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1.  Children at risk: measuring racial/ethnic disparities in potential exposure to air pollution at school and home 
Study objective
This paper addresses the environmental justice implications of children's health by exploring racial/ethnic disparities in potential exposure to air pollution, based on both school and home locations of children and three different types of pollution sources, in Orange County, Florida, USA.
Methods
Using geocoded school and residence locations of 151 709 children enrolled in the public school system, distribution functions of proximity to the nearest source are generated for each type of air pollution source in order to compare the exposure potential of white, Hispanic, and black children. Discrete buffer distances are utilised to provide quantitative comparisons for statistical testing.
Main results
At any given distance from each type of pollution source, the cumulative proportion of Hispanic or black children significantly exceeds the corresponding proportion of white children, for both school and home locations. Regardless of race, however, a larger proportion of children are potentially exposed to air pollution at home than at school.
Conclusions
This study addresses the growing need to consider both daytime and nighttime activity patterns in the assessment of children's exposure to environmental hazards and related health risks. The results indicate a consistent pattern of racial inequity in the spatial distribution of all types of air pollution sources examined, with black children facing the highest relative levels of potential exposure at both school and home locations.
doi:10.1136/jech.2006.054130
PMCID: PMC2465656  PMID: 18000130
air pollution; environmental justice; children; race; school
2.  Going beyond The three worlds of welfare capitalism: regime theory and public health research 
International research on the social determinants of health has increasingly started to integrate a welfare state regimes perspective. Although this is to be welcomed, to date there has been an over‐reliance on Esping‐Andersen's The three worlds of welfare capitalism typology (1990). This is despite the fact that it has been subjected to extensive criticism and that there are in fact a number of competing welfare state typologies within the comparative social policy literature. The purpose of this paper is to provide public health researchers with an up‐to‐date overview of the welfare state regime literature so that it can be reflected more accurately in future research. It outlines The three worlds of welfare capitalism typology, and it presents the criticisms it received and an overview of alternative welfare state typologies. It concludes by suggesting new avenues of study in public health that could be explored by drawing upon this broader welfare state regimes literature.
doi:10.1136/jech.2007.064295
PMCID: PMC2465657  PMID: 18000134
3.  [No title available] 
PMCID: PMC2465658
4.  Use of statins and beta‐blockers after acute myocardial infarction according to income and education 
Objective
To study the initiation of and long‐term refill persistency with statins and beta‐blockers after acute myocardial infarction (AMI) according to income and education.
Design and setting
Linkage of individuals through national registers of hospitalisations, drug dispensation, income and education.
Participants
30 078 patients aged 30–74 years surviving first hospitalisation for AMI in Denmark between 1995 and 2001.
Main outcome measures
Initiation of statin or beta‐blocker treatment (out‐patient claim of prescriptions within 6 months of discharge) and refill persistency (first break in treatment lasting at least 90 days, and re‐initiation of treatment after a break).
Results
When simultaneously estimating the effect of income and education on initiation of treatment, the effect of education attenuated and a clear income gradient remained for both drugs. Among patients aged 30–64 years, high income (adjusted hazard ratio (HR) 1.27; 95% confidence interval (CI) 1.19–1.35) and medium income (HR 1.13; 95% CI 1.06–1.20) was associated with initiation of statin treatment compared with low income. The risk of break in statin treatment was lower for patients with high (HR 0.73; 95% CI 0.66–0.82) and medium (HR 0.82; 95% CI 0.74–0.92) income compared with low income, whereas there was a trend in the opposite direction concerning a break in beta‐blocker treatment. There was no gradient in re‐initiation of treatment.
Conclusion
Patients with low compared with high income less frequently initiated preventive treatment post‐AMI, had worse long‐term persistency with statins, but tended to have better persistency with beta‐blockers. Low income by itself seems not to be associated with poor long‐term refill persistency post‐AMI.
doi:10.1136/jech.2006.055525
PMCID: PMC2465659  PMID: 18000133
acute myocardial infarction; statins; beta‐blockers; income and education; initiation and persistency
5.  The relative impact of 13 chronic conditions across three different outcomes 
Study objective
Previous estimates of individual and population attributable risks for adverse outcomes due to chronic conditions have considered only a limited number of conditions and outcomes, with some studies using inappropriate formulae or methods of estimation. This study re‐examines the magnitude of individual and population attributable risks for a wide range of conditions and various health outcomes.
