Lifetime risk of diabetes in metropolitan cities in India.

AIMS/HYPOTHESIS: We aimed to estimate the lifetime risk of diabetes and diabetes-free life expectancy in metropolitan cities in India among the population aged 20 years or more, and their variation by sex, age and BMI. METHODS: A Markov simulation model was adopted to estimate age-, sex- and BMI-specific lifetime risk of developing diabetes and diabetes-free life expectancy. The main data inputs used were as follows: age-, sex- and BMI-specific incidence rates of diabetes in urban India taken from the Centre for Cardiometabolic Risk Reduction in South Asia (2010-2018); age-, sex- and urban-specific rates of mortality from period lifetables reported by the Government of India (2014); and prevalence of diabetes from the Indian Council for Medical Research INdia DIABetes study (2008-2015). RESULTS: Lifetime risk (95% CI) of diabetes in 20-year-old men and women was 55.5 (51.6, 59.7)% and 64.6 (60.0, 69.5)%, respectively. Women generally had a higher lifetime risk across the lifespan. Remaining lifetime risk (95% CI) declined with age to 37.7 (30.1, 46.7)% at age 60 years among women and 27.5 (23.1, 32.4)% in men. Lifetime risk (95% CI) was highest among obese Indians: 86.0 (76.6, 91.5)% among 20-year-old women and 86.9 (75.4, 93.8)% among men. We identified considerably higher diabetes-free life expectancy at lower levels of BMI. CONCLUSIONS/INTERPRETATION: Lifetime risk of diabetes in metropolitan cities in India is alarming across the spectrum of weight and rises dramatically with higher BMI. Prevention of diabetes among metropolitan Indians of all ages is an urgent national priority, particularly given the rapid increase in urban obesogenic environments across the country. Graphical abstract.

Do trends in the prevalence of overweight by socio-economic position differ between India's most and least economically developed states?

BACKGROUND: India's economic development and urbanisation in recent decades has varied considerably between states. Attempts to assess how overweight (including obesity) varies by socioeconomic position at the national level may mask considerable sub-national heterogeneity. We examined the socioeconomic patterning of overweight among adults in India's most and least economically developed states between 1998 and 2016. METHODS: We used state representative data from the National Family Health Surveys from 1998 to 99, 2005-06 and 2015-16. We estimated the prevalence of overweight by socioeconomic position in men (15-54 years) and women (15-49 years) from India's most and least economically developed states using multilevel logistic regressions. RESULTS: We observed an increasing trend of overweight prevalence among low socioeconomic position women. Amongst high socioeconomic position women, overweight prevalence either increased to a smaller extent, remained the same or even declined between 1998 and 2016. This was particularly the case in urban areas of the most developed states, where in the main analysis, the prevalence of overweight increased from 19 to 33% among women from the lowest socioeconomic group between 1998 and 2016 compared to no change among women from the highest socioeconomic group. Between 2005 and 2016, the prevalence of overweight increased to similar extents among high and low socioeconomic status men, irrespective of residence. CONCLUSIONS: The converging prevalence of overweight by socioeconomic position in India's most developed states, particularly amongst urban women, implies that this subpopulation may be the first to exhibit a negative association between socioeconomic position and overweight in India. Programs aiming to reduce the increasing overweight trends may wish to focus on poorer women in India's most developed states, amongst whom the increasing trend in prevalence has been considerable.

Trends in catastrophic health expenditure in India: 1993 to 2014.

OBJECTIVE: To investigate trends in out-of-pocket health-care payments and catastrophic health expenditure in India by household age composition. METHODS: We obtained data from four national consumer expenditure surveys and three health-care utilization surveys conducted between 1993 and 2014. Households were divided into five groups by age composition. We defined catastrophic health expenditure as out-of-pocket payments equalling or exceeding 10% of household expenditure. Factors associated with catastrophic expenditure were identified by multivariable analysis. FINDINGS: Overall, the proportion of catastrophic health expenditure increased 1.47-fold between the 1993-1994 expenditure survey (12.4%) and the 2011-2012 expenditure survey (18.2%) and 2.24-fold between the 1995-1996 utilization survey (11.1%) and the 2014 utilization survey (24.9%). The proportion increased more in the poorest than the richest quintile: 3.00-fold versus 1.74-fold, respectively, across the utilization surveys. Catastrophic expenditure was commonest among households comprising only people aged 60 years or older: the adjusted odds ratio (aOR) was 3.26 (95% confidence interval, CI: 2.76-3.84) compared with households with no older people or children younger than 5 years. The risk was also increased among households with both older people and children (aOR: 2.58; 95% CI: 2.31-2.89), with a female head (aOR: 1.32; 95% CI: 1.19-1.47) and with a rural location (aOR: 1.27; 95% CI: 1.20-1.35). CONCLUSION: The proportion of households experiencing catastrophic health expenditure in India increased over the past two decades. Such expenditure was highest among households with older people. Financial protection mechanisms are needed for population groups at risk for catastrophic health expenditure.

