Complex differences in infection rates between ethnic groups in Scotland: a retrospective, national census-linked cohort study of 1.65 million cases.

BACKGROUND: Ethnicity can influence susceptibility to infection, as COVID-19 has shown. Few countries have systematically investigated ethnic variations in infection. METHODS: We linked the Scotland 2001 Census, including ethnic group, to national databases of hospitalizations/deaths and serological diagnoses of bloodborne viruses for 2001-2013. We calculated age-adjusted rate ratios (RRs) in 12 ethnic groups for all infections combined, 15 infection categories, and human immunodeficiency virus (HIV), hepatitis B (HBV) and hepatitis C (HCV) viruses. RESULTS: We analysed over 1.65 million infection-related hospitalisations/deaths. Compared with White Scottish, RRs for all infections combined were 0.8 or lower for Other White British, Other White and Chinese males and females, and 1.2-1.4 for Pakistani and African males and females. Adjustment for socioeconomic status or birthplace had little effect. RRs for specific infection categories followed similar patterns with striking exceptions. For HIV, RRs were 136 in African females and 14 in males; for HBV, 125 in Chinese females and 59 in males, 55 in African females and 24 in males; and for HCV, 2.3-3.1 in Pakistanis and Africans. CONCLUSIONS: Ethnic differences were found in overall rates and many infection categories, suggesting multiple causative pathways. We recommend census linkage as a powerful method for studying the disproportionate impact of COVID-19.

The challenge of using routinely collected data to compare hospital admission rates by ethnic group: a demonstration project in Scotland.

BACKGROUND: Recording patients' ethnic group supports efforts to achieve equity in health care provision. Before the Equality Act (2010), recording ethnic group at hospital admission was poor in Scotland but has improved subsequently. We describe the first analysis of the utility of such data nationally for monitoring ethnic variation. METHODS: We analysed all in-patient or day case hospital admissions in 2013. We imputed missing data using the most recent ethnic group recorded for a patient from 2009 to 2015. For episodes lacking an ethnic code, we attributed known ethnic codes proportionately. Using the 2011 Census population, we calculated rates and rate ratios for all-cause admissions and ischaemic heart diseases (IHDs) directly standardized for age. RESULTS: Imputation reduced missing ethnic group codes from 24 to 15% and proportionate redistribution to zero. While some rates for both all-cause and IHD admissions appeared plausible, unexpectedly low or high rates were observed for several ethnic groups particularly amongst White groups and newly coded groups. CONCLUSIONS: Completeness of ethnicity recoding on hospital admission records has improved markedly since 2010. However the validity of admission rates based on these data is variable across ethnic groups and further improvements are required to support monitoring of inequality.

Differences in all-cause hospitalisation by ethnic group: a data linkage cohort study of 4.62 million people in Scotland, 2001-2013.

OBJECTIVES: Immigration into Europe has raised contrasting concerns about increased pressure on health services and equitable provision of health care to immigrants or ethnic minorities. Our objective was to find out if there were important differences in hospital use between the main ethnic groups in Scotland. STUDY DESIGN: A census-based data linkage cohort study. METHODS: We anonymously linked Scotland's Census 2001 records for 4.62 million people, including their ethnic group, to National Health Service general hospitalisation records for 2001-2013. We used Poisson regression to calculate hospitalisation rate ratios (RRs) in 14 ethnic groups, presented as percentages of the White Scottish reference group (RR = 100), for males and females separately. We adjusted for age and socio-economic status and compared those born in the United Kingdom or the Republic of Ireland (UK/RoI) with elsewhere. We calculated mean lengths of hospital stay. RESULTS: 9.79 million hospital admissions were analysed. Compared with the White Scottish, unadjusted RRs for both males and females in most groups were about 50-90, e.g. Chinese males 49 (95% confidence interval [CI] = 45-53) and Indian females 76 (95% CI 71-81). The exceptions were White Irish, males 120 (95% CI 117-124) and females 115 (95% CI 112-119) and Caribbean females, 103 (95% CI 85-126). Adjusting for age increased the RRs for most groups towards or above the reference. Socio-economic status had little effect. In many groups, those born outside the UK/RoI had lower admission rates. Unadjusted mean lengths of stay were substantially lower in most ethnic minorities. CONCLUSIONS: Use of hospital beds in Scotland by most ethnic minorities was lower than by the White Scottish majority, largely explained by their younger average age. Other countries should use similar methods to assess their own experience.