Design
Log‐Poisson regression was used to calculate prevalence ratios as an indicator of individual risk and population‐associated fractions of 13 chronic conditions, examining activity limitations, self‐rated health and physician visits. The effect of multimorbidity on prevalence ratios was examined.
Setting
Canada, 2000–01.
Participants
Nationally representative sample of Canadians aged 12+ years (n = 130 880).
Main results
At the individual level, fibromyalgia/chronic fatigue syndrome and cancer, and to a lesser extent stroke and heart disease, were associated with an increased risk of both activity limitations and a self‐rated health status of fair or poor; high blood pressure was associated with four or more physician visits in the previous 12 months. In contrast, population attributable fractions were substantial for arthritis/rheumatism, heart disease, back problems and high blood pressure across all outcomes. Adjustment for multimorbidity resulted in a marked decreases in prevalence ratios.
Conclusions
Differences in the ranking of individual risks and population attributable fractions for different diseases and outcomes are substantial. This needs to be taken into account when setting priorities, as interventions may need to be targeted to different conditions depending on which aspects of health are being considered, and whether the focus is on individuals, such as in clinical care, or improving the health of the population.
doi:10.1136/jech.2006.047308
PMCID: PMC2465660  PMID: 18000127
chronic disease; health survey; population; cross‐sectional analysis; health priorities
6.  The economics of cancer care 
doi:10.1136/jech.2007.062448
PMCID: PMC2465661
7.  Systematic review of the fetal effects of prenatal binge‐drinking 
Objective
The effects of binge‐drinking during pregnancy on the fetus and child have been an increasing concern for clinicians and policy‐makers. This study reviews the available evidence from human observational studies.
Design
Systematic review of observational studies.
Population
Pregnant women or women who are trying to become pregnant.
Methods
A computerised search strategy was run in Medline, Embase, Cinahl and PsychInfo for the years 1970–2005. Titles and abstracts were read by two researchers for eligibility. Eligible papers were then obtained and read in full by two researchers to decide on inclusion. The papers were assessed for quality using the Newcastle–Ottawa Quality Assessment Scales and data were extracted.
Main outcome measures
Adverse outcomes considered in this study included miscarriage; stillbirth; intrauterine growth restriction; prematurity; birth‐weight; small for gestational age at birth; and birth defects, including fetal alcohol syndrome and neurodevelopmental effects.
Results
The search resulted in 3630 titles and abstracts, which were narrowed down to 14 relevant papers. There were no consistently significant effects of alcohol on any of the outcomes considered. There was a possible effect on neurodevelopment. Many of the reported studies had methodological weaknesses despite being assessed as having reasonable quality.
Conclusions
This systematic review found no convincing evidence of adverse effects of prenatal binge‐drinking, except possibly on neurodevelopmental outcomes.
doi:10.1136/jech.2006.054213
PMCID: PMC2465662  PMID: 18000129
fetus; pregnancy; binge‐drinking
8.  Income redistribution is not enough: income inequality, social welfare programs, and achieving equity in health 
Income inequality is widely assumed to be a major contributor to poorer health at national and subnational levels. According to this assumption, the most appropriate policy strategy to improve equity in health is income redistribution. This paper considers reasons why tackling income inequality alone could be an inadequate approach to reducing differences in health across social classes and other population subgroups, and makes the case that universal social programs are critical to reducing inequities in health. A health system oriented around a strong primary care base is an example of such a strategy.
doi:10.1136/jech.2006.054627
PMCID: PMC2465663  PMID: 18000124
10.  Are program evaluators judges and/or knowledge brokers? 
doi:10.1136/jech.2007.065573
PMCID: PMC2465665
11.  Hygieia 
PMCID: PMC2465666
13.  Children's use of dental services in the five Nordic countries 
Background
An increase in the use of general practitioner services for children has taken place since the 1980s in the Nordic countries, but little is known about the use of dental services during this time.
Aim
To compare differences in children's use of dental services in the five Nordic countries and to analyse changes over time from the 1980s to the 1990s.
Methods
The participants were 20 500 children aged 2–17 years from Denmark, Finland, Iceland, Norway and Sweden. Cross‐sectional population surveys using random samples comprising 3000 children in each country were conducted in 1984 and 1996. Changes over time in the use of dental services were studied in each country by age, sex, level of parental education and living area.