Factorial structure of the locomotor disability scale in a sample of adults with mobility impairments in Bangladesh.

BACKGROUND: Disability does not only depend on individuals' health conditions but also the contextual factors in which individuals live. Therefore, disability measurement scales need to be developed or adapted to the context. Bangladesh lacks any locally developed or validated scales to measure disabilities in adults with mobility impairment. We developed a new Locomotor Disability Scale (LDS) in a previous qualitative study. The present study developed a shorter version of the scale and explored its factorial structure. METHODS: We administered the LDS to 316 adults with mobility impairments, selected from outpatient and community-based settings of a rehabilitation centre in Bangladesh. We did exploratory factor analysis (EFA) to determine a shorter version of the LDS and explore its factorial structure. RESULTS: We retained 19 items from the original LDS following evaluation of response rate, floor/ceiling effects, inter-item correlations, and factor loadings in EFA. The Eigenvalues greater than one rule and the Scree test suggested a two-factor model of measuring locomotor disability (LD) in adults with mobility impairment. These two factors are 'mobility activity limitations' and 'functional activity limitations'. We named the higher order factor as 'locomotor disability'. This two-factor model explained over 68% of the total variance among the LD indicators. The reproduced correlation matrix indicated a good model fit with 14% non-redundant residuals with absolute values > 0.05. However, the Chi-square test indicated poor model fit (p < .001). The Bartlett's test of Sphericity confirmed patterned relationships amongst the LD indicators (p < .001). The Kaiser-Meyer-Olkin Measure (KMO) of sampling adequacy was .94 and the individual diagonal elements in the anti-correlation matrix were > .91. Among the retained 19 items, there was no correlation coefficient > .9 or a large number of correlation coefficients < .3. The communalities were high: between .495 and .882 with a mean of 0.684. As an evidence of convergent validity, we had all loadings above .5, except one. As an evidence of discriminant validity, we had no strong (> .3) cross loadings and the correlation between the two factors was .657. The 'mobility activity limitations' and 'functional activity limitations' sub-scales demonstrated excellent internal consistency (Cronbach's alpha were .954 and .937, respectively). CONCLUSIONS: The 19-item LDS was found to be a reliable and valid scale to measure the latent constructs mobility activity limitations and functional activity limitations among adults with mobility impairments in outpatient and community-based settings in Bangladesh.

Changing family structures and self-rated health of India's older population (1995-96 to 2014).

A common view within academia and Indian society is that older Indians are cared for by their families less than in the past. Children are a key source of support in later life and alternatives are limited, therefore declining fertility appears to corroborate this. However, the situation may be more complex. Having many children may be physiologically burdensome for women, sons and daughters have distinct care roles, social trends could affect support provision, and spouses also provide support. We assessed whether the changing structure of families has negatively affected health of the older population using three cross-sectional and nationally representative surveys of India's 60-plus population (1995-96, 2004 and 2014). We described changes in self-rated health and family structure (number of children, sons, and daughters, and marital status) and, using ordinal regression modelling, determined the association between family structure and self-rated health, stratified by survey year and gender. Our results indicate that family structure changes that occurred between 1995-96 and 2014 were largely associated with better health. Though family sizes declined, there were no health gains from having more than two children. In fact, having many children (particularly daughters) was associated with worse health for both men and women. There was some evidence that being sonless or childless was associated with worse health, but it remained rare to not have a son or child. Being currently married was associated with better health and became more common over the inter-survey period. Although our results suggest that demographic trends have not adversely affected health of the older population thus far, we propose that the largest changes in family structure are yet to come. The support available in coming years (and potential health impact) will rely on flexibility of the current system.

Forecasting the prevalence of overweight and obesity in India to 2040.