Physical, mental and social consequences in civilians who have experienced war-related sexual violence: a systematic review (1981-2014).

OBJECTIVES: To identify the health outcomes of sexual violence on civilians in conflict zones between 1981 and 2014. STUDY DESIGN: Systematic review. METHODS: For the purpose of this study, we defined sexual violence as sexual torture including, individual rape, gang rape, and sexual slavery. All types of conflicts were included (intrastate, interstate, and internationalized intrastate). Quantitative and mixed-method studies, reporting any physical, mental, and social consequences, were retrieved from Medline, Embase, Global Health, Global Health Library, WHOLIS, Popline, and Web of Sciences (n = 3075) and from checking reference lists and personal communications (n = 359). Data were analyzed using Microsoft Excel and MetaXL. Given inherent variation, the means derived from combining studies were misleading; thus, we focused on the range of values. RESULTS: The 20 studies were from six countries, five in Africa (18 studies), and especially in Democratic Republic of Congo (12 studies). The number of subjects varied from 63 to 20,517, with 17 studies including more than 100 subjects. Eight studies included males. Gang rape, rape, and abduction were the most commonly reported types of sexual violence. Sixteen studies provided data on physical outcomes of which the most common were pregnancy (range 3.4-46.3%), traumatic genital injuries/tears (range 2.1-28.7%), rectal and vaginal fistulae (range 9.0-40.7%), sexual problems/dysfunction (range 20.1-56.7%), and sexually transmitted diseases (range 4.6-83.6%). Mental health outcomes were reported in 14 studies, the most frequent being post-traumatic stress disorder (range 3.1-75.9%), anxiety (range 6.9-75%), and depression (range 8.8-76.5%). Eleven studies provided social outcomes, the most common being rejection by family and/or community (range of 3.5-28.5%) and spousal abandonment (range 6.1-64.7%). CONCLUSIONS: Wartime sexual violence is highly traumatic, causing multiple, long-term negative outcomes. The number and quality of studies published does not match the significance of the problem. The findings highlight the need for care of the survivors and their relatives and raise concerns about how they and their children will be affected in the long term.

Culturally adapting the prevention of diabetes and obesity in South Asians (PODOSA) trial.

Type 2 diabetes is extremely common in South Asians, e.g. in men from Pakistani and Indian populations it is about three times as likely as in the general population in England, despite similarities in body mass index. Lifestyle interventions reduce the incidence of diabetes. Trials in Europe and North America have not, however, reported on the impact on South Asian populations separately or provided the details of their cross-cultural adaptation processes. Prevention of diabetes and obesity in South Asians (PODOSA) is a randomized, controlled trial in Scotland of an adapted, lifestyle intervention aimed at reducing weight and increasing physical activity to reduce type 2 diabetes in Indians and Pakistanis. The trial was adapted from the Finnish Diabetes Prevention Study. We describe, reflect on and discuss the following key issues: The core adaptations to the trial design, particularly the delivery of the intervention in homes by dietitians rather than in clinics. The use of both a multilingual panel and professional translators to help translate and/or develop materials. The processes and challenges of phonetic translation. How intervention resources were adapted, modified, newly developed and translated into Urdu and Gurmukhi (written Punjabi). The insights gained in PODOSA (including time pressures on investigators, imperfections in the adaptation process, the power of verbal rather than written information, the utilization of English and the mother-tongue languages simultaneously by participants and the costs) might help the research community, given the challenge of health promotion in multi-ethnic, urban societies.

A four-stage model explaining the higher risk of Type 2 diabetes mellitus in South Asians compared with European populations.