Results
The prevalence of children's utilisation of dental services varied between 60% and 34% in 1984, and between 42% and 30% in 1996. A clear change towards decreasing utilisation over time (p<0.05) was found in all countries except Finland, where utilisation increased statistically significantly (p<0.05). Odds ratios (1984 = 1.00) for the changes ranged between 0.66 (95% confidence interval 0.58 to 0.75) in Sweden and 0.71 (0.62 to 0.81) in Iceland, while the corresponding figure was 1.32 (1.16 to 1.48) in Finland. In 1996, children from families with the lowest education in Finland and Norway used dental services more frequently than children from families with higher education.
Conclusion
Children's use of dental services decreased significantly in four of the five Nordic countries between the mid‐1980s and the mid‐1990s.
doi:10.1136/jech.2006.052910
PMCID: PMC2465668  PMID: 18000131
children; dental services; health service utilisation; Nordic countries; oral health care
15.  Analysis of social epidemiology research on infectious diseases: historical patterns and future opportunities 
Background
Despite the many triumphs of biomedical research over infectious diseases, human pathogens continue to impact profoundly populations deprived of social resources. Correspondingly, health researchers have advocated a social determinants approach to the study and prevention of infectious diseases. However, it is unknown whether this call has resulted in an increase in the number of studies examining social determinants of infectious outcomes.
Methods
Research on social determinants of infectious diseases was systematically quantified by assessing temporal trends in the published literature using MEDLINE, PsycINFO and ISI Web of Science.
Results
Results of the literature review spanning 1966–2005 show that socially related citations increased an annual average of 180.3 for neuropsychiatric conditions, 81.9 for chronic conditions, 44.7 for sexually transmitted diseases and 18.9 for non‐sexually transmitted infectious diseases (p<0.0001). Of the 279 publications found to employ the term “social epidemiology”, 15 (5.4%) investigated infectious outcomes.
Conclusions
The results of the literature review suggest a paucity of social research on infectious diseases. There is a need for increased dialogue and collaboration between infectious disease epidemiologists and social epidemiologists.
doi:10.1136/jech.2006.057216
PMCID: PMC2465670  PMID: 18000122
16.  The area‐level association between hospital‐treated deliberate self‐harm, deprivation and social fragmentation in Ireland 
Background
The extensive literature on the area‐level association between socioeconomic characteristics and suicide indicates that the more deprived and socially fragmented an area, the higher its suicide rate. Relatively few studies have examined the association between the incidence of non‐fatal suicidal behaviour and area characteristics.
Aim
This study investigated the area‐level association between hospital‐treated deliberate self‐harm, deprivation and social fragmentation in Ireland.
Methods
During 2002–2004, the Irish National Registry of Deliberate Self Harm collected data on self‐harm presentations to 38 of Ireland's 40 hospital accident and emergency (A&E) departments, using a standardised methodology that included geocoding patient addresses to small‐area level. Annual deliberate self‐harm incidence rates and levels of deprivation and social fragmentation were examined nationally and by geographic area. Negative binomial regression was used to investigate the small‐area association between deliberate self‐harm, deprivation and social fragmentation.
Results
During 2002–2004, an estimated 32 777 deliberate self‐harm presentations to A&E departments were made by 25 797 individuals. The total, male and female annual incidence rates were 204, 172 and 237 per 100 000, respectively. There were striking geographic differences in deliberate self‐harm presentation rates which were largely explained by the distribution of deprivation, fragmentation, age and gender, and interactions between these factors. Deprivation, rather than fragmentation, had the stronger independent effect on small‐area rates of self‐harm.
Conclusions
The highest rates of hospital‐treated deliberate self‐harm in Ireland are in deprived urban areas. Priority should be given to these areas when implementing community‐based interventions aimed at reducing suicidal behaviour.
doi:10.1136/jech.2006.055855
PMCID: PMC2465671  PMID: 18000126
18.  The association of neighbourhood psychosocial stressors and self‐rated health in Amsterdam, The Netherlands 
Objective
To investigate associations between neighbourhood‐level psychosocial stressors (i.e. experience of crime, nuisance from neighbours, drug misuse, youngsters frequently hanging around, rubbish on the streets, feeling unsafe and dissatisfaction with the quality of green space) and self‐rated health in Amsterdam, the Netherlands.
Participants
A random sample of 2914 subjects aged ⩾ 18 years from 75 neighbourhoods in the city of Amsterdam, the Netherlands.
Design
Individual data from the Social State of Amsterdam Survey 2004 were linked to data on neighbourhood‐level attributes from the Amsterdam Living and Security Survey 2003. Multilevel logistic regression was used to estimate odds ratios and neighbourhood‐level variance.