BACKGROUND: In India, the prevalence of overweight and obesity has increased rapidly in recent decades. Given the association between overweight and obesity with many non-communicable diseases, forecasts of the future prevalence of overweight and obesity can help inform policy in a country where around one sixth of the world's population resides. METHODS: We used a system of multi-state life tables to forecast overweight and obesity prevalence among Indians aged 20-69 years by age, sex and urban/rural residence to 2040. We estimated the incidence and initial prevalence of overweight using nationally representative data from the National Family Health Surveys 3 and 4, and the Study on global AGEing and adult health, waves 0 and 1. We forecasted future mortality, using the Lee-Carter model fitted life tables reported by the Sample Registration System, and adjusted the mortality rates for Body Mass Index using relative risks from the literature. RESULTS: The prevalence of overweight will more than double among Indian adults aged 20-69 years between 2010 and 2040, while the prevalence of obesity will triple. Specifically, the prevalence of overweight and obesity will reach 30.5% (27.4%-34.4%) and 9.5% (5.4%-13.3%) among men, and 27.4% (24.5%-30.6%) and 13.9% (10.1%-16.9%) among women, respectively, by 2040. The largest increases in the prevalence of overweight and obesity between 2010 and 2040 is expected to be in older ages, and we found a larger relative increase in overweight and obesity in rural areas compared to urban areas. The largest relative increase in overweight and obesity prevalence was forecast to occur at older age groups. CONCLUSION: The overall prevalence of overweight and obesity is expected to increase considerably in India by 2040, with substantial increases particularly among rural residents and older Indians. Detailed predictions of excess weight are crucial in estimating future non-communicable disease burdens and their economic impact.

Prevalence and correlates of 'sexual competence' at first heterosexual intercourse among young people in Britain.

BACKGROUND: A greater understanding of the circumstances of first sexual intercourse, as opposed to an exclusive focus on age at occurrence, is required in order that sexual health and well-being can be promoted from the onset of sexual activity. METHODS: We used data from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3) conducted in Britain. Participants were categorised as 'sexually competent' at first heterosexual intercourse if the following self-reported criteria applied to the event: contraceptive use, autonomy of decision, both partners 'equally willing', and occurrence at the perceived 'right time'. We examined the prevalence of 'sexual competence', and its component parts, by age at first intercourse among 17-24-year-olds. Using multivariable logistic regression, we explored associations between sexual competence and potential explanatory factors. RESULTS: Variation in 'sexual competence' and its component parts was associated with, but not fully explained by, age at first sex: 22.4% and 36.2% of men and women who had first sex at age 13-14 years were categorised as 'sexually competent', rising to 63.7% and 60.4% among those aged ≥18 years at first intercourse. Lack of sexual competence was independently associated with: first intercourse before the age of 16 years, area-level deprivation (men only), lower educational level, black ethnicity (women only), reporting 'friends' as main source of learning about sex (women only), non-'steady' relationship at first sex, and uncertainty of first partner's virginity status. CONCLUSIONS: A substantial proportion of young people in Britain transition into sexual activity under circumstances incompatible with positive sexual health. Social inequalities in sexual health are reflected in the context of first intercourse.

Inequity in out-of-pocket payments for hospitalisation in India: Evidence from the National Sample Surveys, 1995-2014.

OBJECTIVE: We report inequity in out-of-pocket payments (OOPP) for hospitalisation in India between 1995 and 2014 contrasting older population (60 years or more) with a population under 60 years (younger population). METHODS: We used data from nationwide healthcare surveys conducted in India by the National Sample Survey Organisation in 1995-96, 2004 and 2014 with the sample sizes ranging from 333,104 to 629,888. We used generalised linear and fractional response models to study the determinants of OOPP and their burden (share of OOPP in household consumption expenditure) at a constant price. The relationship between predicted OOPP and its burden with monthly per capita consumption expenditure (MPCE) quintiles and selected socioeconomic characteristics were used to examine vertical and horizontal inequities in OOPP. RESULTS: The older population had higher OOPP for hospitalisation at all time points (range: 1.15-1.48 times) and a greater increase between 1995-96 and 2014 than the younger population (2.43 vs 1.88 times). Between 1995-96 and 2014, the increase in predicted mean OOPP for hospitalisation was higher for the poorest than the richest (3.38 vs 1.85 times) older population. The increase in predicted mean OOPP was higher for the poorest (2.32 vs 1.46 times) and poor (2.87 vs 1.05 times) older population between 1995-96 and 2004 than in the latter decade. In 2014, across all MPCE quintiles, the burden of OOPP was higher for the less developed states, females, private hospitals, and non-communicable disease and injuries, more so for the older than the younger population. In 2014, the predicted absolute OOPP for hospitalisation was positively associated with MPCE quintiles; however, the burden of OOPP was negatively associated with MPCE quintiles indicating a regressive system of healthcare financing. CONCLUSION: High OOPP for hospitalisation and greater inequity among older population calls for better risk pooling and prepayment mechanisms in India.

