How important is it to avoid indices of deprivation that include health variables in analyses of health inequalities?

OBJECTIVES: This study aimed to quantify the difference in mortality inequalities using the Scottish Index of Multiple Deprivation (SIMD) and the Income and Employment Index (IEI; a subindex of SIMD, which excludes health) as ranking measures in Scotland. STUDY DESIGN: This ecological study was a cross-sectional analysis of routine administrative data. METHODS: Data from the 2020 SIMD and the subindex using data from only the Income and Employment domains, the IEI, were obtained. The correlation between data zones, percentage of data zones that changed deprivation tenth and differences in the Slope Index of Inequality (SII) and Relative Index of Inequality (RII) for Standardised Mortality Ratios (SMRs) across tenths were compared when data zones were ranked by SIMD and IEI. RESULTS: There was a close correlation between data zones ranked by SIMD and IEI (R2 = 0.96). When data zones were ranked by IEI, 18.7% of data zones moved to a lower deprivation tenth, and 20.8% of data zones moved to a higher deprivation tenth, compared with SIMD. However, only a negligible number of data zones moved two or more tenths. The SMRs across deprivation tenths were very similar between the SIMD and IEI, as were the summary health inequality measures of SII (87.3 compared with 85.7) and RII (0.88 and 0.86). CONCLUSION: Although there is a logical problem in using deprivation indices that include health outcomes to rank areas to calculate the scale of health inequalities, the impact of using an alternative subindex containing only data from the income and employment domains is minimal. For population-wide analyses of health inequalities in Scotland, the SIMD does not introduce a substantial bias in the health inequalities summary measures despite substantial movement of small areas between ranked population tenths. Although not examined here, this is likely to be relevant to other similar indices across the United Kingdom.

Wildlife health surveillance: gaps, needs and opportunities.

Disease emergence represents a global threat to public health, economy and biological conservation. Most emerging zoonotic diseases have an animal origin, most commonly from wildlife. To prevent their spread and to support the implementation of control measures, disease surveillance and reporting systems are needed, and due to globalisation, these activities should be carried out at the global level. To define the main gaps affecting the performance of wildlife health surveillance and reporting systems globally, the authors analysed data from a questionnaire sent to National Focal Points of the World Organisation for Animal Health that inquired on structure and limits of wildlife surveillance and reporting systems in their territories. Responses from 103 Members, covering all areas of the globe, revealed that 54.4% have a wildlife disease surveillance programme and 66% have implemented a strategy to manage disease spread. The lack of dedicated budget affected the possibility of outbreak investigations, sample collection and diagnostic testing. Although most Members maintain records relating to wildlife mortality or morbidity events in centralised databases, data analysis and disease risk assessment are reported as priority needs. The authors' evaluation of surveillance capacity found an overall low level, with marked variability among Members that was not restricted to a specific geographical area. Increased wildlife disease surveillance globally would help in understanding and managing risks to animal and public health. Moreover, consideration of the influence of socio-economic, cultural and biodiversity aspects could improve disease surveillance under a One Health approach.

L'émergence de maladies représente une menace pour la santé publique, l'économie et la conservation de la biodiversité au niveau mondial. La plupart des maladies émergentes sont d'origine animale et proviennent de la faune sauvage. Afin de prévenir leur propagation et de soutenir la mise en oeuvre de mesures de contrôle, une surveillance des maladies et des systèmes de notification sont nécessaires - et ce à l'échelle internationale, en raison de la mondialisation. En vue de définir les lacunes principales affectant les performances de la surveillance et de la notification sanitaire relative à la faune sauvage au niveau mondial, les auteurs ont analysé les données d'un questionnaire envoyé aux Points focaux nationaux de l'Organisation mondiale de la santé animale et traitant de la structure et des limites des systèmes de surveillance et de notification applicables à la faune sauvage sur leur territoire. Selon les réponses des 103 Membres, qui représentaient toutes les régions du monde, 54,4 % disposent d'un programme de surveillance et 66 % ont mis en oeuvre une stratégie visant à gérer la propagation de maladies. L'absence de budgets dédiés affecte la possibilité d'enquêter sur l'apparition d'épidémies, de prélever des échantillons et d'effectuer des tests diagnostiques. Bien que la majorité des Membres consignent dans des bases de données centralisées les événements de mortalité et de morbidité affectant la faune sauvage, l'analyse des données et l'évaluation des risques sanitaires ont été mentionnées comme étant des besoins prioritaires. Les auteurs ont évalué les capacités de surveillance qui se situent, selon eux, à un niveau faible et se caractérisent par une grande variabilité entre les Membres, indépendamment des zones géographiques dont il s'agit. Une meilleure surveillance sanitaire de la faune sauvage au niveau mondial permettrait d'améliorer la compréhension et la gestion des risques pour la santé animale et publique. Par ailleurs, une réflexion sur l'influence des aspects socio-économiques, culturels et liés à la biodiversité améliorerait la surveillance sanitaire mise en place dans le cadre de l'approche Une seule santé.

