Equity-specific effects of interventions to promote physical activity among middle-aged and older adults: results from applying a novel equity-specific re-analysis strategy.

BACKGROUND: Reducing inequalities in physical activity (PA) and PA-associated health outcomes is a priority for public health. Interventions to promote PA may reduce inequalities, but may also unintentionally increase them. Thus, there is a need to analyze equity-specific intervention effects. However, the potential for analyzing equity-specific effects of PA interventions has not yet been sufficiently exploited. The aim of this study was to set out a novel equity-specific re-analysis strategy tried out in an international interdisciplinary collaboration. METHODS: The re-analysis strategy comprised harmonizing choice and definition of outcomes, exposures, socio-demographic indicators, and statistical analysis strategies across studies, as well as synthesizing results. It was applied in a collaboration of a convenience sample of eight European PA intervention studies in adults aged ≥45 years. Weekly minutes of moderate-to-vigorous PA was harmonized as outcome. Any versus no intervention was harmonized as exposure. Gender, education, income, area deprivation, and marital status were harmonized as socio-demographic indicators. Interactions between the intervention and socio-demographic indicators on moderate-to-vigorous PA were analyzed using multivariable linear regression and random-effects meta-analysis. RESULTS: The collaborative experience shows that the novel re-analysis strategy can be applied to investigate equity-specific effects of existing PA interventions. Across our convenience sample of studies, no consistent pattern of equity-specific intervention effects was found. Pooled estimates suggested that intervention effects did not differ by gender, education, income, area deprivation, and marital status. CONCLUSIONS: To exploit the potential for equity-specific effect analysis, we encourage future studies to apply the strategy to representative samples of existing study data. Ensuring sufficient representation of 'hard to reach' groups such as the most disadvantaged in study samples is of particular importance. This will help to extend the limited evidence required for the design and prioritization of future interventions that are most likely to reduce health inequalities.

Impact of health warning labels communicating the risk of cancer on alcohol selection: an online experimental study.

AIMS: Evidence from tobacco research suggests that health warning labels (HWLs) depicting the adverse consequences of consumption change smoking behaviours, with image-and-text (also known as 'pictorial' or 'graphic') HWLs most effective. There is an absence of evidence concerning the potential impact of HWLs placed on alcohol products on selection of those products. This study aimed to obtain a preliminary assessment of the possible impact of (i) image-and-text, (ii) text-only, and (iii) image-only HWLs on selection of alcoholic versus non-alcoholic drinks. DESIGN: A between-subjects randomised experiment with a 2 (image: present versus absent) × 2 (text: present versus absent) factorial design. SETTING: The study was conducted on the online survey platform Qualtrics. PARTICIPANTS: Participants (n = 6024) were adults over the age of 18 who consumed beer or wine regularly (i.e. at least once a week), recruited through a market research agency. INTERVENTIONS: Participants were randomised to one of four groups varying in the HWL displayed on the packaging of alcoholic drinks: (i) image-and-text HWL; (ii) text-only HWL; (iii) image-only HWL; and (iv) no HWL. HWLs depicted bowel cancer, breast cancer and liver cancer, which were each displayed twice across six alcoholic drinks. Each group viewed six alcoholic and six non-alcoholic drinks and selected one drink that they would like to consume. MEASUREMENTS: The primary outcome was the proportion of participants selecting an alcoholic versus a non-alcoholic drink. FINDINGS: Alcoholic drink selection was lower for all HWL types compared with no HWL (image-and-text: 56%; image-only: 49%; text-only: 61%; no HWL: 77%), with selection lowest for HWLs that included an image. Image-and-text HWLs reduced the odds of selecting an alcoholic drink compared with text-only HWLs (OR = 0.80, 95% CI = 0.69, 0.92), but increased the odds of selecting an alcoholic drink compared with image-only HWLs (OR = 1.34, 95% CI = 1.16, 1.55). CONCLUSIONS: Health warning labels communicating the increased risk of cancers associated with alcohol consumption reduced selection of alcoholic versus non-alcoholic drinks in a hypothetical choice task in an online setting; labels displaying images had the largest effect. Their impact in laboratory and real-world field settings using physical products awaits investigation.

The impact on selection of non-alcoholic vs alcoholic drink availability: an online experiment.