With approximately 1.5 billion people at risk, the staggeringly high risk of Type 2 diabetes in South Asians comprises a global problem. The causes of this high risk are complex, with 23 major risk factors identified in a Lancet seminar. This paper proposes a four-stage explanatory model: (1) the birth of a small, adipose, lowlean mass South Asian baby--the phenotype tracking through life; (2) in childhood and early adulthood, the deposition of any excess energy intake preferentially in upper body and ectopic fat stores rather than in the lower body or superficial subcutaneous fat stores; (3) as a consequence of points 1 and 2, and exacerbated by an environment of low physical activity and excess calories, the accelerated appearance of high levels of plasma insulin, triglycerides and glucose, and the fatty-liver vicious cycle; (4) ß-cell failure as a result of fewer ß-cells at birth, exposure to apoptotic triggers such as fat in the pancreas, and high demand from insulin resistance, which causes diabetes. Other risk factors--especially energy-dense hyperglycaemic diet and low physical activity--play into this pathway. The recommended behavioural changes fit with this model, which brings clarity to guide future research, policy, practice and health promotion.

Meteorological conditions and incidence of Legionnaires' disease in Glasgow, Scotland: application of statistical modelling.

This study investigated the relationships between Legionnaires' disease (LD) incidence and weather in Glasgow, UK, by using advanced statistical methods. Using daily meteorological data and 78 LD cases with known exact date of onset, we fitted a series of Poisson log-linear regression models with explanatory variables for air temperature, relative humidity, wind speed and year, and sine-cosine terms for within-year seasonal variation. Our initial model showed an association between LD incidence and 2-day lagged humidity (positive, P = 0·0236) and wind speed (negative, P = 0·033). However, after adjusting for year-by-year and seasonal variation in cases there were no significant associations with weather. We also used normal linear models to assess the importance of short-term, unseasonable weather values. The most significant association was between LD incidence and air temperature residual lagged by 1 day prior to onset (P = 0·0014). The contextual role of unseasonably high air temperatures is worthy of further investigation. Our methods and results have further advanced understanding of the role which weather plays in risk of LD infection.

Major ethnic group differences in breast cancer screening uptake in Scotland are not extinguished by adjustment for indices of geographical residence, area deprivation, long-term illness and education.

BACKGROUND: Breast cancer screening data generally show lower uptake in minority ethnic groups. We investigated whether such variations occur in Scotland. METHODS: Using non-disclosive computerised linkage we combined Scottish breast screening and Census 2001 data. Non-attendance at first breast-screening invitation (2002-2008) was compared between 11 ethnic groups using age-adjusted risk ratios (RR) with 95% confidence intervals (CI), multiplied by 100, using Poisson regression. RESULTS: Compared with the White Scottish (RR=100), non-attendance was similar for Other White British (99.5, 95% CI 96.1-103.2) and Chinese (112.8, 95% CI 96.3-132.2) and higher for Pakistani (181.7, 95% CI 164.9-200.2), African (162.2, 95% CI 130.8-201.1), Other South Asian (151.7, 95% CI 118.9-193.7) and Indian (141.7, 95% CI 121.1-165.7) groups. Adjustment for rural vs urban residence, long-term illness, area deprivation and education, associated with risk of non-attendance, increased the RR for non-attendance except for Pakistani women where it was modestly attenuated (RR=164.9, 149.4-182.1). CONCLUSION: Our data show important inequality in breast cancer screening uptake, not attenuated by potential confounding factors. Ethnic inequalities in breast screening attendance are of concern especially given evidence that the traditionally lower breast cancer rates in South Asian groups are converging towards the risks in the White UK population. Notwithstanding the forthcoming review of breast cancer screening, these data call for urgent action.

A systematic review on the social context of smokeless tobacco use in the South Asian population: implications for public health.