Trends in the socioeconomic patterning of overweight/obesity in India: a repeated cross-sectional study using nationally representative data.

OBJECTIVES: We aimed to examine trends in prevalence of overweight/obesity among adults in India by socioeconomic position (SEP) between 1998 and 2016. DESIGN: Repeated cross-sectional study using nationally representative data from India collected in 1998/1999, 2005/2006 and 2015/2016. Multilevel regressions were used to assess trends in prevalence of overweight/obesity by SEP. SETTING: 26, 29 and 36 Indian states or union territories, in 1998/99, 2005/2006 and 2015/2016, respectively. PARTICIPANTS: 628 795 ever-married women aged 15-49 years and 93 618 men aged 15-54 years. PRIMARY OUTCOME MEASURE: Overweight/obesity defined by body mass index >24.99 kg/m2. RESULTS: Between 1998 and 2016, overweight/obesity prevalence increased among men and women in both urban and rural areas. In all periods, overweight/obesity prevalence was consistently highest among higher SEP individuals. In urban areas, overweight/obesity prevalence increased considerably over the study period among lower SEP adults. For instance, between 1998 and 2016, overweight/obesity prevalence increased from approximately 15%-32% among urban women with no education. Whereas the prevalence among urban men with higher education increased from 26% to 34% between 2005 and 2016, we did not observe any notable changes among high SEP urban women between 1998 and 2016. In rural areas, more similar increases in overweight/obesity prevalence were found among all individuals across the study period, irrespective of SEP. Among rural women with higher education, overweight/obesity increased from 16% to 25% between 1998 and 2016, while the prevalence among rural women with no education increased from 4% to 14%. CONCLUSIONS: We identified some convergence of overweight/obesity prevalence across SEP in urban areas among both men and women, with fewer signs of convergence across SEP groups in rural areas. Efforts are therefore needed to slow the increasing trend of overweight/obesity among all Indians, as we found evidence suggesting it may no longer be considered a 'diseases of affluence'.

Socio-demographic determinants of the severity of locomotor disability among adults in Bangladesh: a cross-sectional study, December 2010-February 2011.

BACKGROUND: Socio-demographic variables are widely known to have an association with the presence of any disability. However, the association between the severity of locomotor disability and socio-demographic variables has never been investigated in Bangladesh. METHODS: A cross sectional survey of adults with locomotor disabilities was conducted between December 2010 and February 2011 at the Centre for the Rehabilitation of the Paralysed (CRP), Dhaka, Bangladesh. During the study period 328 adults with locomotor disabilities met our selection criteria, but 316 consented and participated in the study. The 55-item Locomotor Disability Scale was used to measure disability. This study investigated the socio-demographic determinants of the severity of locomotor disability: age, gender, marital status, educational attainment, occupation, income status, type of house, living in own/rented house, household monthly income, household population and area of residence. RESULTS: Participants' age was positively associated with the severity of their locomotor disability (ß = 0.01; 95% CI: 0.004 to 0.02), adjusting for diagnosis and other socio-demographic variables studied. Individuals who had an income experienced 0.35 (95% CI: -0.63 to -0.07) points decrease in the severity of disability than those did not have an income, adjusting for diagnosis and rest of the socio-demographic variables studied. In comparison to the unemployed individuals, students, homemakers, and individuals in elementary occupation respectively experienced 0.75 (95% CI: -1.08 to -0.43), 0.51 (95% CI: -0.82 to -0.19) and 0.37 (95% CI: -0.66 to -0.08) points decrease in the severity of locomotor disability, adjusting for diagnosis and rest of the socio-demographic variables studied. CONCLUSIONS: The severity of locomotor disability has an association with individuals' age, income status and occupation of the adults with such disability in Bangladesh. No such association was evident with other socioeconomic position and demographic variables. This finding suggests that people with locomotor disabilities in Bangladesh experience similar disabling built and attitudinal environments irrespective of their socioeconomic positions and demographic characteristics. Further community-based studies are needed to confirm such conclusions.