BACKGROUND: Increasing the availability of healthier food increases its selection and consumption. However, there is an absence of evidence related to alcohol. This study aimed to estimate the impact of increasing the absolute and relative availability of non-alcoholic compared to alcoholic drinks on selection. We also assessed whether effects were modified by cognitive resource. METHODS: UK adult weekly alcohol consumers (n = 808) were recruited to an online experiment with a hypothetical drink selection task. Participants were randomly assigned to one of eight conditions, in a 4 (availability) × 2 (cognitive resource) factorial design. The four availability conditions were: i. Reference 1 (two non-alcoholic, two alcoholic drinks); ii. Reference 2 (four non-alcoholic, four alcoholic drinks); iii. Increased non-alcoholic drinks (six non-alcoholic, two alcoholic drinks); iv. Increased alcoholic drinks (two non-alcoholic, six alcoholic drinks). The two cognitive resource conditions were: a. Low (high time pressure); b. High (low time pressure). Logistic regression was used to assess selection of a non-alcoholic drink. RESULTS: 49% of participants selected a non-alcoholic drink in the Increased non-alcoholic drinks condition, compared to 36% in Reference 1, 39% in Reference 2, and 26% in the Increased alcoholic drinks condition. Non-alcoholic drink selection was similar between Reference 1 and 2 when the total number of drinks increased (absolute availability) but the proportion of non-alcoholic compared to alcoholic drinks (relative availability) was unchanged (OR = 1.15, 95% CI 0.77, 1.73). In contrast, the odds of selecting a non-alcoholic drink were 71% higher when both absolute and relative availability of non-alcoholic compared to alcoholic drinks was increased from Reference 1 to the Increased non-alcoholic drinks condition (OR: 1.71, 95% CI 1.15, 2.54), and 48% higher when increased from Reference 2 to the Increased non-alcoholic drinks condition (OR: 1.48, 95% CI 0.99, 2.19). There was no evidence of an effect of cognitive resource. CONCLUSIONS: Greater availability of non-alcoholic drinks, compared to alcoholic drinks, increased their online selection, an effect that may be larger when changing their relative availability, i.e., increasing the proportion of non-alcoholic drinks. Naturalistic studies are needed to determine the impact of availability interventions on reducing alcohol purchasing and consumption.

The impact of a named GP scheme on continuity of care and emergency hospital admission: a cohort study among older patients in England, 2012-2016.

OBJECTIVE: To investigate whether the introduction of a named general practitioner (GP, family physician) improved patients' healthcare for patients aged 75 and over in England. SETTING: Random sample of 27 500 patients aged 65 to 84 in 2012 within 139 English practices from the Clinical Practice Research Datalink linked with Hospital Episode Statistics. DESIGN: Prospective cohort approach, measuring patients' GP consultations and emergency hospital admissions 2 years before/after the intervention. Patients were grouped in (i) aged over 74 and (ii) younger than 75 in both periods in order to compare who were or were not subject to the intervention. Adjusted associations between the named GP scheme, continuity of care and emergency hospital admission were examined using multilevel modelling. INTERVENTION: National Health Service policy to introduce a named accountable GP for patients aged over 74 in April 2014. MAIN OUTCOME MEASURES: (A) Continuity of care index-score, (B) risk of emergency hospital admissions, (C) number of emergency hospital admissions. RESULTS: The intervention was associated with a decrease in continuity index-scores of -0.024 (95% CI -0.030 to -0.018, p<0.001); there were no differences in the decrease between the two age groups (-0.005, 95% CI -0.014 to 0.005). In the pre-intervention and post-intervention periods, respectively, 15.4% and 19.4% patients had an emergency admission. The probability of an emergency hospital admission increased after the intervention (OR 1.156, 95% CI 1.064 to 1.257, p=0.001); this increase was bigger for patients over 74 (relative OR 1.191, 95% CI 1.066 to 1.330, p=0.002). The average number of emergency hospital admissions increased after the intervention (rate ratio (RR) 1.178, 95% CI 1.103 to 1.259, p<0.001); this increase was greater for patients over 74 (relative RR 1.143, 95% CI 1.052 to 1.242, p=0.001). CONCLUSION: The introduction of the named GP scheme was not associated with improvements in either continuity of care or rates of unplanned hospitalisation.

Partial factorial trials: comparing methods for statistical analysis and economic evaluation.