Results
Fair to poor self‐rated health was significantly associated with neighbourhood‐level psychosocial stressors: nuisance from neighbours, drug misuse, youngsters frequently hanging around, rubbish on the streets, feeling unsafe and dissatisfaction with green space. In addition, when all the neighbourhood‐level psychosocial stressors were combined, individuals from neighbourhoods with a high score of psychosocial stressors were more likely than those from neighbourhoods with a low score to report fair to poor health. These associations remained after adjustments for individual‐level factors (i.e. age, sex, educational level, income and ethnicity). The neighbourhood‐level variance showed significant differences in self‐rated health between neighbourhoods independent of individual‐level demographic and socioeconomic factors.
Conclusion
Our findings show that neighbourhood‐level psychosocial stressors are associated with self‐rated health. Strategies that target these factors might prove a promising way to improve public health.
doi:10.1136/jech.2006.052548
PMCID: PMC2465673  PMID: 18000125
self‐rated health; neighbourhood psychosocial stressor; multilevel; the Netherlands
19.  HPV vaccine: positive insights from universal adolescent HepB vaccination 
The introduction of universal adolescent HPV vaccination in schools has a positive outlook
doi:10.1136/jech.2007.059832
PMCID: PMC2465674  PMID: 18000120
20.  [No title available] 
PMCID: PMC2465675
21.  End‐of‐life decision‐making in Belgium, Denmark, Sweden and Switzerland: does place of death make a difference? 
Objective
To examine differences in end‐of‐life decision‐making in patients dying at home, in a hospital or in a care home.
Design
A death certificate study: certifying physicians from representative samples of death certificates, taken between June 2001 and February 2002, were sent questionnaires on the end‐of‐life decision‐making preceding the patient's death.
Setting
Four European countries: Belgium (Flanders), Denmark, Sweden, and Switzerland (German‐speaking part).
Main outcome measures
The incidence of and communication in different end‐of‐life decisions: physician‐assisted death, alleviation of pain/symptoms with a possible life‐shortening effect, and non‐treatment decisions.
Results
Response rates ranged from 59% in Belgium to 69% in Switzerland. The total number of deaths studied was 12 492. Among all non‐sudden deaths the incidence of several end‐of‐life decisions varied by place of death. Physician‐assisted death occurred relatively more often at home (0.3–5.1%); non‐treatment decisions generally occurred more often in hospitals (22.4–41.3%), although they were also frequently taken in care homes in Belgium (26.0%) and Switzerland (43.1%). Continuous deep sedation, in particular without the administration of food and fluids, was more likely to occur in hospitals. At home, end‐of‐life decisions were usually more often discussed with patients. The incidence of discussion with other caregivers was generally relatively low at home compared with in hospitals or care homes.
Conclusion
The results suggest the possibility that end‐of‐life decision‐making is related to the care setting where people die. The study results seem to call for the development of good end‐of‐life care options and end‐of‐life communication guidelines in all settings.
doi:10.1136/jech.2006.056341
PMCID: PMC2465676  PMID: 18000128
decision making; epidemiology; euthanasia; terminal care; withholding treatment
22.  Functional health literacy and health‐promoting behaviour in a national sample of British adults 
Objectives
To measure the prevalence of limited functional health literacy in the UK, and examine associations with health behaviours and self‐rated health.
Design
Psychometric testing using a British version of the Test of Functional Health Literacy in Adults (TOFHLA) in a population sample of adults.
Setting
UK‐wide interview survey (excluding Northern Ireland and the Scottish Isles).
Participants
759 adults (439 women, 320 men) aged 18–90 years (mean age = 47.6 years) selected using random location sampling.
Main outcome measures
Functional health literacy, self‐rated health, fruit and vegetable consumption, physical exercise and smoking.
Results
We found that 11.4% of participants had either marginal or inadequate health literacy. Multivariable logistic regression analysis indicated that the risk of having limitations in health literacy increased with age (adjusted odds ratio 1.04; 95% confidence interval 1.02 to 1.06), being male (odds ratio = 2.04; 95% confidence interval 1.16 to 3.55), low educational attainment (odds ratio = 7.46; 95% confidence interval 3.35 to 16.58) and low income (odds ratio = 5.94; 95% confidence interval 1.87 to 18.89). In a second multivariable logistic regression analysis, every point higher on the health literacy scale increased the likelihood of eating at least five portions of fruit and vegetables a day (odds ratio = 1.02; 95% confidence interval 1.003 to 1.03), being a non‐smoker (odds ratio = 1.02; 95% confidence interval 1.0003 to 1.03) and having good self‐rated health (odds ratio = 1.02; 95% confidence interval 1.01 to 1.04), independently of age, education, gender, ethnicity and income.
