Greater income inequality is associated with higher rates of intimate partner violence in Latin America.

OBJECTIVE: The aim of the study was to examine the association between income inequality and experiences of past-year intimate partner violence. STUDY DESIGN: Multiple country population-based surveys. METHODS: We examined associations between experiences of past year physical or sexual violence perpetrated by an intimate partner and income inequality using correlation tests. Income inequality was measured using both the Gini coefficient and ratios between the incomes of the richest 10% and the poorest 10%; data on gross domestic product (GDP) per capita were also retrieved. All income data were sourced from Human Development Reports closest to the year each violence survey was administered. RESULTS: A positive association between income inequality and intimate partner violence was statistically significant using either the 10:10 ratio of income inequality (r = 0.78, P = 0.003) or the Gini coefficient (r = 0.69, P = 0.011). Including GDP per capita as a covariate slightly strengthened these associations (r = 0.79, P = 0.004 and r = 0.73, P = 0.011, respectively). CONCLUSIONS: To our knowledge, this is the first quantitative study of societal income inequality and intimate partner violence. Despite the small sample of countries, there is a significant association between higher inequality and higher levels of violence.

Association of food security status with overweight and dietary intake: exploration of White British and Pakistani-origin families in the Born in Bradford cohort.

BACKGROUND: Food insecurity has been associated with dietary intake and weight status in UK adults and children although results have been mixed and ethnicity has not been explored. We aimed to compare prevalence and trajectories of weight and dietary intakes among food secure and insecure White British and Pakistani-origin families. METHODS: At 12 months postpartum, mothers in the Born in Bradford cohort completed a questionnaire on food security status and a food frequency questionnaire (FFQ) assessing their child's intake in the previous month; at 18 months postpartum, mothers completed a short-form FFQ assessing dietary intake in the previous 12 months. Weights and heights of mothers and infants were assessed at 12-, 24-, and 36-months postpartum, with an additional measurement of children taken at 4-5 years. Associations between food security status and dietary intakes were assessed using Wilcoxon-Mann-Whitney for continuous variables and χ2 or Fisher's exact tests for categorical variables. Quantile and logistic regression were used to determine dietary intakes adjusting for mother's age. Linear mixed effects models were used to assess longitudinal changes in body mass index (BMI) in mothers and BMI z-scores in children. RESULTS: At 12 months postpartum, White British mothers reported more food insecurity than Pakistani-origin mothers (11% vs 7%; p < 0.01) and more food insecure mothers were overweight. Between 12 and 36 months postpartum, BMI increased more among food insecure Pakistani-origin mothers (ß = 0.77 units, [95% Confidence Interval [CI]: 0.40, 1.10]) than food secure (ß = 0.44 units, 95% CI: 0.33, 0.55). This was also found in Pakistani-origin children (BMI z-score: food insecure ß = 0.40 units, 95% CI: 0.22, 0.59; food secure ß = 0.25 units, 95% CI: 0.20, 0.29). No significant increases in BMI were observed for food secure or insecure White British mothers while BMI z-score increased by 0.17 (95% CI: 0.13, 0.21) for food secure White British children. Food insecure mothers and children had dietary intakes of poorer quality, with fewer vegetables and higher consumption of sugar-sweetened drinks. CONCLUSIONS: Food security status is associated with body weight and dietary intakes differentially by ethnicity. These are important considerations for developing targeted interventions.

Ethnic differences in the clustering and outcomes of health behaviours during pregnancy: results from the Born in Bradford cohort.

