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1.  Angiosarcoma of the liver in Great Britain in proximity to vinyl chloride sites. 
OBJECTIVES: To study the incidence of angiosarcoma of the liver in England and Wales 1979-86 and Scotland 1975-87. To investigate whether any non-occupational neighbourhood cases occurred near a vinyl chloride site. METHODS: This is a geographical study of incident cases among the general population of Great Britain. Diagnosis of angiosarcoma of the liver was based mainly on the national cancer registry, the world register of cases among vinyl chloride workers, and the register of cases (including histological review) maintained by the Health and Safety Executive. Proximity (< 10 km) of residence to a vinyl chloride site was based on postcode of address at the time of diagnosis. RESULTS: 55 cases were ascribed to angiosarcoma of the liver in England and Wales with a further six cases in Scotland (annual incidence in Great Britain from all sources of around 1.4 cases per 10 million population). There were two cases with documented exposure to Thorotrast, and 10 cases among vinyl chloride workers. There were no vinyl chloride sites in Scotland. Among the 25 cases in England and Wales with histological diagnosis after review by a panel of pathologists, only 15 were confirmed as angiosarcoma, and one of the two Scottish cases after histological review was also confirmed. Overall, 11 cases ascribed to angiosarcoma were resident within 10 km of a vinyl chloride site; nine were vinyl chloride workers, one further case on histological review was not considered to have been correctly diagnosed as angiosarcoma, and the remaining case, confirmed as angiosarcoma, was employed at a vinyl chloride factory during the late 1950s, although not as a vinyl chloride worker. CONCLUSION: The incidence of angiosarcoma of the liver in Great Britain remains extremely rare. The one confirmed case in a non-vinyl chloride worker within 10 km of a site must nevertheless be presumed to have been exposed to vinyl chloride in the workplace. In the period of study, there were no confirmed non-occupationally exposed cases of angiosarcoma among residents living near a vinyl chloride site in Great Britain.
PMCID: PMC1128629  PMID: 9072028
2.  Is there a north-south divide in social class inequalities in health in Great Britain? Cross sectional study using data from the 2001 census 
BMJ : British Medical Journal  2004;328(7447):1043-1045.
Objective To examine individual social class inequalities in self rated general health within and between the constituent countries of Great Britain and the regions of England.
Design Cross sectional study using data from the 2001 national census.
Setting Great Britain.
Participants Adults aged between 25 and 64 in Great Britain and enumerated in the 2001 population census (n = 25.6 million).
Main outcome measures European age standardised rates of self rated general health, for men and women classified by the government social class scheme.
Results In each of the seven social classes, Wales and the North East and North West regions of England had high rates of poor health. There were large social class inequalities in self rated health, with rates of poor health generally increasing from class 1 (higher professional occupations) to class 7 (routine occupations). The size of the health divide varied between regions: the largest rate ratios for routine versus higher professional classes were for Scotland (2.9 for men; 2.8 for women) and London (2.9 for men; 2.4 for women). Women had higher rates of poor health compared to men in the same social class, except in class 6 (semi-routine occupations).
Conclusions A northwest-southeast divide in social class inequalities existed in Great Britain at the start of the 21st century, with each of the seven social classes having higher rates of poor health in Wales, the North East and North West regions of England than elsewhere. The widest health gap between social classes, however, was in Scotland and London, adding another dimension to the policy debate on resource allocation and targets to tackle the health divide.
PMCID: PMC403842  PMID: 15117791
3.  Prevalence and pattern of occupational exposure to hand transmitted vibration in Great Britain: findings from a national survey 
OBJECTIVES—To estimate the number of workers in Great Britain with significant occupational exposure to hand transmitted vibration (HTV). Also, to identify the occupations and industries where such exposures arise, and the main sources of exposure.
METHODS—A questionnaire was posted to 22 194 men and women aged 16-64, comprising 21 201 subjects selected at random from the age-sex registers of 34 general practices in England, Scotland, and Wales, and a further 993 subjects selected at random from the central pay registers of the three armed services. Among other things, the questionnaire asked about exposure to sources of HTV in current and earlier employment. Responses were assessed by occupation and industry, and prevalence estimates for the country as a whole were derived from census information on occupational and industrial populations nationally. Estimates were also made in exposed workers of the average daily dose of vibration (A(8) root mean squared (rms) for the past week, based on their reported sources and durations of exposure.
RESULTS—Usable questionnaires were returned by 12 907 subjects (overall response rate 58%). From these it was estimated that some 4.2 million men and 667 000 women in Great Britain are exposed to HTV at work in a 1 week period, and that personal daily exposures to vibration exceed a suggested action level equivalent to 2.8 ms-2 for 8 hours (A(8) >2.8 ms-2 rms) in at least 1.2 million men and 44 000 women. High estimated doses (A(8) >5 ms-2 rms) arose most often in bricklayers and masons, gardeners and groundsmen, carpenters and joiners, electricians and electrical maintenance fitters, and builders and building contractors. The industries where high A(8) values most often arose were construction, motor vehicle repair and maintenance, manufacture of basic metals, and agriculture. The most common sources of exposure were hammer drills, hand held portable grinders, and jigsaws.