Conclusions
The results encourage efforts to monitor health literacy in the British population and examine associations with engagement with preventative health behaviours.
doi:10.1136/jech.2006.053967
PMCID: PMC2465677  PMID: 18000132
health literacy; health communication; health behaviour; self‐rated health
23.  The psychosocial and health effects of workplace reorganisation. 2. A systematic review of task restructuring interventions 
Objective
To systematically review the health and psychosocial effects (with reference to the demand–control–support model) of changes to the work environment brought about by task structure work reorganisation, and to determine whether those effects differ for different socioeconomic groups.
Design
Systematic review (QUORUM) of experimental and quasi‐experimental studies (any language) reporting health and psychosocial effects of such interventions.
Data sources
Seventeen electronic databases (medical, social science and economic), bibliographies and expert contacts.
Results
Nineteen studies were reviewed. Some task‐restructuring interventions failed to alter the psychosocial work environment significantly, and so could not be expected to have a measurable effect on health. Those that increased demand and decreased control tended to have an adverse effect on health, while those that decreased demand and increased control resulted in improved health, although some effects were minimal. Increases in workplace support did not appear to mediate this relationship.
Conclusion
This systematic review suggests that task‐restructuring interventions that increase demand or decrease control adversely affect the health of employees, in line with observational research. It lends support to policy initiatives such as the recently enforced EU directive on participation at work, which aims to increase job control and autonomy.
doi:10.1136/jech.2006.054999
PMCID: PMC2465678  PMID: 18000123
systematic review; health inequalities; psychosocial work environment
24.  Applications submitted and grants awarded to men and women in nationwide biomedical competitive research, in 2006, in Spain 
Journal of Epidemiology and Community Health  2007;61(Suppl 2):ii17-ii19.
Background
According to European reports, women participate in research less than men, especially in positions of responsibility. This kind of analysis has not been carried out in Spain in the field of biomedical research. This study describes participation of men and women as grant applicants in two different calls for research funding, held in Spain in 2006.
Methods
Data collected from grant applicants and from grantees, for two different competitive grant researches areas: human resources and CIBER (Spanish acronym for Biomedical Research Network Centres) have been described by sex.
Results
The human resources call shows that the number of applications submitted by women is higher (67.8% vs 32.2%), but the percentage of awards are similar (20.3% vs 22.7%), OR = 1.15 (95% CI: 0.82 to 1.62), with no statistical differences, although there are more men in the upper categories (superior technical experts (OR = 1.19 (0.58 to 2.45)) post‐doctoral (OR = 1.36 (0.65 to 2.86)) and research personnel (OR = 1.48 (0.67 to 3.25)). With the CIBER call (senior researchers) there is a clear difference in the number of applicants (women 19.6%, men 80.4%) but the number of awardees is similar (40.3% vs 43.1%) OR = 0.89 (0.65 to 1.34).
Conclusions
Although there are no statistical differences between women and men, with respect the awards obtained, there is a different pattern to the type of grant application, with fewer women in the more senior call.
doi:10.1136/jech.2007.067413
PMCID: PMC2465766  PMID: 18000109
human resources; Spain; gender inequalities; research policy
25.  Occupational epidemiology and work related inequalities in health: a gender perspective for two complementary approaches to work and health research 
Journal of Epidemiology and Community Health  2007;61(Suppl 2):ii39-ii45.
Objectives
To provide a framework for epidemiological research on work and health that combines classic occupational epidemiology and the consideration of work in a structural perspective focused on gender inequalities in health.
Methods
Gaps and limitations in classic occupational epidemiology, when considered from a gender perspective, are described. Limitations in research on work related gender inequalities in health are identified. Finally, some recommendations for future research are proposed.
Results
Classic occupational epidemiology has paid less attention to women's problems than men's. Research into work related gender inequalities in health has rarely considered either social class or the impact of family demands on men's health. In addition, it has rarely taken into account the potential interactions between gender, social class, employment status and family roles and the differences in social determinants of health according to the health indicator analysed.
Conclusions
Occupational epidemiology should consider the role of sex and gender in examining exposures and associated health problems. Variables should be used that capture the specific work environments and health conditions of both sexes. The analysis of work and health from a gender perspective should take into account the complex interactions between gender, family roles, employment status and social class.
doi:10.1136/jech.2007.059774
PMCID: PMC2465767  PMID: 18000116
gender; occupational health; socioeconomic factors; family characteristics

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