Background: Pregnancy is a time of optimal motivation for many women to make positive behavioural changes. We aim to describe pregnant women with similar patterns of self-reported health behaviours and examine associations with birth outcomes. Methods: We examined the clustering of multiple health behaviours during pregnancy in the Born in Bradford cohort, including smoking physical inactivity, vitamin d supplementation and exposure to second-hand smoke. Latent class analysis was used to identify groups of individuals with similar patterns of health behaviours separately for White British (WB) and Pakistani mothers. Multinomial regression was then used to examine the association between group membership and birth outcomes, which included preterm birth and mean birthweight. Results: For WB mothers, offspring of those in the 'Unhealthiest' group had lower mean birthweight than those in the 'Mostly healthy but inactive' class, although no association was observed for preterm birth. For Pakistani mothers, group membership was not associated with birthweight differences, although the odds of preterm birth was higher in 'Inactive smokers' compared to the 'Mostly healthy but inactive' group. Conclusions: The use of latent class methods provides important information about the clustering of health behaviours which can be used to target population segments requiring behaviour change interventions considering multiple risk factors. Given the dominant negative association of smoking with the birth outcomes investigated, latent class groupings of other health behaviours may not confer additional risk information for these outcomes.

The effects of socioeconomic incongruity in the neighbourhood on social support, self-esteem and mental health in England.

Analyses of neighbourhood socioeconomic characteristics and health indicators consistently show that health is worse in poorer neighbourhoods. However, some studies that examined neighbourhood effects separately for individuals of different socioeconomic position found that poor people may derive health benefits from living in poor neighbourhoods where they are socioeconomically congruous. This study investigates whether such patterns may be driven by psychosocial factors. The sample consisted of 4871 mothers in the Millennium Cohort Study aged 14-53. The outcomes analysed were neighbourhood friendship, emotional support, self-esteem and depression or anxiety. Neighbourhood status was classified by residents' educational and occupational status derived from the 2001 Census. We used multilevel logistic regression, adjusting for mothers' socio-demographic characteristics: first analysing health by neighbourhood status separately for the highest and lowest status mothers, then testing for modification in the association between neighbourhood status and health, by individual status. Results show that for highest status mothers, living in mixed or high status neighbourhoods compared to low status neighbourhoods significantly reduced the odds of having no friends in the neighbourhood by 65%. Living in high status neighbourhoods compared to low status neighbourhoods also significantly reduced the odds of depression or anxiety for highest status mothers by 41%. No associations were found for emotional support or self-esteem amongst highest status mothers. No associations were found for any outcome among lowest status mothers. In conclusion, low status mothers in England did not have better social support, self-esteem, or mental health when living in low status neighbourhoods compared to high status neighbourhoods; any benefits of socioeconomic congruity may have been counteracted by neighbourhood deprivation. Nevertheless, we found that mothers of high status do have significantly better neighbourhood friendship and mental health when living in socioeconomic congruity within neighbourhoods. Whether these associations are causal or are another reflection of material advantage remains unclear.

Which women are at an increased risk of a caesarean section or an instrumental vaginal birth in the UK: an exploration within the Millennium Cohort Study.

OBJECTIVE: To explore the maternal demographic factors associated with operative births (instrumental vaginal births or caesarean section), after adjustment for health, interpersonal, pregnancy, labour and infant covariates. DESIGN: Nationally representative cohort study. SETTING: Women giving birth in the UK, during the period 2000-2002. SAMPLE: A total of 18,239 mother-infant pairs. METHODS: Multinomial logistic regression models were estimated to explore the relationship between demographic characteristics and mode of birth, stratified by parity. MAIN OUTCOME MEASURES: Self-reported mode of birth, defined as unassisted vaginal birth, instrumental vaginal birth, emergency caesarean section and planned caesarean section. RESULTS: For primiparous women, operative births rose steeply with increasing maternal age. Women from lower occupational status households were at an increased risk of planned caesarean section. Mode of birth differed significantly by ethnicity. For multiparous women, a younger age at first birth was protective of a later caesarean section or instrumental vaginal birth at the cohort birth. Women with qualifications normally taken at the age 18 years were at an increased risk of planned caesarean section compared with women with degree-level qualifications. Mode of birth differed significantly by ethnicity, and non-UK born women were at an increased risk of emergency caesarean section. CONCLUSIONS: The sociodemographic characteristics of UK women independently predict mode of birth. Further research is needed to establish to what extent sociodemographic differences in mode of birth are a reflection of the attitudes and behaviours of women, or health professionals, and are therefore amenable to change.