Developing the content of a locomotor disability scale for adults in Bangladesh: a qualitative study.

BACKGROUND: Bangladesh has an estimated 17 million adults with disabilities. A significant proportion of them are believed to have locomotor disabilities. There are over 300 non-governmental organizations providing different types of rehabilitation services to them. However, there is no locally developed and validated locomotor disability measurement scale in Bangladesh. The purpose of this study was to develop a locomotor disability scale with disability indicators suitable for adults in Bangladesh. METHODS: Semi-structured interviews were conducted with 25 purposively selected adults with locomotor disabilities to generate scale items. At the second stage, cognitive interviews were conducted with 12 purposively selected adults with locomotor disabilities in order to refine the measurement questions and response categories. Data were analysed using the framework technique- identifying, abstracting, charting and matching themes across the interviews. RESULTS: For a locomotor disability scale, 70 activities (disability indicators) were identified: 37 mobility activities, 9 activities of daily living, 17 work/productivity activities and 7 leisure activities. Cognitive interviews revealed that when asking the respondents to rate their difficulty in performing the activities, instead of just mentioning the activity name, such as taking a bath or shower, a detailed description of the activity and response options were necessary to ensure consistent interpretation of the disability indicators and response options across all respondents. CONCLUSIONS: Identifying suitable disability indicators was the first step in developing a locomotor disability scale for adults in Bangladesh. Interviewing adults with locomotor disabilities in Bangladesh ensured that the locomotor disability scale is of relevance to them and consequently it has excellent content validity. Further research is needed to evaluate the psychometric properties of this scale.

Horizontal inequity in outpatient care use and untreated morbidity: evidence from nationwide surveys in India between 1995 and 2014.

Equity in healthcare has been a long-term guiding principle of health policy in India. We estimate the change in horizontal inequities in healthcare use over two decades comparing the older population (60 years or more) with the younger population (under 60 years). We used data from the nationwide healthcare surveys conducted in India by the National Sample Survey Organization in 1995-96 and 2014 with sample sizes 633 405 and 335 499, respectively. Bivariate and multivariate logit regression analyses were used to study the socioeconomic differentials in self-reported morbidity (SRM), outpatient care and untreated morbidity. Deviations in the degree to which healthcare was distributed according to need were measured by horizontal inequity index (HI). In each consumption quintile the older population had four times higher SRM and outpatient care rate than the younger population in 2014. In 1995-96, the pro-rich inequity in outpatient care was higher for the older (HI: 0.085; 95% CI: 0.066, 0.103) than the younger population (0.039; 0.034, 0.043), but by 2014 this inequity became similar. Untreated morbidity was concentrated among the poor; more so for the older (-0.320; -0.391, -0.249) than the younger (-0.176; -0.211, -0.141) population in 2014. The use of public facilities increased most in the poorest and poor quintiles; the increase was higher for the older than the younger population in the poorest (1.19 times) and poor (1.71 times) quintiles. The use of public facilities was disproportionately higher for the poor in 2014 than in 1995-96 for the older (-0.189; -0.234, -0.145 vs - 0.065; -0.129, -0.001) and the younger (-0.145; -0.175, -0.115 vs - 0.056; -0.086, -0.026) population. The older population has much higher morbidity and is often more disadvantaged in obtaining treatment. Health policy in India should pay special attention to equity in access to healthcare for the older population.

Hospitalisation trends in India from serial cross-sectional nationwide surveys: 1995 to 2014.