La aparición de enfermedades representa una amenaza de dimensión mundial para la salud pública, la economía y la conservación de los recursos biológicos. La mayor parte de las enfermedades zoonóticas tienen un origen animal, por lo general localizado en la fauna silvestre. Para evitar que estas enfermedades se propaguen y apoyar la aplicación de medidas de lucha hacen falta sistemas de vigilancia y notificación de enfermedades, sistemas que, teniendo en cuenta las dinámicas de la mundialización, deben declinarse a escala planetaria. Con objeto de determinar las principales carencias que lastran el buen funcionamiento de los sistemas de vigilancia y notificación de enfermedades de la fauna silvestre a escala mundial, los autores analizaron datos extraídos de un cuestionario distribuido entre los puntos focales nacionales de la Organización Mundial de Sanidad Animal, en el cual se les preguntaba por la estructura y los límites que presentaban en su territorio dichos sistemas. Las respuestas recibidas de 103 Miembros de todas las zonas del globo pusieron de relieve que un 54,4% de ellos cuenta con un programa de vigilancia sanitaria de la fauna silvestre y que un 66% tiene implantada una estrategia para contener la propagación de enfermedades. La falta de un presupuesto asignado específicamente a estas tareas limita la posibilidad de investigar eventuales brotes, obtener muestras y practicar pruebas de diagnóstico. Aunque la mayoría de los Miembros lleva un registro de los episodios de mortalidad y morbilidad de animales salvajes en bases de datos centralizadas, el análisis de datos y la determinación del riesgo de enfermedad son dos de los aspectos mencionados como necesidad prioritaria. La evaluación de la capacidad de vigilancia realizada por los autores puso de manifiesto un nivel en general bajo, con una marcada heterogeneidad entre los Miembros que no se circunscribía a una zona geográfica en particular. Una mayor vigilancia de las enfermedades de la fauna silvestre a escala mundial ayudaría a aprehender y manejar mejor los riesgos que estas presentan para la sanidad animal y la salud pública. Además, el hecho de tener en cuenta la influencia de factores socioeconómicos, culturales y ligados a la diversidad biológica podría traducirse en una más eficaz vigilancia sanitaria en clave de Una sola salud.

How well do area-based deprivation indices identify income- and employment-deprived individuals across Great Britain today?

BACKGROUND: Area-based deprivation indices are used in many countries to target interventions and policies to populations with the greatest needs. Analyses of the Carstairs deprivation index applied to postcode sectors in 2001 identified that less than half of all deprived individuals lived in the most deprived areas. OBJECTIVE: This article examines the specificity and sensitivity of deprivation indices across Great Britain in identifying individuals claiming income- and employment-related social security benefits. STUDY DESIGN: This was a descriptive analysis of cross-sectional administrative data. METHODS: The data sets for the 2020 Scottish Index of Multiple Deprivation, Scottish Income and Employment Index, the 2019 English Index of Multiple Deprivation and the 2019 Welsh Index of Multiple Deprivation were obtained. For each data set, small areas were ranked by increasing overall deprivation, and the cumulative proportions of individuals who were income and employment deprived were calculated. Receiver operating characteristic curves were plotted to show the sensitivity and specificity of each index, and the percentages of income- and employment-deprived individuals captured at different overall deprivation thresholds were calculated. RESULTS: Across all indices, the sensitivity and specificity for detecting income- and employment-deprived individuals were low, with less than half living in the most deprived 20% of areas. Between 55% and 62% of income-deprived people and between 56% and 63% of employment-deprived people were missed across the indices at the 20% deprivation threshold. The sensitivity and specificity were slightly higher for income deprivation than employment deprivation across indices and slightly higher for the Scottish Index of Multiple Deprivation and Scottish Income and Employment Index than for the English Index of Multiple Deprivation and Welsh Index of Multiple Deprivation. CONCLUSION: Area-based deprivation measures in Great Britain have limited sensitivity and specificity for identifying individuals who are income or employment deprived. Place-based policies and interventions are unlikely to be effective at reducing inequalities as a result. Creation of individually linked data sets and interventions that recognise the social and economic relationships between social groups are likely to be more effective.