Smoking in pregnancy and disruptive behaviour in 3-year-old boys and girls: an analysis of the UK Millennium Cohort Study.

BACKGROUND: Maternal smoking during pregnancy has been consistently associated with disruptive behaviour in male offspring; however, results for girls are inconsistent and little is known about emergent patterns in young children. Additionally, it is unclear whether maternal smoking is independently associated in offspring with hyperactivity-inattention or only when it co-occurs with conduct problems. Further, few studies have controlled for a broad range of maternal psychosocial problems. METHODS: Associations between self-reported smoking in pregnancy and maternal reports of externalising behaviour were analysed in more than 13 000 3-year-old boys and girls in the UK Millennium Cohort Study. Conduct and hyperactivity-inattention problems were assessed using the Strength and Difficulties Questionnaire. RESULTS: Boys whose mothers persistently smoked throughout pregnancy were at significant risk of conduct and hyperactivity-inattention problems compared with sons of non-smokers: the effect was stronger for heavy smokers. After excluding children with co-occurring problems, conduct-only problems remained a significant risk for sons of heavy smokers, OR 1.92 (95% CI 1.29 to 2.86); and hyperactivity-inattention only for sons of light or heavy smokers, OR 1.79 (95% CI 1.27 to 2.51) and 1.64 (1.10 to 2.46). Daughters of light or heavy smokers were at significant risk of conduct-only problems, OR 1.73 (95% CI 1.14 to 2.61) and 1.73 (1.06 to 2.83). Relative to non-smokers, daughters of pregnancy quitters had significantly reduced odds of having conduct 0.61(0.39 to 0.97) or co-occurring problems 0.26(0.08 to 0.82), although only 79 and 20 girls met these criteria, respectively. All findings were robust to controlling for key social and psychosocial factors. CONCLUSIONS: Associations between maternal smoking during pregnancy and disruptive behaviour in 3-year-old children vary by sex, smoking status and whether or not conduct or hyperactivity problems occur together or separately.

Interaction of prenatal exposure to cigarettes and MAOA genotype in pathways to youth antisocial behavior.

Genetic susceptibility to antisocial behavior may increase fetal sensitivity to prenatal exposure to cigarette smoke. Testing putative gene x exposure mechanisms requires precise measurement of exposure and outcomes. We tested whether a functional polymorphism in the gene encoding the enzyme monoamine oxidase A (MAOA) interacts with exposure to predict pathways to adolescent antisocial behavior. We assessed both clinical and information-processing outcomes. One hundred seventy-six adolescents and their mothers participated in a follow-up of a pregnancy cohort with well-characterized exposure. A sex-specific pattern of gene x exposure interaction was detected. Exposed boys with the low-activity MAOA 5' uVNTR (untranslated region variable number of tandem repeats) genotype were at increased risk for conduct disorder (CD) symptoms. In contrast, exposed girls with the high-activity MAOA uVNTR genotype were at increased risk for both CD symptoms and hostile attribution bias on a face-processing task. There was no evidence of a gene-environment correlation (rGE). Findings suggest that the MAOA uVNTR genotype, prenatal exposure to cigarettes and sex interact to predict antisocial behavior and related information-processing patterns. Future research to replicate and extend these findings should focus on elucidating how gene x exposure interactions may shape behavior through associated changes in brain function.

The psychosocial context of pregnancy smoking and quitting in the Millennium Cohort Study.