CONCLUSIONS—Exposure to HTV is surprisingly prevalent, and preventive measures and health surveillance may be warranted for many men in Britain. Control strategies should focus on prevention at source, with priority accorded to the common sources of exposure and the occupations in which significant exposures tend to arise. Many vibratory tools that are common in Britain have been overlooked in previous surveys, highlighting an important focus for future research.

Keywords: hand transmitted vibration; population; prevalence; exposure
PMCID: PMC1739937  PMID: 10810107
4.  Prevalence of Raynaud's phenomenon in Great Britain and its relation to hand transmitted vibration: a national postal survey 
OBJECTIVES—To assess the prevalence of Raynaud's phenomenon in the general population of Great Britain and to estimate the proportion and number of cases attributable to hand transmitted vibration (HTV).
METHODS—A questionnaire was posted to a random sample of 22 194 adults of working age. Information was collected on the lifetime prevalence of finger blanching, smoking habits, and occupational and leisure time exposures to HTV. Associations with risk factors were explored by logistic regression, with odds ratios converted into prevalence ratios (PRs).
RESULTS—Among the 12 907 respondents, 1835 (14.2%) reported finger blanching at some time, including 1529 (11.8%) in whom symptoms were induced by cold, and 597 (4.6%) in whom the blanched area was also clearly demarcated. Prevalences were higher in women than men. Around one fifth of cases (2% of respondents) had consulted a doctor about their symptoms. By comparison with men who had never been exposed to HTV, the PR for cold induced blanching in those exposed only at work was 2.0 (95% CI 1.7 to 2.3), and in men exposed both at work and in leisure it was 2.5 (95% CI 2.1 to 3.1). Higher risks were found in men who consulted a doctor about cold induced blanching, among whom 37.6% of cases were estimated to arise from exposure to HTV. The estimated number of cases attributable to HTV nationally was 222 000 in men who reported extensive blanching (blanching affecting at least eight of the digits or 15 phalanges). Similar patterns of risk were found in women, but the attributable proportion was much lower (5.3% in cases consulting a doctor).
CONCLUSIONS—Raynaud's phenomenon is common in the general population. Many cases are attributable to HTV, especially in men, emphasising the public health importance of this common occupational hazard.

Keywords: Reynaud's phenomenon; vibration induced white finger; population; attributable number; vibration
PMCID: PMC1739982  PMID: 10854496
5.  Educational attainment, deprivation-affluence and self reported health in Britain: a cross sectional study 
STUDY OBJECTIVE: The level of material deprivation or affluence is strongly and independently correlated with all cause mortality at an area level, but educational attainment, after controlling for deprivation-affluence, remains strongly associated with coronary and infant mortality. This study investigated whether these relations hold at an individual level with self reported morbidity. DESIGN: Analysis of the cross sectional associations of self reported longstanding illness and "not good" or "fairly good" self assessed health with individual educational attainment in seven levels, adjusting for deprivation measures (economic status of head of household, car ownership, housing tenure, overcrowding). SETTING: The 1993 General Household Survey, a random sample of households in Great Britain. PARTICIPANTS: 11,634 subjects aged 22 to 69. MAIN RESULTS: After adjusting for household deprivation, lower educational attainment was significantly associated with longstanding illness in men (odds ratio 1.05 per education category, 95% CI 1.02 to 1.08), but not in women (odds ratio 1.01, 95% CI 0.98 to 1.04). The associations with "not good" or "fairly good" self assessed health were stronger and significant in both men and women (men 1.13, 95% CI 1.10 to 1.17; women 1.10, 95% CI 1.07 to 1.14). The findings were little changed by allowing for people in poor health becoming economically inactive. CONCLUSIONS: The associations of self reported health with deprivation- affluence are stronger than with educational attainment. However, educational attainment is associated with self assessed health in adulthood, independently of deprivation-affluence. Longstanding illness may be associated with educational attainment in men only. Educational attainment may be a marker for childhood socioeconomic circumstances, its association with health may result from occupational characteristics, or education may influence the propensity to follow health education advice.
PMCID: PMC1756962  PMID: 10562877
6.  Socioeconomic position and hysterectomy: a cross-cohort comparison of women in Australia and Great Britain 
To examine the associations between indicators of socioeconomic position (SEP) and hysterectomy in two Australian and two British cohorts.
Study population:
Women participating in the Australian Longitudinal Study on Women’s Health (ALSWH), born 1921–1926 and 1946–1951, and two cohorts of British women, the British Women’s Heart and Health Study and the MRC National Survey of Health and Development, born at similar times (1920 to 1939 and 1946, respectively) and surveyed at similar ages to the ALSWH cohorts.
Relative indices of inequality were derived for own and head of household occupational class, educational level attained and age at leaving school. Logistic regression was used to test the associations between these indicators of SEP and self-reported hysterectomy and/or oophorectomy.