BACKGROUND: Partial factorial trials compare two or more pairs of treatments on overlapping patient groups, randomising some (but not all) patients to more than one comparison. The aims of this research were to compare different methods for conducting and analysing economic evaluations on partial factorial trials and assess the implications of considering factors simultaneously rather than drawing independent conclusions about each comparison. METHODS: We estimated total costs and quality-adjusted life years (QALYs) within 10 years of surgery for 2252 patients in the Knee Arthroplasty Trial who were randomised to one or more comparisons of different surgical types. We compared three analytical methods: an "at-the-margins" analysis including all patients randomised to each comparison (assuming no interaction); an "inside-the-table" analysis that included interactions but focused on those patients randomised to two comparisons; and a Bayesian vetted bootstrap, which used results from patients randomised to one comparison as priors when estimating outcomes for patients randomised to two comparisons. Outcomes comprised incremental costs, QALYs and net benefits. RESULTS: Qualitative interactions were observed for costs, QALYs and net benefits. Bayesian bootstrapping generally produced smaller standard errors than inside-the-table analysis and gave conclusions that were consistent with at-the-margins analysis, while allowing for these interactions. By contrast, inside-the-table gave different conclusions about which intervention had the highest net benefits compared with other analyses. CONCLUSIONS: All analyses of partial factorial trials should explore interactions and assess whether results are sensitive to assumptions about interactions, either as a primary analysis or as a sensitivity analysis. For partial factorial trials closely mirroring routine clinical practice, at-the-margins analysis may provide a reasonable estimate of average costs and benefits for the whole trial population, even in the presence of interactions. However, such conclusions will be misleading if there are large interactions or if the proportion of patients allocated to different treatments differs markedly from what occurs in clinical practice. The Bayesian bootstrap provides an alternative to at-the-margins analysis for analysing clinical or economic endpoints from partial factorial trials, which allows for interactions while making use of the whole sample. The same techniques could be applied to analyses of clinical endpoints. TRIAL REGISTRATION: ISRCTN, ISRCTN45837371 . Registered on 25 April 2003.

Use of primary care data to predict those most vulnerable to cold weather: a case-crossover analysis.

BACKGROUND: The National Institute for Health and Care Excellence (NICE) recommends that GPs use routinely available data to identify patients most at risk of death and ill health from living in cold homes. AIM: To investigate whether sociodemographic characteristics, clinical factors, and house energy efficiency characteristics could predict cold-related mortality. DESIGN AND SETTING: A case-crossover analysis was conducted on 34 777 patients aged ≥65 years from the Clinical Practice Research Datalink who died between April 2012 and March 2014. The average temperature of date of death and 3 days previously were calculated from Met Office data. The average 3-day temperature for the 28th day before/after date of death were calculated, and comparisons were made between these temperatures and those experienced around the date of death. METHOD: Conditional logistic regression was applied to estimate the odds ratio (OR) of death associated with temperature and interactions between temperature and sociodemographic characteristics, clinical factors, and house energy efficiency characteristics, expressed as relative odds ratios (RORs). RESULTS: Lower 3-day temperature was associated with higher risk of death (OR 1.011 per 1°C fall; 95% CI = 1.007 to 1.015; P<0.001). No modifying effects were observed for sociodemographic characteristics, clinical factors, and house energy efficiency characteristics. Analysis of winter deaths for causes typically associated with excess winter mortality (N = 7710) showed some evidence of a weaker effect of lower 3-day temperature for females (ROR 0.980 per 1°C, 95% CI = 0.959 to 1.002, P = 0.082), and a stronger effect for patients living in northern England (ROR 1.040 per 1°C, 95% CI = 1.013 to 1.066, P = 0.002). CONCLUSION: It is unlikely that GPs can identify older patients at highest risk of cold-related death using routinely available data, and NICE may need to refine its guidance.

Exploring the relationship between general practice characteristics, and attendance at walk-in centres, minor injuries units and EDs in England 2012/2013: a cross-sectional study.

BACKGROUND: For several years, EDs in the UK NHS have faced considerable increases in attendance rates. Walk-in centres (WiCs) and minor injuries units (MIUs) have been suggested as solutions. We aimed to investigate the associations between practice and practice population characteristics with ED attendance rates or combined ED/WiC/MIU attendance, and the associations between WiC/MIU and ED attendance. METHODS: We used general practice-level data including 7462 English practices in 2012/2013 and present adjusted regression coefficients from linear multivariable analysis for relationships between patients' emergency attendance rates and practice characteristics. RESULTS: Every percentage-point increase in patients reporting inability to make an appointment was associated with an increase in emergency attendance by 0.36 (95% CI 0.06 to 0.66) per 1000 population. Percentage-point increases in patients unable to speak to a general practitioner (GP)/nurse within two workdays and patients able to speak often to their preferred GP were associated with increased emergency attendance/1000 population by 0.23 (95% CI 0.05 to 0.42) and 0.10 (95% CI 0.00 to 0.19), respectively. Practices in areas encompassing several towns (conurbations) had higher attendance than rural practices, as did practices with more non-UK-qualified GPs. Practice population characteristics associated with increased emergency attendance included higher unemployment rates, higher percentage of UK whites and lower male life expectancy, which showed stronger associations than practice characteristics. Furthermore, higher MIU or WiC attendance rates were associated with lower ED attendance rates. CONCLUSIONS: Improving availability of appointments and opportunities to speak a GP/nurse at short notice might reduce ED attendance. Establishing MIUs and WiCs might also reduce ED attendance.