BACKGROUND: Although pregnancy is a time when women have increased motivation to quit smoking, approximately half of female smokers persist in smoking throughout their pregnancies. Persistent pregnancy smokers are known to be more nicotine dependent and to have greater sociodemographic disadvantage. Less is known about the psychosocial context of persistent pregnancy smokers and factors that distinguish them from pregnancy quitters. METHODS: A cross-sectional study was conducted within the UK Millennium Cohort Study. Participants were 18 225 women, including 13.3% quitters, 12% light smokers and 8% heavy smokers. Data were collected when the infants were 9 months old. Maternal psychosocial problems were assessed in three domains: interpersonal, adaptive functioning and health-related behaviours. RESULTS: In general, psychosocial problems in all domains increased across the pregnancy smoking continuum (non-smoker, quitter, light smoker, heavy smoker). All three psychosocial domains added incremental utility to prediction of pregnancy smoking status, after adjustment for sociodemographic risk. CONCLUSION: Problems in multiple psychosocial domains systematically distinguish women along a pregnancy smoking gradient, with heavy smokers having the most problematic psychosocial context. This subgroup of pregnant smokers is unlikely to be able to benefit from usual-care antenatal cessation interventions, which rely on women's capacity for self-initiation, self-control and social resources. Consideration should be given to tiered interventions that provide more intensive and targeted interventions to pregnant women unable to quit with usual care.

Meaningful differences in maternal smoking behaviour during pregnancy: implications for infant behavioural vulnerability.

BACKGROUND: Smoking during pregnancy has been consistently associated with risk of problem behaviour in offspring. There is debate about whether this association reflects a teratological effect or is a marker for problematic maternal characteristics. We test these "competing" hypotheses by examining whether (1) exposure is associated with an early risk pathway by testing its association with infant temperamental difficultness, and (2) whether pregnancy quitting is associated with an early protective pathway, testing its association with easy infant temperament. METHODS: We used the 9-month-old sweep of the Millennium Cohort Study, a cohort of over 18,000 infants born in 2000-2. Mothers were classified as pregnancy non-smokers, quitters and light or heavy smokers. Temperamental positive mood, receptivity to novelty and regularity were assessed with the Carey Infant Temperament Scale. RESULTS: Pregnancy quitters had infants with the highest scores of easy temperament and heavy smokers had infants with the lowest scores (F = 28.51, p<0.001). Pregnancy smoking also predicted difficult temperament: heavy smoking was associated with increased risk of low positive mood (OR = 1.17, p = 0.09). In contrast, pregnancy quitting exerted a protective effect with decreased risk of distress to novelty (OR = 0.79, p<0.01) and irregularity (OR = 0.89, p = 0.02) in these infants. CONCLUSIONS: Pathways from pregnancy smoking to offspring behaviour are complex and multi-determined. These findings suggest that both exposure and maternal characteristics associated with pregnancy smoking status contribute to offspring behavioural patterns. Research that characterises differences between quitters and persistent smokers and examines the role of these differences in prediction of early vulnerabilities and problems in adaptation over time will be important for elucidating these pathways.

Relationship of erythrocyte membrane polyunsaturated fatty acids and prostate-specific antigen levels in Jamaican men.

OBJECTIVE: To investigate the relationship between erythrocyte membrane polyunsaturated fatty acid (PUFA) and serum prostate- specific antigen (PSA) levels in Jamaican men, as there may be an association between prostate cancer incidence and dietary fatty acids, and prostate cancer incidence in Jamaica is among the highest in the world. PATIENTS AND METHODS: Blood from 107 Jamaican men was analysed for 32 individual fatty acids and PSA levels. Special attention was given to correlations between Omega3 and Omega6 PUFAs and PSA. Data were analysed using standard linear regression methods. RESULTS: The mean PSA was 18.6 ng/mL (normal 0-4.0); for age groups of 51-60, 61-70 and 71-80 years the levels were 14, 26 and 23 ng/mL, respectively. Eicosapentaenoic acid (Omega3) levels decreased as PSA exceeded 10 ng/mL (P = 0.02). Arachidonic acid (Omega6) levels decreased as PSA was < 2 ng/mL (P = 0.02). Linoleic acid (Omega6) levels decreased in men with PSA levels of 2-10 ng/mL (P = 0.04). In men with a PSA of > 10 ng/mL there was a positive correlation between the ratio of Omega6 to Omega3 PUFAs and PSA (P = 0.036); there was also a negative correlation between the ratio of Omega3 to Omega6 PUFAs and PSA (P = 0.08). When the ratio of Omega3 PUFAs over the products of Omega6 PUFAs were used, this trend was significant (P= 0.03). CONCLUSIONS: Increased levels of Omega6 PUFAs and the ratio of Omega6/Omega3 PUFAs in Jamaican men are associated with an increased mean PSA level and risk of prostate cancer. Additional studies are needed to establish a causal link between dietary fatty acid intake and the development of prostate cancer in Jamaican men.