Inverse associations between indicators of SEP and hysterectomy were found in both the Australian and British cohorts of women born in 1946 or later. There was also evidence of an inverse association between education and hysterectomy in the older Australian cohort. However, the associations in this older cohort were weaker than those found in the mid-aged Australian cohort. In the older British cohort, born in the 1920s and 1930s, little evidence of association between SEP in adulthood and hysterectomy was found.
These results suggest that inverse associations between indicators of SEP and hysterectomy are stronger in younger than in older cohorts in both Australia and Great Britain. They provide further evidence of the dynamic nature of the association between indicators of SEP and hysterectomy.
PMCID: PMC2582341  PMID: 18413433
7.  Prevalence and pattern of occupational exposure to whole body vibration in Great Britain: findings from a national survey 
OBJECTIVES—To estimate the number of workers in Great Britain with significant occupational exposure to whole body vibration (WBV) and to identify the common sources of exposure and the occupations and industries where such exposures arise.
METHODS—A postal questionnaire was posted to a random community sample of 22 194 men and women of working age. Among other things, the questionnaire asked about exposure to WBV in the past week, including occupational and common non-occupational sources. Responses were assessed by occupation and industry, and national prevalence estimates were derived from census information. Estimates were also made of the average estimated daily personal dose of vibration (eVDV).
RESULTS—From the 12 907 responses it was estimated that 7.2 million men and 1.8 million women in Great Britain are exposed to WBV at work in a 1 week period if the occupational use of cars, vans, buses, trains, and motor cycles is included within the definition of exposure. The eVDV of >374 000 men and 9000 women was estimated to exceed a proposed British Standard action level of 15 ms-1.75. Occupations in which the estimated exposures most often exceeded 15 ms-1.75 included forklift truck and mechanical truck drivers, farm owners and managers, farm workers, and drivers of road goods vehicles. These occupations also contributed the largest estimated numbers of workers in Great Britain with such levels of exposure. The highest estimated median occupational eVDVs were found in forklift truck drivers, drivers of road goods vehicles, bus and coach drivers, and technical and wholesale sales representatives, among whom a greater contribution to total dose was received from occupational exposures than from non-occupational ones; but in many other occupations the reverse applied. The most common sources of occupational exposure to WBV are cars, vans, forklift trucks, lorries, tractors, buses, and loaders.
CONCLUSIONS—Exposure to whole body vibration is common, but only a small proportion of exposures exceed the action level proposed in British standards, and in many occupations, non-occupational sources are more important than those at work. The commonest occupational sources of WBV and occupations with particularly high exposures have been identified, providing a basis for targeting future control activities.

Keywords: whole body vibration; population; prevalence; exposure
PMCID: PMC1739944  PMID: 10810108
8.  Paternal occupation and neuroblastoma: a case–control study based on cancer registry data for Great Britain 1962–1999 
British Journal of Cancer  2010;102(3):615-619.
Neuroblastoma is the most common malignancy of infancy but little is known about the aetiological factors associated with the development of this tumour. A number of epidemiological studies have previously examined the risk associated with paternal occupational exposures but most have involved small numbers of cases. Here we present results from a large, population-based, case–control study of subjects diagnosed over a period of more than 30 years and recorded in the national registry of childhood tumours in Great Britain.
A case–control study of paternal occupational data for 2920 cases of neuroblastoma, born and diagnosed in Great Britain between 1962 and 1999 and recorded in the National Registry of Childhood Tumours, and 2920 controls from the general population matched on sex, date of birth and birth registration district. Paternal occupations at birth, of the case or control child, were grouped by inferred exposure using an occupational exposure classification scheme. Conditional logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (95% CI), for each of the 32 paternal occupational exposure groups.
Only paternal occupational exposure to leather was statistically significantly associated with neuroblastoma, OR=5.00 (95% CI 1.07–46.93). However, this association became non-significant on correction for multiple testing.
Our findings do not support the hypothesis that paternal occupational exposure is an important aetiological factor for neuroblastoma.
PMCID: PMC2822941  PMID: 20068570
neuroblastoma; case–control study; paternal occupation
9.  Case–control study of paternal occupation and childhood leukaemia in Great Britain, 1962–2006 
British Journal of Cancer  2012;107(9):1652-1659.
Paternal occupational exposures have been proposed as a risk factor for childhood leukaemia. This study investigates possible associations between paternal occupational exposure and childhood leukaemia in Great Britain.
The National Registry of Childhood Tumours provided all cases of childhood leukaemia born and diagnosed in Great Britain between 1962 and 2006. Controls were matched on sex, period of birth and birth registration subdistrict. Fathers' occupations were assigned to 1 or more of 33 exposure groups. Social class was derived from father's occupation at the time of the child's birth.
A total of 16 764 cases of childhood leukaemia were ascertained. One exposure group, paternal social contact, was associated with total childhood leukaemia (odds ratio 1.14, 1.05–1.23); this association remained significant when adjusted for social class. The subtypes lymphoid leukaemia (LL) and acute myeloid leukaemia showed increased risk with paternal exposure to social contact before adjustment for social class. Risk of other leukaemias was significantly increased by exposure to electromagnetic fields, persisting after adjustment for social class. For total leukaemia, the risks for exposure to lead and exhaust fumes were significantly <1. Occupationally derived social class was associated with risk of LL, with the risk being increased in the higher social classes.