Frailty predicts trajectories of quality of life over time among British community-dwelling older people.

PURPOSE: To investigate associations between baseline frailty status and subsequent changes in QOL over time among community-dwelling older people. METHODS: Among 363 community-dwelling older people ≥65 years, frailty was measured using Frailty Index (FI) constructed from 40 deficits at baseline. QOL was measured using Older People's Quality of Life Questionnaire (OPQOL) six times over 2.5 years. Two-level hierarchical linear models were employed to predict QOL changes over time according to baseline frailty. RESULTS: At baseline, mean age was 73.1 (range 65-90) and 62.0 % were women. Mean FI was 0.17 (range 0.00-0.66), and mean OPQOL was 130.80 (range 93-163). The hierarchical linear model adjusted for age, gender, ethnicity, education, and enrollment site predicted that those with higher FI at baseline have lower QOL than those with lower FI (regression coefficient = -47.64, p < 0.0001) and that QOL changes linearly over time with slopes ranging from 0.80 (FI = 0.00) to -1.15 (FI = 0.66) as the FI increases. A FI of 0.27 is the cutoff point at which improvements in QOL over time change to declines in QOL. CONCLUSIONS: Frailty was associated with lower QOL among British community-dwelling older people. While less frail participants had higher QOL at baseline and QOL improved over time, QOL of frailer participants was lower at baseline and declined.

"Keeping Moving": factors associated with sedentary behaviour among older people recruited to an exercise promotion trial in general practice.

BACKGROUND: Sedentary behaviour is detrimental to health, even in those who achieve recommended levels of physical activity. Efforts to increase physical activity in older people so that they reach beneficial levels have been disappointing. Reducing sedentary behaviour may improve health and be less demanding of older people, but it is not clear how to achieve this. We explored the characteristics of sedentary older people enrolled into an exercise promotion trial to gain insights about those who were sedentary but wanted to increase activity. METHOD: Participants in the ProAct65+ trial (2009-2013) were categorised as sedentary or not using a self-report questionnaire. Demographic data, health status, self-rated function and physical test performance were examined for each group. 1104 participants aged 65 & over were included in the secondary analysis of trial data from older people recruited via general practice. Results were analysed using logistic regression with stepwise backward elimination. RESULTS: Three hundred eighty seven (35 %) of the study sample were characterised as sedentary. The likelihood of being categorised as sedentary increased with an abnormal BMI (<18.5 or >25 g/m(2)) (Odds Ratio 1.740, CI 1.248-2.425), ever smoking (OR 1.420, CI 1.042-1.934) and with every additional medication prescribed (OR 1.069, CI 1.016-1.124). Participants reporting better self-rated physical health (SF-12) were less likely to be sedentary; (OR 0.961, 0.936-0.987). Participants' sedentary behaviour was not associated with gender, age, income, education, falls, functional fitness, quality of life or number of co-morbidities. CONCLUSION: Some sedentary older adults will respond positively to an invitation to join an exercise study. Those who did so in this study had poor self-rated health, abnormal BMI, a history of smoking, and multiple medication use, and are therefore likely to benefit from an exercise intervention. TRIAL REGISTRATION: ISRCTN reference: ISRCTN43453770.

Diet quality in older age: the influence of childhood and adult socio-economic circumstances.