Economics of timed artificial insemination with unsorted or sexed semen in a high-producing, pasture-based dairy production system.

This study used a stochastic simulation model to estimate the potential economic benefit of using timed artificial insemination (TAI) in combination with conventional unsorted (TCONV) and sexed (TSEX) semen in heifers only (TCONV-H, TSEX-H) and in both heifers and lactating cows (TCONV-HC, TSEX-HC) in a high-producing, pasture-based production system. The scenarios were compared with a conventional reproductive policy (CONV) in which heifers and cows were inseminated with conventional unsorted semen after estrus detection. Sensitivity analysis was also used to estimate the effect of hormone costs from TAI use on the profitability of each program relative to CONV. The mean annual (± standard deviation) profit advantage (ΔPROF) over CONV for TCONV-H, TCONV-HC, TSEX-H, and TSEX-HC scenarios were €3.90/cow ± 4.65, €34.11/cow ± 25.69, €13.96/cow ± 6.83, and €41.52/cow ± 42.86, respectively. Combined application of both technologies was shown to return a greater annual ΔPROF on average compared with that achievable from TAI alone. However, the risk of not returning a positive annual ΔPROF varied across the scenarios with higher risk in TCONV-H and TSEX-HC. Specifically, TCONV-H and TSEX-HC had a 24 and 18% chance, respectively, of not returning a positive annual ΔPROF. Sensitivity analysis showed that when hormone costs increased by €10/cow TCONV-H and TSEX-HC had a 38 and 23% chance, respectively, of not returning a positive annual ΔPROF. The range in ΔPROF for TCONV policies was most sensitive to the TAI pregnancy rate and TSEX policies were most sensitive to the relative fertility achieved with sexed compared with unsorted semen. This study has shown TAI and sexed semen are complementary technologies that can increase genetic gain and profitability in a pasture-based, dairy production system.

Excess mortality in Glasgow: further evidence of 'political effects' on population health.

OBJECTIVES: The aim of the study was to update previous analyses of 'excess mortality' in Glasgow (Scotland) relative to the similar postindustrial cities of Liverpool and Manchester (England). The excess is defined as mortality after adjustment for socio-economic deprivation; thus, we sought to compare changes over time in both the deprivation profiles of the cities and the levels of deprivation-adjusted mortality in Glasgow relative to the other cities. This is important not only because the original analyses are now increasingly out of date but also because since publication, important (prepandemic) changes to mortality trends have been observed across all parts of the United Kingdom. STUDY DESIGN AND METHODS: Replicating as far as possible the methods of the original study, we developed a three-city deprivation index based on the creation of spatial units in Glasgow that were of similar size to those in Liverpool and Manchester (average population sizes of approximately 1600, 1500 and 1700 respectively) and an area-based measure of 'employment deprivation'. Mortality and matching population data by age, sex and small area were obtained from national agencies for two periods: 2003-2007 (the period covered by the original study) and 2014-2018. The rates of employment deprivation for each city's small areas were calculated for both periods. Indirectly standardised mortality ratios (SMRs) were calculated for Glasgow relative to Liverpool and Manchester, standardised by age and three-city deprivation decile. For context, city-level trends in age-standardised mortality rates by year, sex and city were also calculated. RESULTS: There was evidence of a stalling of improvement in mortality rates in all three cities from the early 2010s. After adjustment for area deprivation, all-cause mortality in Glasgow in 2014-2018 was c.12% higher than in Liverpool and Manchester for all ages (SMR 112.4, 95% CI 111.1-113.6) and c.17% higher for deaths under 65 years (SMR 117.1, 95% CI 114.5-119.7). The excess was higher for males (17% compared with 9% for deaths at all ages; 25% compared with 5% for 0-64 years) and for particular causes of death such as suicide and drug-related and alcohol-related causes. The results were broadly similar to those previously described for 2003-2007, although the excess for premature mortality was notably lower. In part, this was explained by changes in levels of employment deprivation, which had decreased to a greater degree in the English cities: this was particularly true of Manchester (a reduction of -43%, compared with -38% in Liverpool and -31% in Glasgow) where the overall population size had also increased to a much greater extent than in the other cities. CONCLUSIONS: High levels of excess mortality persist in Glasgow. With the political causes recently established - the excess is a 'political effect', not a 'Glasgow effect' - political solutions are required. Thus, previously published recommendations aimed at addressing poverty, inequality and vulnerability in the city are still highly relevant. However, given the evidence of more recent, UK-wide, political effects on mortality - widening mortality inequalities resulting from UK Government 'austerity' measures - additional policies at UK Government level to protect, and restore, the income of the poorest in society are also urgently needed.