Our results showed some support for a positive association between childhood leukaemia risk and paternal occupation involving social contact. Additionally, LL risk increased with higher paternal occupational social class.
PMCID: PMC3493752  PMID: 22968649
childhood cancer; childhood leukaemia; epidemiology; paternal occupation; social class
10.  Case-control study of paternal occupation and social class with risk of childhood central nervous system tumours in Great Britain, 1962–2006 
British Journal of Cancer  2013;108(9):1907-1914.
Paternal occupational exposures have been proposed as a risk factor for childhood central nervous system (CNS) tumours. This study investigates possible associations between paternal occupational exposure and childhood CNS tumours in Great Britain.
The National Registry of Childhood Tumours provided all cases of childhood CNS tumours born and diagnosed in Great Britain from 1962 to 2006. Controls without cancer were matched on sex, period of birth and birth registration sub-district. Fathers' occupations were assigned to one or more of 33 exposure groups. A measure of social class was also derived from father's occupation at the time of the child's birth.
Of 11 119 cases of CNS tumours, 5 722 (51%) were astrocytomas or other gliomas, 2 286 (21%) were embryonal and 985 (9%) were ependymomas. There was an increased risk for CNS tumours overall with exposure to animals, odds ratio (OR) 1.40 (95% confidence intervals (CIs) 1.01, 1.94) and, after adjustment for occupational social class (OSC), with exposure to lead, OR 1.18 (1.01, 1.39). Exposure to metal-working oil mists was associated with reduced risk of CNS tumours, both before and after adjustment for OSC, OR 0.87 (0.75, 0.99).
Risk of ependymomas was raised for exposure to solvents, OR 1.73 (1.02,2.92). For astrocytomas and other gliomas, risk was raised with high social contact, although this was only statistically significant before adjustment for OSC, OR 1.15 (1.01,1.31). Exposure to paints and metals appeared to reduce the risk of astrocytomas and embryonal tumours, respectively. However, as these results were the result of a number of statistical tests, it is possible they were generated by chance.
Higher social class was a risk factor for all CNS tumours, OR 0.97 (0.95, 0.99). This was driven by increased risk for higher social classes within the major subtype astrocytoma, OR 0.95 (0.91, 0.98).
Our results provide little evidence that paternal occupation is a significant risk factor for childhood CNS tumours, either overall or for specific subtypes. However, these analyses suggest that OSC of the father may be associated with risk of some childhood CNS cancers.
PMCID: PMC3658514  PMID: 23612452
childhood cancer; childhood CNS tumours; epidemiology; paternal occupation; social class
11.  Dietary fibre and regional large-bowel cancer mortality in Britain. 
British Journal of Cancer  1979;40(3):456-463.
The relationship between food intake and cancer of the large bowel was assessed by calculating the average intakes of foods, nutrients and dietary fibre in the different regions of Great Britain and relating these to the regional pattern of death from colon and rectal cancers between 1969 and 1973. No significant associations were found with the consumption of fat, animal protein or beer, nor with current estimates of total dietary fibre intake. Average intakes of the pentose fraction of total dietary fibres, and of vegetables other than potatoes, were negatively correlated with the truncated age- and sex-standardized death rates from colon cancer (r = -0.960 and -0.940). Specific components of dietary fibre may therefore inhibit colon carcinogenesis.
PMCID: PMC2010038  PMID: 574389
12.  Deputising services in Denmark—some implications for Great Britain 
In Denmark charges for home visits were abolished in April 1973. This paper analyses how this change affected the number of consultations undertaken by the deputising service in one Danish town and how the increase in consultations was distributed in time and place in a sample of individual families. It also describes how, in comparison with the deputising services sponsored by the British Medical Association in Great Britain, the more widely-used Danish deputising services operate.
PMCID: PMC2157859  PMID: 1249793
13.  Occupational exposure to noise and the attributable burden of hearing difficulties in Great Britain 
Aims: To determine the prevalence of self reported hearing difficulties and tinnitus in working aged people from the general population, and to estimate the risks from occupational exposure to noise and the number of attributable cases nationally.
Methods: A questionnaire was mailed to 22 194 adults of working age selected at random from the age–sex registers of 34 British general practices (21 201 subjects) and from the central pay records of the British armed services (993 subjects). Information was collected on years of employment in a noisy job; and whether the respondent wore a hearing aid, had difficulty in hearing conversation, or had experienced persistent tinnitus over the past year. Associations of hearing difficulty and tinnitus with noise exposure were examined by logistic regression, with adjustment for age, sex, smoking habits, and frequent complaints of headaches, tiredness, or stress. The findings were expressed as prevalence ratios (PRs) with associated 95% confidence intervals (CIs). Attributable numbers were calculated from the relevant PRs and an estimate of the prevalence of occupational exposure to noise nationally.
