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Background: Studies aimed at understanding the association between induced abortion and HIV are scarce and differ on the direction of the association. This paper aims to show the prevalence of induced abortion in a sample of pregnancies of women living and not living with HIV/Aids, determining variables associated with pregnancy termination and linked to the life course of women and to the specific context of the pregnancy. Methods: Data came from a cross-sectional study, using interviewer-administered questionnaire, developed with women that attended public health services in Porto Alegre, Brazil. A generalized estimating equation model with logit link measured the association between determinants and abortion. Findings: The final sample was composed of 684 women living with HIV/Aids (2,039 pregnancies) and 639 women not living with HIV/Aids (1,539 pregnancies). The prevalence of induced abortion among pregnancies in women living with HIV/Aids was 6.5%, while in women not living with HIV/Aids was 2.9%. Among women living with HIV/Aids, the following were associated with induced abortion in the multivariable analysis: being older, having a higher education level, having had more sexual partners (i.e., variables linked to the life course of women), having had children prior to the index pregnancy and living with a sexual partner during pregnancy (i.e., variables linked to the context of each pregnancy). On the other hand, among women not living with HIV/Aids, only having a higher education level and having had more sexual partners (i.e., determinants linked to the life course of women) were associated with voluntary pregnancy termination in multivariable analysis. Conclusion: Although determinants are similar between women living and not living with HIV/Aids, prevalence of induced abortion is higher among pregnancies in women living with HIV/Aids, pointing to their greater social vulnerability and to the need for public policy to address prevention and treatment of HIV associated with reproductive issues. [ABSTRACT FROM AUTHOR]

Background: Little is known about how to tailor implementation of mental health services in low- and middle-income countries (LMICs) to the diverse settings encountered within and between countries. In this paper we compare the baseline context, challenges and opportunities in districts in five LMICs (Ethiopia, India, Nepal, South Africa and Uganda) participating in the PRogramme for Improving Mental health carE (PRIME). The purpose was to inform development and implementation of a comprehensive district plan to integrate mental health into primary care. Methods: A situation analysis tool was developed for the study, drawing on existing tools and expert consensus. Cross-sectional information obtained was largely in the public domain in all five districts. Results: The PRIME study districts face substantial contextual and health system challenges many of which are common across sites. Reliable information on existing treatment coverage for mental disorders was unavailable. Particularly in the low-income countries, many health service organisational requirements for mental health care were absent, including specialist mental health professionals to support the service and reliable supplies of medication. Across all sites, community mental health literacy was low and there were no models of multi-sectoral working or collaborations with traditional or religious healers. Nonetheless health system opportunities were apparent. In each district there was potential to apply existing models of care for tuberculosis and HIV or non-communicable disorders, which have established mechanisms for detection of drop-out from care, outreach and adherence support. The extensive networks of community-based health workers and volunteers in most districts provide further opportunities to expand mental health care. Conclusions: The low level of baseline health system preparedness across sites underlines that interventions at the levels of health care organisation, health facility and community will all be essential for sustainable delivery of quality mental health care integrated into primary care. [ABSTRACT FROM AUTHOR]

Objectives: To extend existing research on the US health disadvantage relative to Europe by studying the relationships of disability with age from midlife to old age in the US and four European regions (England/Northern and Western Europe/Southern Europe/Eastern Europe) including their wealth-related differences, using a flexible statistical approach to model the age-functions. Methods: We used data from three studies on aging, with nationally representative samples of adults aged 50 to 85 from 15 countries (N = 48225): the US-American Health and Retirement Study (HRS), the English Longitudinal Study of Ageing (ELSA) and the Survey of Health, Ageing and Retirement in Europe (SHARE). Outcomes were mobility limitations and limitations in instrumental activities of daily living. We applied fractional polynomials of age to determine best fitting functional forms for age on disability in each region, while controlling for socio-demographic characteristics and important risk factors (hypertension, diabetes, obesity, smoking, physical inactivity). Results: Findings showed high levels of disability in the US with small age-related changes between 50 and 85. Levels of disability were generally lower in Eastern Europe, followed by England and Southern Europe and lowest in Northern and Western Europe. In these latter countries age-related increases of disability, though, were steeper than in the US, especially in Eastern and Southern Europe. For all countries and at all ages, disability levels were higher among adults with low wealth compared to those with high wealth, with largest wealth-related differences among those in early old age in the USA. Conclusions: This paper illustrates considerable variations of disability and its relationship with age. It supports the hypothesis that less developed social policies and more pronounced socioeconomic inequalities are related to higher levels of disability and an earlier onset of disability. [ABSTRACT FROM AUTHOR]