OBJECTIVES: Smokeless tobacco (SLT) is an addiction resulting in serious health problems including cancers. The social context around SLT use among South Asians was reviewed to help inform interventions for its prevention and cessation. STUDY DESIGN: Systematic review. METHODS: Electronic databases were searched to identify studies examining the social context of SLT use. As heterogeneous qualitative, quantitative and mixed method studies were included, meta-analysis was not appropriate. RESULTS: Of 428 studies identified, 17 were reviewed. These studies were conducted in India, Nepal, Pakistan and the UK between 1994 and 2009. SLT use among South Asians was culturally widely acceptable due to its association with socializing, sharing and family tradition (100% in Anwar et al.'s study). Other reasons for use were addiction, easy accessibility, low cost and lack of prohibitive legislation. SLT users had limited awareness of its association with oral cancer (29.3% in Ahmed et al.'s study); however, there was a distinct lack of knowledge regarding other health effects, such as cardiovascular disease (0.85%). Users attempted to quit (32.7% in Prabhu et al.'s study) but success was low (8.2%). CONCLUSIONS: Cessation programmes for South Asians should address cultural acceptance, limited knowledge of health effects, inadequate legislation and controls, scarce social support and insufficient SLT cessation services.

Organising a World Congress of Epidemiology (WCE): reflections and lessons from the XIX WCE, Scotland.

The 3-yearly World Congress of Epidemiology is the premier, international, scientific conference organised under the auspices of the International Epidemiological Association (in open competition). This paper explores the justification for seeking to host the Congress and reflects on the structures and processes adopted in making the XIXth Congress in Scotland happen. Preparing the bid was invaluable for forming collaborations, generating scientific ideas, and garnering opinion. After the bid was accepted, we formed a local organising committee, named the Management Executive Committee to signal its decision making authority; and scientific, fundraising, marketing, international and social subcommittees. There was uncertainty about critical matters such as delegate numbers, costs and the total budget. Early decisions had to be made on, for example, the fee and fundraising target (£250,000), despite financial risks. Development of the scientific programme was a critical step that underpinned fundraising and marketing and permitted involvement of the international committee. Overall the 2011 WCE succeeded. The key ingredients to success were: a large collaboration of institutions and individuals; early pledges of financial support mostly from the UK; the valuable and relevant experience of the professional conference organisers; unstinting support and advice from IEA; and the effectiveness of the committee structure. The educational and professional development benefits of this WCE will reach a worldwide community and not just delegates, because of video, PowerPoint and textual accounts being open access on the Internet. This reach is unprecedented for IEA's World Congresses. We anticipate that the Congress will translate into better public health practice, better future Congresses, advances in epidemiology and improved population health.

Challenges in recruiting South Asians into prevention trials: health professional and community recruiters' perceptions on the PODOSA trial.

BACKGROUND: Recruitment of ethnic minority groups into trials is important. This was studied from the recruiters' perspective in the Prevention of Diabetes and Obesity in South Asians (PODOSA) trial. METHODS: Semi-quantitative questionnaire survey of all 22 health professionals and 27 community workers involved in Edinburgh and Glasgow. Numbers and proportions were tabulated, while free-text responses were grouped into themes. RESULTS: The response rate was 40/49 (82%). In the closed questions, family responsibilities, prior general practitioner screening and low interest were the main factors reported by recruiters as hindering referrals (each 28%), followed by fear of needle pricks and finding out their diabetes status (each 23%). The importance of the prevention of diabetes (60%), explaining the trial in a South Asian language (46%), verbal dialogue (43%) and the recruiter's personal relationship with the recruitee (40%) favoured referrals. Health professionals' perceived strength was their knowledge of diabetes (66%), and community workers' strength was explaining the trial in South Asian languages (65%). Strategies to improve recruitment included stronger partnership between researchers and community organizations. The open-ended response identified seven main themes: (1) shortage of recruiters' and recruitees' time; (2) poor understanding of the trial by recruitees; (3) lack of knowledge about the disease among recruitees; (4) lack of motivation and interest among recruitees; (5) delay in receiving appointments from the PODOSA team; (6) mistrust of research; and (7) narrow entry criteria. CONCLUSION: These insights into recruiters' perspectives should help trialists improve participation by ethnic minority populations.

Prevalence and time trends in diabetes and physical inactivity among adult West African populations: the epidemic has arrived.