Results: Some 2% of subjects reported severe hearing difficulties (wearing a hearing aid or having great difficulty in both ears in hearing conversation in a quiet room). In men, the prevalence of this outcome rose steeply with age, from below 1% in those aged 16–24 years to 8% in those aged 55–64. The pattern was similar in women, but severe hearing loss was only about half as prevalent in the oldest age band. Tinnitus was far more common in subjects with hearing difficulties. In both sexes, after adjustment for age, the risk of severe hearing difficulty and persistent tinnitus rose with years spent in a noisy job. In men older than 35 years with 10 or more years of exposure, the PR for severe hearing difficulty was 3.8 (95% CI 2.4 to 6.2) and that for persistent tinnitus 2.6 (95% CI 2.0 to 3.4) in comparison with those who had never had a noisy job. Nationally, some 153 000 men and 26 000 women aged 35–64 years were estimated to have severe hearing difficulties attributable to noise at work. For persistent tinnitus the corresponding numbers were 266 000 and 84 000.
Conclusions: Significant hearing difficulties and tinnitus are quite common in men from the older working age range. Both are strongly associated with years spent in a noisy occupation—a predominantly male exposure. The national burden of hearing difficulties attributable to noise at work is substantial.
PMCID: PMC1740364  PMID: 12205239
14.  Internationally trained pharmacists in Great Britain: what do registration data tell us about their recruitment? 
Internationally trained health professionals are an important part of the domestic workforce, but little is known about pharmacists who come to work in Great Britain. Recent changes in the registration routes onto the Register of Pharmacists of the Royal Pharmaceutical Society of Great Britain may have affected entries from overseas: reciprocal arrangements for pharmacists from Australia and New Zealand ended in June 2006; 10 new states joined the European Union in 2004 and a further two in 2007, allowing straightforward registration.
The aims of the paper are to extend our knowledge about the extent to which Great Britain is relying on the contribution of internationally trained pharmacists and to explore their routes of entry and demographic characteristics and compare them to those of pharmacists trained in Great Britain.
The August 2007 Register of Pharmacists provided the main data for analysis. Register extracts between 2002 and 2005 were also explored, allowing longitudinal comparison, and work pattern data from the 2005 Pharmacist Workforce Census were included.
In 2007, internationally trained pharmacists represented 8.8% of the 43 262 registered pharmacists domiciled in Great Britain. The majority (40.6%) had joined the Register from Europe; 33.6% and 25.8% joined via adjudication and reciprocal arrangements. Until this entry route ended for pharmacists from Australia and New Zealand in 2006, annual numbers of reciprocal pharmacists increased. European pharmacists are younger (mean age 31.7) than reciprocal (40.0) or adjudication pharmacists (43.0), and the percentage of women among European-trained pharmacists is much higher (68%) when compared with British-trained pharmacists (56%). While only 7.1% of pharmacists registered in Great Britain have a London address, this proportion is much higher for European (13.9%), adjudication (19.5%) and reciprocal pharmacists (28.9%). The latter are more likely to work in hospitals than in community pharmacies, and all groups of internationally trained pharmacist are more likely to work full-time than British-trained ones. Adjudication pharmacists appear to stay on the Register longer than their reciprocal and European colleagues.
Analysis of the Register of Pharmacists provides novel insights into the origins, composition and destinations of internationally trained pharmacists. They represent a notable proportion of the Register, indicating that British employers are relying on their contribution for the delivery of pharmacy services. With the increasing mobility of health care professionals across geographical borders, it will be important to undertake primary research to gain a better understanding of the expectations, plans and experiences of pharmacists entering from outside Great Britain.
PMCID: PMC2714492  PMID: 19555489
15.  An analysis of injuries resulting from professional horse racing in France during 1991–2001: a comparison with injuries resulting from professional horse racing in Great Britain during 1992–2001 
It has been previously shown that professional jockeys suffer high rates of fatal and non‐fatal injuries in the pursuit of their occupation. Little is known, however, about differences in injury rates between countries.
To determine the rate of fatal and non‐fatal injuries in flat and jump jockeys in France and to compare the injury rates with those in Great Britain and Ireland
Prospectively collected injury data on professional jockeys were used as the basis of the analysis.
Limb fractures occur four times more often in both flat and jump racing in France than in Great Britain. Similarly dislocations are diagnosed 20 times more often in flat and three times more often in jump racing. This difference is surprising given that French jockeys have fewer falls per ride than their British counterparts in flat racing, although they do have more falls than the British in jump racing. Similarly concussion rates seem to be higher in French jockeys, although there may be a difference in the diagnostic methods used in the different countries. By contrast, soft tissue injuries account for a far smaller percentage of injuries than in Great Britain.
There are striking differences in injury rates between countries which may be explained in part by a difference in track conditions—for example, harder tracks in France—or different styles of racing—for example, larger fields of horses per race in France.