Cognitive assessment using the Rapid Assessment for Developmental Disabilities, Second Edition (RADD-2).

BACKGROUND: Individuals with developmental disabilities (DD) often have severe impairments and maladaptive behaviours that make it difficult to reliably assess their cognitive abilities. Given these challenges, the Rapid Assessment of Developmental Disabilities, Second Edition (RADD-2), was designed to measure general cognitive ability in this population. The purpose of this study is to demonstrate the battery's psychometric properties when used with individuals with DD who have challenging behavioural and psychiatric conditions and for those who have limited verbal skills. METHOD: The cognitive and adaptive behaviour skills of 193 children and adults with DD and considerable medical, behavioural and/or psychiatric problems were evaluated using the first and second editions of the RADD, Kaufmann Brief Intelligence Test - 2nd Edition, and Scales of Independent Behaviour - Revised Edition. Medication side effects and challenging behaviours were assessed using the Aberrant Behaviour Checklist. RESULTS: There were no floor or ceiling effects on the RADD-2. Both the nonverbal index and total scores had strong concurrent validity with other abbreviated tests of intellectual ability and good discriminant validity from measures of adaptive behaviour and medication side effects. RADD-2 scores also had strong criterion validity as they successfully differentiated between all levels of intellectual functioning. Age and sex did not differentially affect RADD-2 performance, and the co-occurrence of psychiatric conditions did not negatively affect performance. The only medical condition associated with lower RADD-2 performance was epilepsy. CONCLUSIONS: The RADD-2 can quantify the differential cognitive abilities of individuals with DD, even for those with minimal communication skills, challenging behaviours or severe medication side effects that can typically complicate assessment. This brief cognitive battery can be used to measure changes due to interventions, on the one hand, and progression of neurological disease, on the other.

Effects of herd fertility on the economics of sexed semen in a high-producing, pasture-based dairy production system.

This study used a stochastic simulation model to estimate the potential economic benefit of using sexed semen in heifers only and in heifers and lactating cows in a high-producing, pasture-based system under 3 fertility scenarios. Three breeding strategies were modeled: (1) only heifers inseminated with sexed semen and cows inseminated with conventional unsexed semen (SSH); (2) both heifers and cows inseminated with sexed semen (SSHC); and (3) a reference scenario in which all females were inseminated with conventional, unsexed semen (CONV). Each scenario was evaluated under 3 herd fertility states: high (HF), medium (MF), and low (LF), which, under the reference scenario, corresponded to herd replacement rates of 21, 25, and 31%, respectively. The model estimated the economic profit, including the net present value of the genetic gain from selection intensity. The economic return from adoption of sexed semen strategies declined, with reduced levels of baseline herd fertility turning negative in the LF state. The mean (±SD) sexed semen advantage (SSA) per cow for HF-SSH, MF-SSH, and LF-SSH scenarios were €30.61 ± 8.98, €27.45 ± 7.19, and €14.69 ± 11.06, respectively. However, the SSA per cow for HF-SSHC, MF-SSHC, and LF-SSHC scenarios were €49.14 ± 15.43, €18.46 ± 30.08, and -€19.30 ± 57.11. The range in economic profit for SSA for SSH was most sensitive to calf prices in HF-SSH and the pregnancy rate of sexed semen as a percentage of conventional unsorted semen in MF-SSH and LF-SSH. The range in economic profit for SSA for SSHC scenarios was most sensitive to the pregnancy rate of sexed semen as a percentage of conventional unsorted semen in HF-SSHC, MF-SSHC, and LF-SSHC. This study highlights the effect of baseline herd fertility state on the financial advantage of adopting sexed semen in a pasture-based dairy production system.

A large-scale assessment of lakes reveals a pervasive signal of land use on bacterial communities.

Lakes play a pivotal role in ecological and biogeochemical processes and have been described as "sentinels" of environmental change. Assessing "lake health" across large geographic scales is critical to predict the stability of their ecosystem services and their vulnerability to anthropogenic disturbances. The LakePulse research network is tasked with the assessment of lake health across gradients of land use on a continental scale. Bacterial communities are an integral and rapidly responding component of lake ecosystems, yet large-scale responses to anthropogenic activity remain elusive. Here, we assess the ecological impact of land use on bacterial communities from over 200 lakes covering more than 660,000 km2 across Eastern Canada. In addition to community variation between ecozones, land use across Eastern Canada also appeared to alter diversity, community composition, and network structure. Specifically, increasing anthropogenic impact within the watershed lowered diversity. Likewise, community composition was significantly correlated with agriculture and urban development within a watershed. Interaction networks showed decreasing complexity and fewer keystone taxa in impacted lakes. Moreover, we identified potential indicator taxa of high or low lake water quality. Together, these findings point to detectable bacterial community changes of largely unknown consequences induced by human activity within lake watersheds.