Preterm birth among African American and white women: a multilevel analysis of socioeconomic characteristics and cigarette smoking.

STUDY OBJECTIVE: Research shows that neighbourhood socioeconomic factors are associated with preterm delivery. This study examined whether cigarette smoking and individual socioeconomic factors modify the effects of neighbourhood factors on preterm delivery. DESIGN: Case-control study. SETTING: Moffit Hospital in San Francisco, California. PARTICIPANTS: 417 African American and 1244 white women, including all preterm and a random selection of term deliveries 1980-1990, excluding non-singleton pregnancies, congenital anomolies, induced deliveries, and women transported for special care. US census data from 1980 and 1990 were used to characterise the women's neighbourhoods, defined as census tracts. RESULTS: Cigarette smoking increased the risk of preterm delivery among both African American (OR=1.77, 95% confidence intervals (CI) (1.12 to 2.79)) and white women (OR=1.25, 95% CI (1.01 to 1.55)). However, cigarette smoking did not attenuate or modify the association of neighbourhood factors with preterm delivery. Among African American women, having public insurance modified the relation between neighbourhood unemployment and preterm delivery; among women without public insurance, the risk of preterm delivery was low in areas with low unemployment and high in areas with high unemployment, while among women with public insurance the risk of preterm delivery was highest at low levels of neighbourhood unemployment. CONCLUSIONS: Cigarette smoking was associated with preterm delivery, especially among African Americans. Adverse neighbourhood conditions had an influence on preterm delivery beyond that of cigarette smoking. The effects of some neighbourhood characteristics were different depending on individual socioeconomic status. Examining socioeconomic and behavioural/biological risk factors together may increase understanding of the complex causes of preterm delivery.

The management of ASCUS cervical cytologic abnormalities and HPV testing: a cautionary note.

A recently published study of the management of low-grade cytologic smears compared immediate colposcopy to human papillomavirus (HPV) triage and entry cytology smears (conservative management) as three triage techniques for managing atypical squamous cells of undetermined significance (ASCUS) smears (Atypical Squamous Cells of Undetermined Significance/Low-grade Squamous Intraepithelial Lesion Triage Study [ALTS]). The study reported a high sensitivity (96.3%) for HPV testing using hybrid capture 2 to detect cervical intraepithelial neoplasia (CIN) III. The authors concluded that HPV testing is a viable option for managing ASCUS smears. We have reviewed the published data from the ALTS trial and have found a large excess of colposcopies and biopsies in the HPV arm in comparison with the conservative management (cytology) arm. In addition, the ALTS trial quality control and pathology review results raise doubts about the diagnostic validity of the study to establish standards of clinical practice. Furthermore, until the 2-year follow-up analysis of the conservative management arm is completed to detect CIN III, a valid comparison between HPV triage and conservative management is not possible. We conclude that, based on published data, HPV testing for routine clinical management of low-grade cytologic abnormalities (ASCUS smears) is not warranted, and that HPV testing is currently an investigational tool.

Multilevel analyses of neighbourhood socioeconomic context and health outcomes: a critical review.