PMCID: PMC2564309  PMID: 16687479
horse racing; injuries; fractures; dislocations; concussion
16.  Material standard of living, social class, and the prevalence of the common mental disorders in Great Britain 
STUDY OBJECTIVE: To test the hypothesis that poor material standard of living is independently associated with the prevalence of the common mental disorders after adjusting for occupational social class, and to estimate the population impact of poor material standard of living on the prevalence of these disorders. DESIGN: Cross sectional survey. Prevalence of the common mental disorders was assessed using the General Health Questionnaire, a self administered measure of psychiatric morbidity. PARTICIPANTS: 9064 adults aged 16-75 living in private households in England, Wales, and Scotland. MAIN RESULTS: The common mental disorders were significantly associated with poor material standard of living, including low household income (OR 1.24, 95% CI 1.00, 1.54) and not saving from income (OR 1.29, 95% CI 1.15, 1.45), after adjusting for occupational social class and other potential confounders. An independent association was also found with occupational social class of the head of household among women, but not men, after adjusting for material standard of living. The adjusted population attributable fraction for poor material standard of living (using a five item index) was 24.0%. CONCLUSIONS: Like mortality and physical morbidity, common mental disorders are associated with a poor material standard of living, independent of occupational social class. These findings support the view that recent widening of inequalities in material standards of living in the United Kingdom pose a substantial threat to health.
PMCID: PMC1756605  PMID: 9604035
17.  Why do workers behave unsafely at work? Determinants of safe work practices in industrial workers 
Aims: To explore the relation between safety climate (workers' perceptions regarding management's attitudes towards occupational safety and health) and workers' behaviour at work.
Methods: Cross sectional survey of workers at the pottery industry in Castellon, Spain. Sampling was stratified by plant size and workers' gender, according to data on the working population at this setting. A total of 734 production workers were interviewed. Information was collected on safety climate and workers' behaviour towards occupational risks with a specific questionnaire. A safety climate index (SCI, scale 0–100) was constructed adding scores for each item measuring safety climate in the questionnaire. Workers' unsafe behaviour was analysed for the different safety climate index levels.
Results: Mean score for SCI was 71.90 (SD 19.19). There were no differences in SCI scores according to age, gender, education, children at charge, seniority at work, or type of employment. Small workplaces (<50 workers) showed significantly worse SCI (mean 67.23, SD 19.73) than the largest factories (>200 workers). Lower levels of SCI (SCI <50) were related to workers' unsafe behaviours (full/high accord with the statement "I excessively expose myself to hazards in my work", adjusted odds ratio ORa 2.79, 95% CI 1.60 to 4.88), and to lack of compliance with safety rules (ORa 12.83, 95% CI 5.92 to 27.80).
Conclusions: Safety climate measures workers' perception of organisational factors related to occupational health and safety (for example, management commitment to risk prevention or priorities of safety versus production). In this study these factors are strongly associated with workers' attitudes towards safety at work. Longitudinal studies can further clarify the relation between safety climate and workers' behaviour regarding occupational safety and health.
PMCID: PMC1740724  PMID: 14985519
18.  Spatial variation of salt intake in Britain and association with socioeconomic status 
BMJ Open  2013;3(1):e002246.
To evaluate spatial effects of variation and social determinants of salt intake in Britain.
Cross-sectional survey.
Great Britain.
2105 white male and female participants, aged 19–64 years, from the British National Diet and Nutrition Survey 2000–2001.
Primary outcomes
Participants’ sodium intake measured both with a 7-day dietary record and a 24-h urine collection. By accounting for important linear and non-linear risk factors and spatial effects, the geographical difference and spatial patterns of both dietary sodium intake and 24-h urinary sodium were investigated using Bayesian geo-additive models via Markov Chain Monte Carlo simulations.
A significant north–south pattern of sodium intake was found from posterior probability maps after controlling for important sociodemographic factors. Participants living in Scotland had a significantly higher dietary sodium intake and 24-h urinary sodium levels. Significantly higher sodium intake was also found in people with the lowest educational attainment (dietary sodium: coeff. 0.157 (90% credible intervals 0.003, 0.319), urinary sodium: 0.149 (0.024, 0.281)) and in manual occupations (urinary sodium: 0.083 (0.004, 0.160)). These coefficients indicate approximately a 5%, 9% and 4% difference in average sodium intake between socioeconomic groups.
People living in Scotland had higher salt intake than those in England and Wales. Measures of low socioeconomic position were associated with higher levels of sodium intake, after allowing for geographic location.
PMCID: PMC3549259  PMID: 23295624
Epidemiology; Social inequalities; Lifestyle; Nutrition & dietetics; Prevention; Public health
19.  Mortality from Asbestosis and Mesothelioma in Britain by Birth Cohort 
Analysis of occupational mortality in England and Wales during 1991-2000 showed no decline in work-attributable deaths from asbestosis.
To explore why there was no decline in mortality from asbestosis despite stricter controls on asbestos exposure over recent decades.
Using data from registers of all deaths in Great Britain with mention of mesothelioma or asbestosis on the death certificate, we plotted death rates by five-year age group within five-year birth cohorts for a) mesothelioma and b) asbestosis without mention of mesothelioma.