Patient preferences for osteoarthritis pain and chronic low back pain treatments in the United States: a discrete-choice experiment.

OBJECTIVE: To quantify preferences for attributes of potential analgesic treatments for moderate-to-severe pain associated with osteoarthritis (OA) and/or chronic low back pain (CLBP) as relevant to injectable nerve growth factor (NGF)-inhibitors, nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids. METHODS: We used a discrete-choice experiment (DCE) to elicit preferences for attributes of OA and CLBP pharmaceutical treatments, and a best-worst scaling (BWS) exercise to further characterize the relative importance of treatment-related side-effect risks. The survey was completed online by 602 US residents with self-reported chronic, moderate-to-severe OA pain and/or CLBP who had tried, had contraindications for, or were unwilling to take currently available pharmaceutical therapies. In the DCE, respondents repeatedly chose between two hypothetical treatments defined by six attributes (symptom control; treatment-related risks of (1) severe joint problems, (2) heart attack, and (3) physical dependence; mode/frequency of administration; and cost). In the BWS exercise, respondents evaluated ten side-effect risks. Random-parameters logit models were estimated; conditional relative attribute importance, maximum acceptable risks, and willingness to pay were calculated. RESULTS: The most important DCE attributes were improving symptom control (scaled conditional relative importance, 10.00) and reducing risk of physical dependence (6.99). The three most important BWS attributes were, in rank order, risks of stroke, physical dependence, and heart attack. Respondents were willing to accept a > 4% treatment-related risk of severe joint problems for even modest symptom improvement. CONCLUSION: A pharmaceutical treatment with a risk of severe joint problems was viewed as an acceptable alternative to other treatments with comparable efficacy but risks associated with NSAIDs or opioids.

A novel electron-microscopic method for measurement of mineral content in enamel lesions.

OBJECTIVE: To assess Scanning Electron Microscopy in Back-Scattered Emission mode (BSE-SEM) for measurement of lesion mineral content as a function of depth. Direct comparison is made with Transverse Micro-Radiography (TMR) and Surface Micro-Hardness (SMH) on carious and erosive lesions. DESIGN: Caries lesions prepared from sound bovine enamel at 37 °C and pH 4.6 in unsaturated (7d) or part-saturated (8d, 4.1 mM Ca2+, 8 mM Pi) lactic acid /methyl cellulose gel system, followed by TMR analysis. Erosive lesions prepared from sound bovine enamel (1% citric acid, pH3.8, room temperature) for 5, 10, 15 or 20 min at n = 10 per treatment group. SMH readings (Vickers diamond, 1.9 N, 20 s) were taken from acid-treated and reference areas of each sample. BSE-SEM performed on polished cross-sections of lesioned samples (Jeol JSM6490LV SEM; high vacuum, 10 keV beam voltage, magnification x500 with constant working distance of 10 mm). Under identical SEM conditions, polished standards i.e. MgF2, alumina, Mg, Al and Si provided a calibration plot of BSE-SEM signal vs. atomic number (z¯). Mineral content vs. depth plots were derived from the cross-sectional BSE-SEM data. RESULTS: Cross-sectional BSE-SEM images clearly differentiate between caries and erosive lesions. Comparison of caries lesion mineral loss from BSE-SEM with TMR data showed good correlation (R2 = 0.98). Similarly, comparison of BSE-SEM data from erosive lesions showed good correlation (R2 = 0.99) with hardness loss data from SMH. CONCLUSION: BSE-SEM provides a relatively rapid and cost-effective method for the assessment of mineral content in demineralised tooth enamel and is applicable to both caries and erosive lesions.

Nutritional status and interventions in hospice: physician assessment of cancer patients.