Socio-economic gradients in diet quality are well established. However, the influence of material socio-economic conditions particularly in childhood, and the use of multiple disaggregated socio-economic measures on diet quality have been little studied in the elderly. In the present study, we examined childhood and adult socio-economic measures, and social relationships, as determinants of diet quality cross-sectionally in 4252 older British men (aged 60-79 years). A FFQ provided data on daily fruit and vegetable consumption and the Elderly Dietary Index (EDI), with higher scores indicating better diet quality. Adult and childhood socio-economic measures included occupation/father's occupation, education and household amenities, which combined to create composite scores. Social relationships included social contact, living arrangements and marital status. Both childhood and adult socio-economic factors were independently associated with diet quality. Compared with non-manual social class, men of childhood manual social class were less likely to consume fruit and vegetables daily (OR 0.80, 95% CI 0.66, 0.97), as were men of adult manual social class (OR 0.65, 95% CI 0.54, 0.79), and less likely to be in the top EDI quartile (OR 0.73, 95% CI 0.61, 0.88), similar to men of adult manual social class (OR 0.66, 95 % CI 0.55, 0.79). Diet quality decreased with increasing adverse adult socio-economic scores; however, the association with adverse childhood socio-economic scores diminished with adult social class adjustment. A combined adverse childhood and adulthood socio-economic score was associated with poor diet quality. Diet quality was most favourable in married men and those not living alone, but was not associated with social contact. Diet quality in older men is influenced by childhood and adulthood socio-economic factors, marital status and living arrangements.

Time trends in socioeconomic inequalities in cancer mortality: results from a 35 year prospective study in British men.

BACKGROUND: Socioeconomic inequalities in cancer mortality in Britain have been shown to be present in the 1990s and early 2000s. Little is known about on-going patterns in such inequalities in cancer mortality. We examined time trends in socioeconomic inequalities in cancer mortality in Britain between 1978 and 2013. METHODS: A socially representative cohort of 7489 British men with data on longest-held occupational social class, followed up for 35 years, in whom 1484 cancer deaths occurred. RESULTS: The hazard ratio for cancer mortality for manual vs. non-manual social classes remained unchanged; among men aged 50-59 years it was 1.62 (95%CI 1.17-2.24) between 1980-1990 and 1.65 (95%CI 1.14-2.40) between 1990-2000. The absolute difference (non-manual minus manual) in probability of surviving death from cancer to 70 years remained at 3% over the follow-up. The consistency of risks over time was similar for both smoking-related and non-smoking related cancer mortality. CONCLUSION: Socioeconomic inequalities in cancer mortality in Britain remain unchanged over the last 35 years and need to be urgently addressed.

A randomised controlled trial of the clinical effectiveness and cost-effectiveness of different knee prostheses: the Knee Arthroplasty Trial (KAT).

BACKGROUND: In the late 1990s, new developments in knee replacement were identified as a priority for research within the NHS. The newer forms of arthroplasty were more expensive and information was needed on their safety and cost-effectiveness. OBJECTIVES: The Knee Arthroplasty Trial examined the clinical effectiveness and cost-effectiveness of four aspects of knee replacement surgery: patellar resurfacing, mobile bearings, all-polyethylene tibial components and unicompartmental replacement. DESIGN: This study comprised a partial factorial, pragmatic, multicentre randomised controlled trial with a trial-based cost-utility analysis which was conducted from the perspective of the NHS and the patients treated. Allocation was computer generated in a 1 : 1 ratio using a central system, stratified by eligible comparisons and surgeon, minimised by participant age, gender and site of disease. Surgeons were not blinded to allocated procedures. Participants were unblinded if they requested to know the prosthesis they received. SETTING: The setting for the trial was UK secondary care. PARTICIPANTS: Patients were eligible for inclusion if a decision had been made for them to have primary knee replacement surgery. Patients were recruited to comparisons for which the surgeon was in equipoise about which type of operation was most suitable. INTERVENTIONS: Patients were randomised to receive a knee replacement with the following: patellar resurfacing or no patellar resurfacing irrespective of the design of the prosthesis used; a mobile bearing between the tibial and femoral components or a bearing fixed to the tibial component; a tibial component made of either only high-density polyethylene ('all polyethylene') or a polyethylene bearing fixed to a metal backing plate with attached stem; or unicompartmental or total knee replacement. MAIN OUTCOME MEASURES: The primary outcome was the Oxford Knee Score (OKS). Other outcomes were Short Form 12; EuroQol 5D; intraoperative and postoperative complications; additional surgery; cost; and cost-effectiveness. Patients were followed up for a median of 10 years; the economic evaluation took a 10-year time horizon, discounting costs and quality-adjusted life-years (QALYs) at 3.5% per annum. RESULTS: A total of 116 surgeons in 34 centres participated and 2352 participants were randomised: 1715 in patellar resurfacing; 539 in mobile bearing; 409 in all-polyethylene tibial component; and 34 in the unicompartmental comparisons. Of those randomised, 345 were randomised to two comparisons. We can be more than 95% confident that patellar resurfacing is cost-effective, despite there being no significant difference in clinical outcomes, because of increased QALYs [0.187; 95% confidence interval (CI) -0.025 to 0.399] and reduced costs (-£104; 95% CI -£630 to £423). We found no definite advantage or disadvantage of mobile bearings in OKS, quality of life, reoperation and revision rates or cost-effectiveness. We found improved functional results for metal-backed tibias: complication, reoperation and revision rates were similar. The metal-backed tibia was cost-effective (particularly in the elderly), costing £35 per QALY gained. CONCLUSIONS: The results provide evidence to support the routine resurfacing of the patella and the use of metal-backed tibial components even in the elderly. Further follow-up is required to assess the stability of these findings over time and to inform the decision between mobile and fixed bearings. TRIAL REGISTRATION: Current Controlled Trials ISRCTN45837371. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and the orthopaedic industry. It will be published in full in Health Technology Assessment; Vol. 18, No. 19. See the NIHR Journals Library website for further project information.