Analysis was based on a total of 33,751 deaths from mesothelioma and 5,396 deaths from asbestosis. For both diseases, mortality showed a clear cohort effect; and within birth cohorts, death rates increased progressively with age through to 85 years and older. However, highest mortality from mesothelioma was in men born during 1939-43, whereas mortality from asbestosis peaked in men born during 1924-38.
Our findings suggest that in Britain, mortality from asbestosis has been determined mainly by cumulative exposure to asbestos before 45 years of age, and that the effect of such exposure continues through to old age. That mortality from asbestosis peaked in earlier birth cohorts than mortality from mesothelioma may reflect a difference in exposure-response relationships for the two diseases. The discrepancy could be explained if risk of asbestosis increased more steeply than that of mesothelioma at higher levels of exposure to asbestos, and if the highest prevalence of heavy exposure occurred in earlier birth cohorts than the highest prevalence of less intense exposures.
PMCID: PMC3471357  PMID: 23034792
Asbestos; asbestosis; mesothelioma; trends; cohort effect
20.  Socioeconomic inequality in salt intake in Britain 10 years after a national salt reduction programme 
BMJ Open  2014;4(8):e005683.
The impact of the national salt reduction programme in the UK on social inequalities is unknown. We examined spatial and socioeconomic variations in salt intake in the 2008–2011 British National Diet and Nutrition Survey (NDNS) and compared them with those before the programme in 2000–2001.
Cross-sectional survey in Great Britain.
1027 Caucasian males and females, aged 19–64 years.
Primary outcome measures
Participants’ dietary sodium intake measured with a 4-day food diary. Bayesian geo-additive models used to assess spatial and socioeconomic patterns of sodium intake accounting for sociodemographic, anthropometric and behavioural confounders.
Dietary sodium intake varied significantly across socioeconomic groups, even when adjusting for geographical variations. There was higher dietary sodium intake in people with the lowest educational attainment (coefficient: 0.252 (90% credible intervals 0.003, 0.486)) and in low levels of occupation (coefficient: 0.109 (−0.069, 0.288)). Those with no qualification had, on average, a 5.7% (0.1%, 11.1%) higher dietary sodium intake than the reference group. Compared to 2000-2001 the gradient of dietary sodium intake from south to north was attenuated after adjustments for confounders. Estimated dietary sodium consumption from food sources (not accounting for discretionary sources) was reduced by 366 mg of sodium (∼0.9 g of salt) per day during the 10-year period, likely the effect of national salt reduction initiatives.
Social inequalities in salt intake have not seen a reduction following the national salt reduction programme and still explain more than 5% of salt intake between more and less affluent groups. Understanding the socioeconomic pattern of salt intake is crucial to reduce inequalities. Efforts are needed to minimise the gap between socioeconomic groups for an equitable delivery of cardiovascular prevention.
PMCID: PMC4156795  PMID: 25161292
21.  Inequalities in reported use of breast and cervical screening in Great Britain: analysis of cross sectional survey data 
Objective To investigate the relation between women’s reported use of breast and cervical screening and sociodemographic characteristics.
Design Cross sectional multipurpose survey.
Setting Private households, Great Britain.
Population 3185 women aged 40-74 interviewed in the National Statistics Omnibus Survey 2005-7.
Main outcome measures Ever had a mammogram, ever had a cervical smear, and, for each, timing of most recent screen.
Results 91% (95% confidence interval 90% to 92%) of women aged 40-74 years reported ever having had a cervical smear, and 93% (92% to 94%) of those aged 53-74 years reported ever having had a mammogram; 3% (2% to 4%) of women aged 53-74 years had never had either breast or cervical screening. Women were significantly more likely to have had a mammogram if they lived in households with cars (compared with no car: one car, odds ratio 1.67, 95% confidence interval 1.06 to 2.62; two or more cars, odds ratio 2.65, 1.34 to 5.26), and in owner occupied housing (compared with rented housing: own with mortgage, odds ratio 2.12, 1.12 to 4.00; own outright, odds ratio 2.19, 1.39 to 3.43), but no significant differences by ethnicity, education, occupation, or region were found. For cervical screening, ethnicity was the most important predictor; white British women were significantly more likely to have had a cervical smear than were women of other ethnicity (odds ratio 2.20, 1.41 to 3.42). Uptake of cervical screening was greater among more educated women but was not significantly associated with cars, housing tenure, or region.
Conclusions Most (84%) eligible women report having had both breast and cervical screening, but 3% report never having had either. Some inequalities exist in the reported use of screening, which differ by screening type; indicators of wealth were important for breast screening and ethnicity for cervical screening. The routine collection within general practice of additional sociodemographic information would aid monitoring of inequalities in screening coverage and inform policies to correct them.
PMCID: PMC2697310  PMID: 19531549
22.  Geographic variation in incidence of coronary heart disease in Britain: the contribution of established risk factors 
Heart  2001;86(3):277-283.
OBJECTIVE—To determine the extent to which geographic variation in the incidence of major coronary heart disease (CHD) in Great Britain may be explained by established risk factors.