BACKGROUND: Cancer cachexia is a multifactorial syndrome characterised by a progressive loss of skeletal muscle mass. It adversely influences quality of life, treatment response and survival. Early identification and multimodal interventions can potentially treat cancer cachexia. However, healthcare professionals demonstrate a lack of understanding and the ability to identify cancer cachexia early. The present study aimed to evaluate the assessment by physicians of nutritional status in cancer patients admitted to hospice. METHODS: A retrospective medical record review was conducted on all cancer admissions to a specialist in-patient palliative care unit over a 4-month period between October 2016 and January 2017. Charts were reviewed for evidence of documented nutritional assessment by physicians. Data were collected from the referral letter, admission notes, drug kardex and discharge letter. The information extracted included: (i) patient demographics and characteristics; (ii) terms used by physicians to describe nutritional status; (iii) any record of nutritional impact symptoms (NIS) experienced by the patient; and (iv) nutritional interventions prescribed. RESULTS: One hundred and forty admissions were evaluated. Nutritional terminology and NIS were most commonly documented on the admission notes. Only 41% of documents recorded any nutritional term used by physicians to assess nutritional status. Furthermore, 71% of documents recorded at least one NIS experienced by the patient. Fatigue was the most frequent NIS. CONCLUSIONS: We identified an inadequate nutritional assessment of cancer patients admitted to hospice. Implementation of a nutritional symptom checklist and nutrition screening tools, along with enhanced physician education and multidisciplinary nutrition care, could improve the identification and management of cancer cachexia in the palliative care setting.

Semi-quantitative assessment of disease risks at the human, livestock, wildlife interface for the Republic of Korea using a nationwide survey of experts: A model for other countries.

Wildlife-associated diseases and pathogens have increased in importance; however, management of a large number of diseases and diversity of hosts is prohibitively expensive. Thus, the determination of priority wildlife pathogens and risk factors for disease emergence is warranted. We used an online questionnaire survey to assess release and exposure risks, and consequences of wildlife-associated diseases and pathogens in the Republic of Korea (ROK). We also surveyed opinions on pathways for disease exposure, and risk factors for disease emergence and spread. For the assessment of risk, we employed a two-tiered, statistical K-means clustering algorithm to group diseases into three levels (high, medium and low) of perceived risk based on release and exposure risks, societal consequences and the level of uncertainty of the experts' opinions. To examine the experts' perceived risk of routes of introduction of pathogens and disease amplification and spread, we used a Bayesian, multivariate normal order-statistics model. Six diseases or pathogens, including four livestock and two wildlife diseases, were identified as having high risk with low uncertainty. Similarly, 13 diseases were characterized as having high risk with medium uncertainty with three of these attributed to livestock, six associated with human disease, and the remainder having the potential to affect human, livestock and wildlife (i.e., One Health). Lastly, four diseases were described as high risk with high certainty, and were associated solely with fish diseases. Experts identified migration of wildlife, international human movement and illegal importation of wildlife as the three routes posing the greatest risk of pathogen introduction into ROK. Proximity of humans, livestock and wildlife was the most significant risk factor for promoting the spread of wildlife-associated diseases and pathogens, followed by high density of livestock populations, habitat loss and environmental degradation, and climate change. This study provides useful information to decision makers responsible for allocating resources to address disease risks. This approach provided a rapid, cost-effective method of risk assessment of wildlife-associated diseases and pathogens for which the published literature is sparse.

Is there a link between childhood adversity, attachment style and Scotland's excess mortality? Evidence, challenges and potential research.

BACKGROUND: Scotland has a persistently high mortality rate that is not solely due to the effects of socio-economic deprivation. This "excess" mortality is observed across the entire country, but is greatest in and around the post-industrial conurbation of West Central Scotland. Despite systematic investigation, the causes of the excess mortality remain the subject of ongoing debate. DISCUSSION: Attachment processes are a fundamental part of human development, and have a profound influence on adult personality and behaviour, especially in response to stressors. Many studies have also shown that childhood adversity is correlated with adult morbidity and mortality. The interplay between childhood adversity and attachment is complex and not fully elucidated, but will include socio-economic, intergenerational and psychological factors. Importantly, some adverse health outcomes for parents (such as problem substance use or suicide) will simultaneously act as risk factors for their children. Data show that some forms of "household dysfunction" relating to childhood adversity are more prevalent in Scotland: such problems include parental problem substance use, rates of imprisonment, rates of suicide and rates of children being taken into care. However other measures of childhood or family wellbeing have not been found to be substantially different in Scotland compared to England. We suggest in this paper that the role of childhood adversity and attachment experience merits further investigation as a plausible mechanism influencing health in Scotland. A model is proposed which sets out some of the interactions between the factors of interest, and we propose parameters for the types of study which would be required to evaluate the validity of the model.

Explaining trends in alcohol-related harms in Scotland, 1991-2011 (I): the role of incomes, effects of socio-economic and political adversity and demographic change.