Inequalities in heart failure in older men: prospective associations between socioeconomic measures and heart failure incidence in a 10-year follow-up study.

AIMS: Socioeconomic position has been linked to incident heart failure (HF), but the underlying mechanisms are unclear. We examined the association of socioeconomic measures with incident HF in older adults and examined possible underlying pathways. METHODS AND RESULTS: A socially representative cohort of men aged 60-79 years in 1998-2000 from 24 British towns was followed-up for 10 years for incident HF. Adult socioeconomic position was based on a cumulative score, including occupation, education, housing tenure, pension, and amenities. Childhood socioeconomic measures included father's occupational social class and household amenities. Prevalent myocardial infarction and HF cases were excluded. Among 3836 men, 229 incident cases of HF occurred over 10 years. Heart failure risk increased with an increasing score of adverse adult socioeconomic measures (P for trend = < 0.0001). Compared with men with a score of 0, the hazard ratio for men with a score of ≥ 4 was 2.19 (95% confidence interval, CI, 1.34-3.55), which was attenuated to 1.87 (95% CI 1.12-3.11) after adjusting for systolic blood pressure, body mass index, smoking, HDL-cholesterol, diabetes, and lung function. Adjustment for left ventricular hypertrophy, atrial fibrillation, heart rate, and renal function made little difference. Further adjustment for C-reactive protein, von Willebrand Factor, N-terminal pro-brain natriuretic peptide, and plasma vitamin C also made little difference to the hazard ratio [1.89 (95% CI 1.10-3.24)]. Heart failure risk did not vary by childhood socioeconomic measures. CONCLUSION: Heart failure risk in older men was greater in the most deprived socioeconomic groups, which was only partly explained by established risk factors for HF. Novel risk factors contribute little to the associated risk.

Longitudinal associations of socioeconomic position in childhood and adulthood with decline in lung function over 20 years: results from a population-based cohort of British men.

BACKGROUND: Associations of socioeconomic position with lung function are reported mostly from cross-sectional studies. The aim of this study was to investigate the associations between socioeconomic position both in adulthood and childhood with changes in lung function over a 20-year period. METHODS: A socioeconomically representative cohort of 7735 British men aged 40-59 years was followed-up from 1978-1980 to 1998-2000. Lung function (height-standardised forced expiratory volume in 1 s (FEV(1)) and forced vital capacity (FVC)) was assessed at both time points in 4252 survivors. Adult socioeconomic position was derived from longest-held occupation in middle age and childhood socioeconomic position from father's longest-held occupation. RESULTS: Both FEV(1) and FVC declined over time; the decline increased progressively from social class I (highest) to V (lowest); p for trend ≤ 0.0001. The mean difference in decline comparing manual versus non-manual groups was -0.13 litres (95% CI -0.16 to -0.10) for FEV(1) and -0.09 litres (95% CI -0.13 to -0.05) for FVC. These differences remained after adjustment for age, cigarette smoking, body mass index, physical activity and history of bronchitis. Similar differences in lung function decline were observed comparing manual with non-manual childhood social classes, although the differences were reduced by adjustment for adult social class and risk factors. Men in manual social classes in both childhood and adulthood had the greatest decline in lung function compared to those in non-manual groups in childhood and adulthood. CONCLUSIONS: Socioeconomic position across the life course could have a significant impact on decline in lung function in later life. The role of environmental factors associated with socioeconomic position merits further exploration.