DESIGN—Prospective study.
SETTING—24 British towns with widely differing CHD mortality.
SUBJECTS—7735 men followed up from screening in 1978-80 for 15 years.
MAIN OUTCOME MEASURES—Percentage of variance between the towns in major CHD incidence that can be explained by individual characteristics of men in the towns.
RESULTS—Age standardised incidence rates over a 15 year period varied from 0.52% per annum in Maidstone to 1.07% per annum in Dewsbury and tended to follow the known pattern of higher rates in Scottish and northern English towns and lower rates in southern English towns ("north-south gradient"). Higher town incidence rates were related to prevalence of current cigarette smoking, low physical activity, and low alcohol consumption, and to mean body mass index, mean systolic blood pressure, low mean height, and prevalence of manual social class, but not to mean serum total cholesterol. The 95% range for true age adjusted CHD incidence (over 15 years) was estimated as 0.58-1.03% per annum among British towns. After adjustment for baseline smoking status, physical activity, body mass index, alcohol consumption, systolic blood pressure, serum total cholesterol, occupational social class, and height, this variation was reduced by 50%. A model based on these eight variables accounted for the major part of the north-south gradient.
CONCLUSIONS—Much of the variation in CHD incidence among British towns was accounted for by established risk variables. The remaining unexplained variation may be related to measurement error in the established risk variables, to environmental factors such as climate, or to the combined effect of a wide range of minor risk factors.

Keywords: geographic variation; established risk factors; coronary heart disease; multilevel modelling
PMCID: PMC1729899  PMID: 11514478
23.  Association of age and social class with suicide among men in Great Britain. 
STUDY OBJECTIVE--The aim was to investigate suicide and "undetermined" deaths by age, economic activity status, and social class in Great Britain among males of working age. DESIGN--The study was a cross sectional analysis of Registrar General's data for England and Wales around 1981, repeated for around 1971, and for Scotland around 1971 and 1981. MEASUREMENTS AND MAIN RESULTS--For England and Wales around 1971, suicide and undetermined death rates showed a progressive increase with age and a markedly higher rate in the lower social classes. A significant interaction effect was identified in the central age groups of the lower occupational categories. This interaction was confirmed in the remaining three data sets, notwithstanding some differences in the profile of age specific mortality. Other findings included a higher standardised mortality ratio for the economically inactive, who also showed an earlier peak in age specific mortality, and a relative concentration of undetermined as compared to suicide deaths in the lower social classes, but not all these further results were fully replicated. CONCLUSIONS--There is a concentration of suicide and undetermined deaths in the middle age groups of the lower social classes. Plausible explanations include both the social drift and the social genesis hypotheses, the latter including the effects of long term unemployment.
PMCID: PMC1060757  PMID: 1757760
24.  Angiosarcoma of the liver in Great Britain, 1963-73. 
British Medical Journal  1977;2(6092):919-921.
Deaths attributed to primary angiosarcoma of the liver (ASL) in Great Britain between 1963-73 were reviewed by submitting available histological material to a panel of histopathologists and by obtaining full occupational and residential histories for the cases agreed as ASL by the panel. On average four recorded cases of ASL occurred a year, but in only one-third of the cases submitted did the panel agree with the original diagnosis. Only one of the agreed cases could be confidently associated with exposure to vinyl chloride.
PMCID: PMC1631623  PMID: 562215
25.  Use of non-orthodox and conventional health care in Great Britain. 
BMJ : British Medical Journal  1991;302(6770):207-210.
OBJECTIVE--To describe the characteristics of patients using non-orthodox health care and their pattern of use of conventional health care with respect to a particular problem. DESIGN--Postal survey of all 2152 practitioners of acupuncture, chiropractic, homeopathy, naturopathy, and osteopathy identified from 11 national professional association registers. Patients attending a representative sample of 101 responding practitioners completed questionnaires covering demographic characteristics, presenting problems, and use of the health service. SETTING--Practices of practitioners of non-orthodox health care in England, Scotland, and Wales. SUBJECTS--Qualified, non-medical practitioners of non-orthodox health care working in Great Britain and 2473 patients who had attended one of the sampled practitioners in an allocated time period between August 1987 and July 1988. RESULTS--An estimated 1909 practitioners were actively practising one of the study treatments in Great Britain in 1987. Of the estimated 70,600 patients seen by this group of practitioners in an average week, most (78%) were attending with a musculoskeletal problem. Two thirds of the patients were women. Only 2% were aged under 16, but 15% were aged 65 or over. One in three patients had not received previous conventional care for their main problem; 18% were receiving concurrent non-orthodox and conventional care. Twenty two per cent of the patients reported having seen their general practitioner for any reason in the two weeks before the surveyed consultation. CONCLUSIONS--Patients of non-orthodox health care, as provided by this group of practitioners, had not turned their backs on conventional health care. Non-orthodox treatment was sought for a limited range of problems and used most frequently as a supplement to orthodox medicine.
PMCID: PMC1669035  PMID: 1998760

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