OBJECTIVES: We report hospitalisation trends for different age groups across the states of India and for various disease groups, compare the hospitalisation trends among the older (aged 60 years or more) and the younger (aged under 60 years) population and quantify the factors that contribute to the change in hospitalisation rates of the older population over two decades. DESIGN: Serial cross-sectional study. SETTING: Nationally representative sample, India. DATA SOURCES: Three consecutive National Sample Surveys (NSS) on healthcare utilisation in 1995-1996, 2004 and 2014. PARTICIPANTS: Six hundred and thirty-three thousand four hundred and five individuals in NSS 1995-1996, 385 055 in NSS 2004 and 335 499 in NSS 2014. METHODS: Descriptive statistics, multivariable analyses and a regression decomposition technique were used to attain the study objectives. RESULT: The annual hospitalisation rate per 1000 increased from 16.6 to 37.0 in India from 1995-1996 to 2014. The hospitalisation rate was about half in the less developed than the more developed states in 2014 (26.1 vs 48.6 per 1000). Poor people used more public than private hospitals; this differential was higher in the more developed (40.7% vs 22.9%) than the less developed (54.3% vs 40.1%) states in 2014. When compared with the younger population, the older population had a 3.6 times higher hospitalisation rate (109.9 vs 30.7) and a greater proportion of hospitalisation for non-communicable diseases (80.5% vs 56.7%) in 2014. Among the older population, hospitalisation rates were comparatively lower for females, poor and rural residents. Propensity change contributed to 86.5% of the increase in hospitalisation among the older population and compositional change contributed 9.3%. CONCLUSION: The older population in India has a much higher hospitalisation rate and has continuing greater socioeconomic differentials in hospitalisation rates. Specific policy focus on the requirements of the older population for hospital care in India is needed in light of the anticipated increase in their proportion in the population.

Is "Sexual Competence" at First Heterosexual Intercourse Associated With Subsequent Sexual Health Status?

The timing of first sexual intercourse is often defined in terms of chronological age, with particular focus on "early" first sex. Arguments can be made for a more nuanced concept of readiness and appropriateness of timing of first intercourse. Using data from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3), conducted in 2010-2012, this study examined whether a context-based measure of first intercourse-termed sexual competence-was associated with subsequent sexual health in a population-based sample of 17-to 24-year-olds residing in Britain (n = 2,784). Participants were classified as "sexually competent" at first intercourse if they reported the following four criteria: contraceptive protection, autonomy of decision (not due to external influences), that both partners were "equally willing," and that it happened at the "right time." A lack of sexual competence at first intercourse was independently associated with testing positive for human papillomavirus (HPV) at interview; low sexual function in the past year; and among women only, reported sexually transmitted infection (STI) diagnosis ever; unplanned pregnancy in the past year; and having ever experienced nonvolitional sex. These findings provide empirical support for defining the nature of first intercourse with reference to contextual aspects of the experience, as opposed to a sole focus on chronological age at occurrence.

Risk factors for low birthweight based on birth registration and census information, England and Wales, 1981-2000.

This study examines whether there are socio-demographic factors (collected at census) that are not routinely available at birth registration that help to explain low birthweight in England and Wales in the 1980s and 1990s. Maternal age and marital status at the time of birth are known to affect the risk of low birthweight. The article looks at whether the additional socio-demographic information about the mother that is collected at Census modifies our understanding. It identifies specific groups at high risk of this negative birth outcome--being a mother from a non-White ethnic group, having a long-standing illness and living in a deprived area.

" . . . I Should Maintain a Healthy Life Now and Not Just Live as I Please . . . ": Men's Health and Fatherhood in Rural South Africa.

This study examines the social context of men's health and health behaviors in rural KwaZulu-Natal, South Africa, particularly in relationship to fathering and fatherhood. Individual interviews and focus groups were conducted with 51 Zulu-speaking men. Three themes related to men's health emerged from the analysis of transcripts: (a) the interweaving of health status and health behaviors in descriptions of "good" and "bad" fathers, (b) the dominance of positive accounts of health and health status in men's own accounts, and (c) fathers' narratives of transformations and positive reinforcement in health behaviors. The study reveals the pervasiveness of an ideal of healthy fathers, one in which the health of men has practical and symbolic importance not only for men themselves but also for others in the family and community. The study also suggests that men hold in esteem fathers who manage to be involved with their biological children who are not coresident or who are playing a fathering role for nonbiological children (social fathers). In South Africa, men's health interventions have predominantly focused on issues related to HIV and sexual health. The new insights obtained from the perspective of men indicate that there is likely to be a positive response to health interventions that incorporate acknowledgment of, and support for, men's aspirations and lived experiences of social and biological fatherhood. Furthermore, the findings indicate the value of data on men's involvement in families for men's health research in sub-Saharan Africa.

The long shadow of childhood: associations between parental social class and own social class, educational attainment and timing of first birth; results from the ONS Longitudinal Study.