Social class differences in secular trends in established coronary risk factors over 20 years: a cohort study of British men from 1978-80 to 1998-2000.

BACKGROUND: Coronary heart disease (CHD) mortality in the UK since the late 1970s has declined more markedly among higher socioeconomic groups. However, little is known about changes in coronary risk factors in different socioeconomic groups. This study examined whether changes in established coronary risk factors in Britain over 20 years between 1978-80 and 1998-2000 differed between socioeconomic groups. METHODS AND FINDINGS: A socioeconomically representative cohort of 7735 British men aged 40-59 years was followed-up from 1978-80 to 1998-2000; data on blood pressure (BP), cholesterol, body mass index (BMI) and cigarette smoking were collected at both points in 4252 survivors. Social class was based on longest-held occupation in middle-age. Compared with men in non-manual occupations, men in manual occupations experienced a greater increase in BMI (mean difference = 0.33 kg/m(2); 95%CI 0.14-0.53; p for interaction = 0.001), a smaller decline in non-HDL cholesterol (difference in mean change = 0.18 mmol/l; 95%CI 0.11-0.25, p for interaction≤0.0001) and a smaller increase in HDL cholesterol (difference in mean change = 0.04 mmol/l; 95%CI 0.02-0.06, p for interaction≤0.0001). However, mean systolic BP declined more in manual than non-manual groups (difference in mean change = 3.6; 95%CI 2.1-5.1, p for interaction≤0.0001). The odds of being a current smoker in 1978-80 and 1998-2000 did not differ between non-manual and manual social classes (p for interaction = 0.51). CONCLUSION: Several key risk factors for CHD and type 2 diabetes showed less favourable changes in men in manual occupations. Continuing priority is needed to improve adverse cardiovascular risk profiles in socially disadvantaged groups in the UK.

Prediction of coronary heart disease risk by Framingham and SCORE risk assessments varies by socioeconomic position: results from a study in British men.

AIM: Evidence is limited on performance of the Framingham risk score (FRS) in different socioeconomic groups; similar limitations apply to the Systematic Coronary Risk Evaluation (SCORE). We examined the performance of coronary risk prediction systems in different socioeconomic groups in British men. METHODS AND RESULTS: In a socially and geographically representative cohort of British men aged 40-59 between 1978 and 1980, predicted 10-year coronary heart disease (CHD) (fatal and non-fatal) risk was calculated using FRS, and CHD mortality using SCORE. Prevalent cardiovascular disease cases were excluded. Occupational social class ranged from I (professionals) to V (unskilled workers), and was summarized as non-manual (I, II, III non-manual) and manual (III manual, IV, V). Both FRS and SCORE over-estimated 10-year CHD risk; over-prediction by both was particularly marked in high social classes. With FRS, predicted/observed risk fell progressively from 2.30 in social class I to 1.19 in social class V. Sensitivity of FRS at a ≥20% threshold (27% of men) fell from 53% to 37% from social class I to V; specificity varied similarly. With SCORE, predicted/observed CHD mortality fell from 1.53 to 1.26 from social class I to V; sensitivity at a ≥5% threshold (29% of men) fell between non-manual (61%) and manual (57%) groups, as did specificity. However, including social class in FRS barely improved risk prediction (net reclassification improvement = 0.18%). CONCLUSIONS: Framingham and SCORE predictions varied between socioeconomic groups and are more likely to identify those at greater CHD risk in higher socioeconomic groups. To ensure equitable primary prevention, strategies to adequately estimate risk in lower socioeconomic groups (at increased CHD risk) should be developed.

Class and lifestyle 'lock-in' among middle-aged and older men: a Multiple Correspondence Analysis of the British Regional Heart Study.

Health lifestyles are collective patterns of health risk behaviour that develop within a social habitus. An important area for research is the extent to which health lifestyles become more individualised over time and as people age, or whether health lifestyles remain socially structured. This article presents findings from a Multiple Correspondence Analysis of the British Regional Heart Study. Our findings suggest that smoking and alcohol use retain a strong class patterning as men age (suggesting some support for the long-term importance of social structures in old age). This indicates that, in later life, some forms of class-related health lifestyles become fixed or 'locked in'. In contrast there is evidence to suggest that, for exercise, class becomes less important as people age (suggesting either some support for growing individualisation and or important ageing effects). Further studies are required to examine different forms of health lifestyle in later life in relation to forms of cultural and economic capital. This study provides evidence in support of attempts to theorise health lifestyles in terms of collectivities. Furthermore, the concept of selective lifestyle 'lock-in' may be a useful way of understanding the relationship between class and health lifestyles in old age.