PURPOSE: Interest in the effects of neighbourhood or local area social characteristics on health has increased in recent years, but to date the existing evidence has not been systematically reviewed. Multilevel or contextual analyses of social factors and health represent a possible reconciliation between two divergent epidemiological paradigms-individual risk factor epidemiology and an ecological approach. DATA SOURCES: Keyword searching of Index Medicus (Medline) and additional references from retrieved articles. STUDY SELECTION: All original studies of the effect of local area social characteristics on individual health outcomes, adjusted for individual socioeconomic status, published in English before 1 June 1998 and focused on populations in developed countries. DATA SYNTHESIS: The methodological challenges posed by the design and interpretation of multilevel studies of local area effects are discussed and results summarised with reference to type of health outcome. All but two of the 25 reviewed studies reported a statistically significant association between at least one measure of social environment and a health outcome (contextual effect), after adjusting for individual level socioeconomic status (compositional effect). Contextual effects were generally modest and much smaller than compositional effects. CONCLUSIONS: The evidence for modest neighbourhood effects on health is fairly consistent despite heterogeneity of study designs, substitution of local area measures for neighbourhood measures and probable measurement error. By drawing public health attention to the health risks associated with the social structure and ecology of neighbourhoods, innovative approaches to community level interventions may ensue.

Defining preterm delivery--the epidemiology of clinical presentation.

It is possible that preterm delivery is not a single entity but a cluster of conditions with different aetiologies that ultimately result in the delivery of an infant before 37 completed weeks of gestation. Whereas some researchers have reported aetiological heterogeneity, others have found no differences between subtypes or have disputed the desirability and utility of classifying preterm birth into subtypes. This study explores the relationship of maternal risk factors to type of preterm delivery in a cohort of over 7000 black and white women delivering singleton infants at the University of California, San Francisco's Moffitt Hospital between 1980 and 1990. Although the magnitude of the effect of individual risk factors differed between preterm delivery subtypes, the set of risk factors significantly associated with both categories of spontaneous preterm delivery was identical, while that associated with medically indicated preterm births was different. This study indicates that whereas the distinction between spontaneous preterm deliveries and those that are medically indicated seems valid, distinguishing between types of spontaneous preterm births may not lead to useful aetiological inferences.

Pregnancy weight gain: still controversial.

During the 20th century, recommendations for maternal weight gain in pregnancy were controversial, ranging from rigid restriction to encouragement of ample gain. In 1990, the Institute of Medicine (IOM) recommended weight-gain ranges with the primary goal of improving infant birth weight. These guidelines were widely adopted but not universally accepted. Critics have argued that the IOM's recommendations are unlikely to improve perinatal outcomes and may actually increase the risk of negative consequences to both infants and mothers. We systematically reviewed studies that examined fetal and maternal outcomes according to the IOM's weight-gain recommendations in women with a normal prepregnancy weight. These studies showed that pregnancy weight gain within the IOM's recommended ranges is associated with the best outcome for both mothers and infants. However, weight gain in most pregnant women is not within the IOM's ranges. All of the studies reviewed were observational and there is a compelling need to conduct experimental studies to examine interventional strategies to improve maternal weight gain with the objective of optimizing health outcomes.

Early nutritional supplementation and skeletal maturation in Guatemalan adolescents.

The effect of early childhood nutritional supplementation on skeletal maturation at adolescence was investigated in 663 rural Guatemalans, aged 11-18 y. Skeletal maturation was assessed by the Tanner-Whitehouse-2 method. The subjects were former participants in the Institute of Nutrition of Central America and Panama longitudinal study of growth and development (1969-77) residing in four villages (two large and two small) in eastern Guatemala. The villages were randomized within pairs to receive either a high energy, high protein supplement (Atole) or a low energy supplement with no protein (Fresco). Skeletal maturity was observed across all villages to be delayed significantly relative to a British reference for boys < 14 y of age, but not for older boys or for girls < 14 y of age. Delays in girls > 14 years could not be determined reliably because many had reached maturity. Girls < 14 years from Atole villages were more advanced in skeletal maturity than similar age girls from Fresco villages but these differences were found only in comparisons of the large villages. The relationship between early nutrition and biological maturation at adolescence may be obscured in this sample by the advanced age at which the subjects were examined in adolescence.