OBJECTIVE: This paper tests the extent to which differing trends in income, demographic change and the consequences of an earlier period of social, economic and political change might explain differences in the magnitude and trends in alcohol-related mortality between 1991 and 2011 in Scotland compared to England & Wales (E&W). STUDY DESIGN: Comparative time trend analyses and arithmetic modelling. METHODS: Three approaches were utilised to compare Scotland with E&W: 1. We modelled the impact of changes in income on alcohol-related deaths between 1991-2001 and 2001-2011 by applying plausible assumptions of the effect size through an arithmetic model. 2. We used contour plots, graphical exploration of age-period-cohort interactions and calculation of Intrinsic Estimator coefficients to investigate the effect of earlier exposure to social, economic and political adversity on alcohol-related mortality. 3. We recalculated the trends in alcohol-related deaths using the white population only to make a crude approximation of the maximal impact of changes in ethnic diversity. RESULTS: Real incomes increased during the 1990s but declined from around 2004 in the poorest 30% of the population of Great Britain. The decline in incomes for the poorest decile, the proportion of the population in the most deprived decile, and the inequality in alcohol-related deaths, were all greater in Scotland than in E&W. The model predicted less of the observed rise in Scotland (18% of the rise in men and 29% of the rise in women) than that in E&W (where 60% and 68% of the rise in men and women respectively was explained). One-third of the decline observed in alcohol-related mortality in Scottish men between 2001 and 2011 was predicted by the model, and the model was broadly consistent with the observed trends in E&W and amongst women in Scotland. An age-period interaction in alcohol-related mortality was evident for men and women during the 1990s and 2000s who were aged 40-70 years and who experienced rapidly increasing alcohol-related mortality rates. Ethnicity is unlikely to be important in explaining the trends or differences between Scotland and E&W. CONCLUSIONS: The decline in alcohol-related mortality in Scotland since the early 2000s and the differing trend to E&W were partly described by a model predicting the impact of declining incomes. Lagged effects from historical social, economic and political change remain plausible from the available data.

Rapid assessment of cognitive function in down syndrome across intellectual level and dementia status.

BACKGROUND: Adults with Down syndrome (DS) are at risk of developing dementia and cognitive assessment is a fundamental part of the diagnostic process. Previously, we developed a Rapid Assessment for Developmental Disabilities (RADD), a brief, broadly focused direct test of cognition. In the current report, we assess whether the RADD is sensitive to dementia in DS and the degree to which it compares with other cognitive measures of dementia in this population. METHODS: In a sample of 114 individuals with DS, with dementia diagnosed in 62%, the RADD was compared with the Dementia Questionnaire for Mentally Retarded Persons (DMR), the Bristol Activities of Daily Living Scale, Severe Impairment Battery (SIB), and the Brief Praxis Test (BPT). RESULTS: The RADD showed predicted effects across intellectual disability (ID) levels and dementia status (p < 0.001). Six-month test-retest reliability for the subset of individuals without dementia was high (r(41) = 0.95, p < 0.001). Criterion-referenced validity was demonstrated by correlations between RADD scores and ID levels based upon prior intelligence testing and clinical diagnoses (rs (114) = 0.67, p = 0.001) and with other measures of cognitive skills, such as the BPT, SIB, and DMR-Sum of Cognitive scores (range 0.84 through 0.92). Using receiver operating characteristic curves for groups varying in pre-morbid severity of ID, the RADD exhibited high sensitivity (0.87) and specificity (0.81) in discriminating among individuals with and without dementia, although sensitivity was somewhat lower (0.73) for the subsample of dementia cases diagnosed no more than 2 years prior to their RADD assessment. CONCLUSION: Taken together, findings indicated that the RADD, a relatively brief, easy-to-administer test for cognitive function assessment across ID levels and dementia status, would be a useful component of cognitive assessments for adults with DS, including assessments explicitly focused on dementia.

Growing up in Glasgow: the social context of adolescence.

The adolescent population of Glasgow, the city with the highest mortality in the UK, has a higher prevalence of risk behaviours than elsewhere in Scotland. Previous research has highlighted the importance of social context in interpreting such differences. Contextual variables from the 2010 Health Behaviour in School-aged Children Scotland survey were analysed. Glaswegian adolescents were more likely to live in low socioeconomic status, single-parent or step-families, or with neither parent in employment, less likely to share family meals, more likely to buy lunch outside school, and spend time with friends after school and in the evenings. They also had a poorer perception of their local neighbourhood. Family affluence only partially explained these differences.