Extent of social inequalities in disability in the elderly: results from a population-based study of British men.

PURPOSE: Little is known about social inequalities in disability in the elderly. We examined the extent and determinants of socioeconomic inequalities in disability and functional limitation in elderly men in Britain. METHODS: Disability was ascertained as problems with activities of daily living (ADLs) and instrumental ADL in a socioeconomically representative sample of 3,981 men from 24 British towns who were between 63 to 82 years of age in 2003. We also examined functional limitation. Measures of socioeconomic position were social class, age at leaving full-time education, and car and house ownership. RESULTS: Men in lower social classes had greater risks of both ADL and instrumental ADL disability and functional limitation compared with higher social classes; odds ratios (95% CI) for social class V compared with I were 3.13 (1.64-5.97), 2.87 (1.49-5.51), and 2.65 (1.31-5.35), respectively. Behavioral risk factors (smoking, body mass index, physical activity) and particularly co-morbidity attenuated these differences; together, they reduced relative risks to 1.11 (0.49-2.51), 1.01 (0.45-2.25), and 1.05 (0.46-2.42). Age at leaving full-time education had no relation to functional limitations after taking social class into account. Men who were not house or car owners had greater odds of functional limitation and ADL disability compared with house or car owners, independent of behavioural risk factors, comorbidities and social class. CONCLUSION: Strong socioeconomic inequalities in disability exist in the elderly, which were considerably explained by behavioral factors and comorbidity. Policy efforts are needed to reduce the social disparities in disability in the elderly.

Do socioeconomic characteristics of neighbourhood of residence independently influence incidence of coronary heart disease and all-cause mortality in older British men?

BACKGROUND: The relationship between coronary heart disease (CHD) incidence and death, and individual sociodemographic status is well established. Our aim was to examine whether neighbourhood deprivation scores predict CHD and death in older men, independently of individual sociodemographic status. METHODS: Prospective study of 5049 men, born between 1918 and 1939, recruited from 24 British towns encompassing 969 electoral wards, without documented evidence of previous major CHD when responding to a questionnaire in 1992, and followed up for incidence of major CHD and death. RESULTS: Four hundred and seventy-two new major CHD events (1.08% pa), and 1021 deaths (2.28% pa) occurred over an average of 9.75 years. When men were divided into fifths according to increasing neighbourhood deprivation score, CHD incidences (% pa) were 0.92, 0.89, 0.99, 1.33 and 1.29. When modelling continuous trends, the rate ratio for men in the top fifth compared with the bottom fifth was 1.55 (95% confidence interval 1.19-2.00) for CHD. This rate ratio was, however, no longer statistically significant [1.22 (95% confidence interval 0.92-1.61)] when effects of individual sociodemographic status measures (car ownership, housing, longest held occupation, marital status and social networks) were accounted for. CONCLUSION: Little evidence of an independent relationship of neighbourhood deprivation with CHD incidence was found once individual measures of sociodemographic status had been adjusted for.

Relationships of inflammatory and haemostatic markers with social class: results from a population-based study of older men.

Haemostatic and inflammatory markers have been hypothesised to mediate the relationship of social class and cardiovascular disease (CVD). We investigated whether a range of inflammatory/haemostatic markers are associated with social class independent of chronic diseases and behavioural risk factors in a population-based sample of 2682 British men aged 60-79 without a physician diagnosis of CVD, diabetes or musculoskeletal disease requiring anti-inflammatory medications. Men in lower social classes had higher mean levels of C-reactive protein, fibrinogen, interleukin-6, white blood cell count, von Willebrand factor (vWF), factor VIII, activated protein C (APC) resistance, plasma viscosity, fibrin D-dimer and platelet count, compared to higher social class groups; but not of tissue plasminogen activator antigen, haematocrit or activated partial prothrombin time. After adjustment for behavioural risk factors (smoking, alcohol, physical activity and body mass), the associations of social class with vWF, factor VIII, APC resistance, plasma viscosity, and platelet count though weakened, remained statistically significant, while those of other markers were considerably attenuated. In this study of older men without CVD, the social gradient in inflammatory and haemostatic markers was substantially explained by behavioural risk factors. The effect of socio-economic gradient on the factor VIII-vWF complex, APC resistance, plasma viscosity and platelet count merits further study.