OBJECTIVE: To determine the prevalence and distribution of, and trends in, physical inactivity and diabetes in adult West African populations. DESIGN: Systematic review and meta-analysis. METHODS: Literature searches were conducted using four electronic databases. Journal hand searches and examination of citations of relevant articles were also undertaken. To be included, studies had to be population based, use clearly defined criteria for measuring diabetes and physical inactivity, present data that allowed calculation of the prevalence of diabetes or physical inactivity, and sample adult participants. Studies retrieved were appraised critically. Meta-analysis was performed using the DerSimonian-Laird random effect model. RESULTS: Twenty-one reports were retrieved for diabetes and 15 reports were retrieved for physical in/activity. Most studies (10 for diabetes and six for physical activity) were conducted solely among urban populations. The prevalence of diabetes in West Africa was approximately 4.0% [95% confidence interval (CI) 2.0-9.0] in urban adults and 2.6% (95%CI 1.5-4.4) in rural adults, and was similar in men and women [prevalence ratio (PR) 1.36, 95%CI 0.96-1.92]. Cumulative time trend analyses suggested an increase in the prevalence of diabetes among adults in urban West Africa, from approximately 3.0% (95%CI 1.0-7.0) to 4.0% (95%CI 2.0-9.0) in the past 10 years. The prevalence of inactivity in West Africa was 13% (95%CI 9.0-18.0). An association was found between physical inactivity and being older (> or = 50 years) (PR 1.82, 95%CI 1.36-2.44), female gender (PR 1.62, 95%CI 1.41-1.87) and urban residence (PR 2.04, 95%CI 1.58-2.63). CONCLUSIONS: Diabetes and physical inactivity are important public health issues in urban West Africa, with similar prevalences to wealthy industrialized countries. There is an urgent need for policy makers, politicians and health promotion experts to put measures in place to encourage active lifestyles and control diabetes in urban West Africa.

Geographical variation of Legionnaires' disease: a critique and guide to future research.

This review considers the value of the observation that Legionnaires' disease varies geographically. Estimates of disease incidence, derived from case registers and from studies measuring the proportion of cases of pneumonia which are Legionnaires' disease, and of the prevalence of the population with antibody, show that there is geographical variation in disease frequency. Much, but not all, of this variation is artefact due to differences in definitions, diagnostic methods, surveillance systems and data presentation. Some of the variation is attributed to publication bias, e.g. in 10 small studies (< 100 patients) 13.2% of pneumonia patients had Legionnaires' disease but in five large studies (> or = 500 patients) the figure was 3.6%. Research to explain variations has been neglected but a few studies have provided important insights into disease transmission. Future studies should: be based on agreed disease definitions and data collection and analysis methods; analyse subgroups separately; and collect data to develop explanations for geographical variation.

Incidence and prevalence of primary biliary cirrhosis in the city of Newcastle upon Tyne, England.

OBJECTIVE: To describe the incidence and prevalence of primary biliary cirrhosis in an urban population between 1987 and 1994, using stringent inclusion criteria and a well-defined study area and population. DESIGN: Descriptive study based on a case register compiled by a retrospective and prospective case-finding exercise and examination of case notes. SETTING: The city of Newcastle upon Tyne. MAIN INCLUSION CRITERIA: (1) Definite cases: fulfilling all three of the following diagnostic criteria: positive antimitochondrial antibody (AMA) > or = 1:40; cholestatic liver function tests (LFT); diagnostic or compatible liver histology. (2) Probable cases: fulfilling two of these criteria. SUBJECTS: All cases of primary biliary cirrhosis identified by multiple case-finding methods, alive from 1 January 1987 to 31 December 1994, in the defined area. MAIN OUTCOME MEASUREMENTS: Incidence and point prevalence rates by age and sex. RESULTS: In all, 202 potential cases were identified, of whom 160 met at least two inclusion criteria. In definite cases annual incidence varied from 14 to 32 (mean 22) per million whole population (with no clear trend) and point prevalence rose from 180 per million in 1987 to 240 in 1994. Mean age at diagnosis in cases incident during the study period was 63.2 years (S.D. 11.1 years, range 39.8-85.7 years). CONCLUSIONS: Primary biliary cirrhosis is much more common in Newcastle than has previously been reported anywhere in the world, and prevalence appears to be rising.