What can ecological data tell us about reasons for divergence in health status between West Central Scotland and other regions of post-industrial Europe?

BACKGROUND: The link between the effects of de-industrialization (unemployment, poverty) and population health is well understood. Post-industrial decline has, therefore, been cited as an underlying cause of high mortality in Scotland's most de-industrialized region. However, previous research showed other comparably de-industrialized regions in Europe to have better and faster improving health (with, in many cases, a widening gap evident from the early to mid-1980s). OBJECTIVES: To explore whether ecological data can provide insights into reasons behind the poorer, and more slowly improving, health status of West Central Scotland (WCS) compared with other European regions that have experienced similar histories of post-industrial decline. Specifically, this study asked: (1) could WCS's poorer health status be explained purely in terms of socio-economic factors (poverty, deprivation etc.)? and (2) could comparisons with other health determinant information identify important differences between WCS and other regions? These aims were explored alongside other research examining the historical, economic and political context in WCS compared with other de-industrialized regions. STUDY DESIGN AND METHODS: A range of ecological data, derived from surveys and routine administrative sources, were collected and analysed for WCS and 11 other post-industrial regions. Analyses were underpinned by the collection and analysis of more detailed data for four particular regions of interest. In addition, the project drew on accompanying literature-based research, analysing important contextual factors in de-industrialized regions, including histories of economic and welfare policies, and national and regional responses to de-industrialization. RESULTS: The poorer health status of WCS cannot be explained in terms of absolute measures of poverty and deprivation. However, compared with other post-industrial regions in Mainland Europe, the region is distinguished by having wider income inequalities and associated social characteristics (e.g. more single adults, lone parent households, higher rates of teenage pregnancy). Some of these distinguishing features are shared by other UK post-industrial regions which experienced the same economic history as WCS. CONCLUSION: From the collection of data and supporting analyses of important contextual factors, one can argue that poor health in WCS can be attributed to three layers of causation: the effects of de-industrialization (which have impacted on health in all post-industrial regions); the impact of 'neoliberal' UK economic policies, resulting in wider inequalities in WCS and the other UK regions; and an as-yet-unexplained (but under investigation) set of factors that cause WCS to experience worse health outcomes than similar regions within the UK.

Trends in termination of pregnancy in Glasgow, Liverpool and Manchester.

BACKGROUND: Research published in 2010 showed that premature mortality in Glasgow over the period 2003-2007 was 30% higher than that in Liverpool and Manchester, despite the three cities sharing almost identical levels and patterns of socio-economic deprivation. A number of theories have been proposed to explain this discrepancy, including [in the light of US research linking variations in the termination of pregnancy (ToP) rate to differences in social and health outcomes] the suggestion that variations in current levels of mortality across the cities could be influenced by differences in earlier ToP rates. OBJECTIVES: To undertake further analyses of mortality data for Glasgow, Liverpool and Manchester to assess the likelihood of differences in ToP rates influencing rates of excess mortality in Glasgow; to analyse long-term trends in numbers and ToP rates in the three cities (and, for comparison, between Scotland and England); and to investigate potential explanations for any differences in ToP rates. STUDY DESIGN AND METHODS: Mortality analyses were based on the same age-, sex- and deprivation-standardized data that were used in the previous research on the three cities. ToP data (and population denominator data) covering the period 1980-2009 were obtained from Scottish and English national organizations. Historical national ToP data for the years 1969-1979 were obtained from an additional published source. Rates were calculated per female aged 15-44 years and, for analyses of ToP among teenagers, per female aged 15-19 years. Potential explanations for differences in rates were investigated by means of literature searches and discussions with key informants. RESULTS: The ToP rate in Glasgow was lower than the ToP rates in Liverpool and Manchester over the total period analysed (as was the case for Scotland compared with England and Wales), although the gap has narrowed considerably, especially among females aged <20 years. This is due to a greater increase in the ToP rate in Glasgow (and Scotland), attributed, in part, to better access to ToP services. The differences in ToP rates do not appear to have been influenced by women travelling to England from Ireland for access to ToP facilities, nor by Glaswegian women travelling outside Scotland for the same reason. However, 90% of 'excess' deaths that took place in Glasgow compared with Liverpool and Manchester between 2003 and 2007 related to individuals born prior to the 1967 Abortion Act; these excess deaths, therefore, are not influenced by earlier variations in ToP rates. CONCLUSIONS: Differences in ToP rates between the cities are unlikely to impact on variations in later mortality rates. Thus, while the topic of ToP is important, investigation into the reasons behind Glasgow's excess mortality levels should focus on other hypotheses.