitivity and specificity for college or higher education were 0.84 (95% confidence interval 0.71-0.97) and 0.99 (0.98-1.00). However, sensitivity was poor for middle school education. The overall agreement rate was 70.7% (66.8%-74.6%) when education was categorized into five groups and increased up to 88.9% (86.2%-91.6%) when three education categories were used. The magnitude of validity and reliability for education did not generally vary with age, duration between health survey and death, and cause of death. However, a significantly smaller likelihood of agreement was found for middle and elementary school education after adjusting for covariates. CONCLUSION: Low percentage of missing information on education in South Korean death certificate data could provide a great potential to monitor mortality inequalities. A more collapsed categorization in education would be recommended when a more definitive conclusion on educational mortality inequality is required.

Social disadvantages in childhood and risk of all-cause death and cardiovascular disease in later life: a comparison of historical and retrospective childhood information.

BACKGROUND: Childhood socioeconomic circumstances have been shown to contribute to adult mortality. The purpose of this study was to compare the association between objective historical records and recalled questionnaire-based information on childhood socioeconomic position (SEP) with regard to cardiovascular and all-cause mortality. METHODS: We examined the association between a socially disadvantaged childhood and all-cause mortality, cardiovascular disease (CVD) mortality, coronary heart disease (CHD) mortality, and acute coronary events among male participants in the Kuopio Ischemic Heart Disease (KIHD) Risk Factor Study, a population-based cohort study in eastern Finland with follow-up until 2002. The historical data on childhood factors were collected from school health records (n = 698), mainly from the 1930s to the 1950s. Recall data on socioeconomic conditions in childhood were obtained from the baseline examinations of the KIHD cohort (n = 2,682) in 1984-89. RESULTS: According to original school health records the men who were socially disadvantaged in childhood had a 1.41-fold (95% confidence interval 1.01-1.97) age-adjusted and examination-year-adjusted risk of all-cause death, a 1.32-fold (0.83-2.11) risk of CVD death, a 1.48-fold (0.85-2.57) risk of CHD death, and a 1.50-fold (1.02-2.20) risk of acute coronary events. After adjustment for biological and behavioural risk factors and for the SEP in adulthood the association was attenuated in all-cause death but did not change in CVD death, CHD death, and acute coronary events. On the contrary, the questionnaire-based recalled childhood data on childhood SEP showed no associations with mortality or acute coronary events. CONCLUSIONS: With regard to adult mortality, the use of historical records concerning hygiene and living conditions collected in childhood may either provide more accurate measures of early-life socioeconomic conditions or capture more relevant aspects of childhood socioeconomic disadvantage than retrospective recall data.