In September 2004, linked data from the 2001 Census was made available in the Office for National Statistics (ONS) Longitudinal Study (a 1 per cent sample of the population of England and Wales). The study now includes information from four censuses on sample members and the people they lived with. The availability of this new information, the length of follow-up and other features of the study (such as records of births and deaths to sample members) provide new opportunities for analysing change--both over the life course, between time periods, and between generations. This article illustrates the potential for analysis of continuity and change with new results on intergenerational social mobility, and on parental social class and age at first birth.

Evaluating youth-friendly health services: young people's perspectives from a simulated client study in urban South Africa.

BACKGROUND: Few§These authors contributed equally to this work. youth-friendly health services worldwide have been scaled up or evaluated from young people's perspectives. South Africa's Youth Friendly Services (YFS) programme is one of the few to have been scaled up. This study investigated young people's experiences of using sexual and reproductive health services at clinics providing the YFS programme, compared to those that did not, using the simulated client method. DESIGN: Fifteen primary healthcare clinics in Soweto were randomly sampled: seven provided the YFS programme. Simulated clients conducted 58 visits; young men requested information on condom reliability and young women on contraceptive methods. There were two outcome measures: a single measure of the overall clinic experience (clinic visit score) and whether or not simulated clients would recommend a clinic to their peers. The clinic visit score was based on variables relating to the simulated clients' interactions with staff, details of their consultation, privacy, confidentiality, the healthcare workers' characteristics, and the clinic environment. A larger score corresponds to a worse experience than a smaller one. Multilevel regression models and framework analysis were used to investigate young people's experiences. RESULTS: Health facilities providing the YFS programme did not deliver a more positive experience to young people than those not providing the programme (mean difference in clinic visit score: -0.18, 95% CI: -0.95, 0.60, p=0.656). They were also no more likely to be recommended by simulated clients to their peers (odds ratio: 0.48, 95% CI: 0.11, 2.10, p=0.331). More positive experiences were characterised by young people as those where healthcare workers were friendly, respectful, knew how to talk to young people, and appeared to value them seeking health information. Less positive experiences were characterised by having to show soiled sanitary products to obtain contraceptives, healthcare workers expressing negative opinions about young people seeking information, lack of privacy, and inadequate information. CONCLUSIONS: The provision and impact of the YFS programme are limited. Future research should explore implementation. Regular training and monitoring could enable healthcare workers to address young people's needs.

Revisiting the 'Low BirthWeight paradox' using a model-based definition.

INTRODUCTION: Immigrant mothers in Spain have a lower risk of delivering Low BirthWeight (LBW) babies in comparison to Spaniards (LBW paradox). This study aimed at revisiting this finding by applying a model-based threshold as an alternative to the conventional definition of LBW. METHODS: Vital information data from Madrid was used (2005-2006). LBW was defined in two ways (less than 2500g and Wilcox's proposal). Logistic and linear regression models were run. RESULTS: According to common definition of LBW (less than 2500g) there is evidence to support the LBW paradox in Spain. Nevertheless, when an alternative model-based definition of LBW is used, the paradox is only clearly present in mothers from the rest of Southern America, suggesting a possible methodological bias effect. CONCLUSION: In the future, any examination of the existence of the LBW paradox should incorporate model-based definitions of LBW in order to avoid methodological bias.

Staying out of trouble: intentions of young male offenders.

During the fall of 2005, we interviewed a sample of 103 young men aged 18 to 21 imprisoned at a young offender's prison in England. Drawing on the theory of planned behavior, as well as the theory of cognitive transformation, our purpose was to investigate prisoners' reports of their likelihood of reoffending following release from prison. Primary explanatory factors included measures of attitudes, behavioral control, and subjective norms. Attitudes measured inmates' plans of what they would do following release. Behavioral control variables included indicators of life control and self-efficacy. Subjective norms measured the number of peers inmates reported ever being imprisoned. Prison activities and background characteristics were also modeled. The data were analyzed using regression techniques and structural equation modeling. Intentions to stay out of trouble were most strongly associated with self-efficacy and the number of imprisoned friends reported. Intentions were also associated with the specificity of postrelease plans and life control. Offenders' feelings of life control were stronger among those who had more frequent contact with family members and friends while in prison. Employment prior to prison and family relationships were predictive of contacts with family and friends in prison. Specific policies consistent with our findings include encouragement of contact with family members and friends. In addition, interventions that help offenders make specific plans and increase feelings of control and self-efficacy have promise in helping released offenders successfully complete the transition from prison to the community.