Background: Vitamin B12 deficiency is prevalent in many countries of origin of refugees. Using a threshold of 5% above which a prevalence of low Vitamin B12 is indicative of a population health problem, we hypothesised that Vitamin B12 deficiency exceeds this threshold among newly-arrived refugees resettling in Australia, and is higher among women due to their increased risk of food insecurity. This paper reports Vitamin B12 levels in a large cohort of newly arrived refugees in five Australian states and territories. Methods: In a cross-sectional descriptive study, we collected Vitamin B12, folate and haematological indices on all refugees (n = 916; response rate 94% of eligible population) who had been in Australia for less than one year, and attended one of the collaborating health services between July 2010 and July 2011. Results: 16.5% of participants had Vitamin B12 deficiency (<150 pmol/L). One-third of participants from Iran and Bhutan, and one-quarter of participants from Afghanistan had Vitamin B12 deficiency. Contrary to our hypothesis, low Vitamin B12 levels were more prevalent in males than females. A higher prevalence of low Vitamin B12 was also reported in older age groups in some countries. The sensitivity of macrocytosis in detecting Vitamin B12 deficiency was only 4.6%. Conclusion: Vitamin B12 deficiency is an important population health issue in newly-arrived refugees from many countries. All newly-arrived refugees should be tested for Vitamin B12 deficiency. Ongoing research should investigate causes, treatment, and ways to mitigate food insecurity, and the contribution of such measures to enhancing the health of the refugee communities. [ABSTRACT FROM AUTHOR]

Objective: Excess mortality from diseases and medical conditions (natural death) in persons with psychiatric disorders has been extensively reported. Even in the Nordic countries with well-developed welfare systems, register based studies find evidence of an excess mortality. In recent years, cardiac mortality and death by diseases of the circulatory system has seen a decline in all the Nordic countries, but a recent paper indicates that women and men in Denmark, Finland, and Sweden, who had been hospitalised for a psychotic disorder, had a two to three-fold increased risk of dying from a cardiovascular disease. The aim of this study was to compare the mortality by diseases of the circulatory system among patients with bipolar disorder or schizophrenia in the three Nordic countries Denmark, Sweden, and Finland. Furthermore, the aim was to examine and compare life expectancy among these patients. Cause specific Standardized Mortality Rates (SMRs) were calculated for each specific subgroup of mortality. Life expectancy was calculated using Wiesler’s method. Results: The SMR for bipolar disorder for diseases of the circulatory system was approximately 2 in all countries and both sexes. SMR was slightly higher for people with schizophrenia for both genders and in all countries, except for men in Denmark. Overall life expectancy was much lower among persons with bipolar disorder or schizophrenia, with life expectancy being from 11 to 20 years shorter. Conclusion: Our data show that persons in the Nordic countries with schizophrenia or bipolar disorder have a substantially reduced life expectancy. An evaluation of the reasons for these increased mortality rates should be prioritized when planning healthcare in the coming years. [ABSTRACT FROM AUTHOR]

Background: This population-based cohort study has the objective to understand the sociodemographic characteristics and health conditions of patients who do not receive surgery within 18 months following an ambulatory visit to an orthopaedic surgeon. Methods: Administrative healthcare databases in Ontario, Canada were linked to identify all patients making an initial ambulatory visit to orthopaedic surgeons between October 1st, 2004 and September 30th, 2005. Logistic regression was used to examine predictors of not receiving surgery within 18 months. Results: Of the 477,945 patients in the cohort 49% visited orthopaedic surgeons for injury, and 24% for arthritis. Overall, 79.3% did not receive surgery within 18 months of the initial visit, which varied somewhat by diagnosis at first visit (84.5% for injury and 73.0% for arthritis) with highest proportions in the 0–24 and 25–44 age groups. The distribution by income quintile of patients visiting was skewed towards higher incomes. Regression analysis for each diagnostic group showed that younger patients were significantly more likely to be non-surgical than those aged 65+ years (age 0–24: OR 3.45 95%CI 3.33–3.57; age 25–44: OR 1.30 95%CI 1.27–1.33). The odds of not getting surgery were significantly higher for women than men for injury and other conditions; the opposite was true for arthritis and bone conditions. Conclusion: A substantial proportion of referrals were for expert diagnosis or advice on management and treatment. The findings also suggest socioeconomic inequalities in access to orthopaedic care. Further research is needed to investigate whether the high caseload of non-surgical cases affects waiting times to see a surgeon. This paper contributes to the development of evidence-based strategies to streamline access to surgery, and to develop models of care for non-surgical patients to optimize the use of scarce orthopaedic surgeon resources and to enhance the management of musculoskeletal disorders across the care continuum. [ABSTRACT FROM AUTHOR]

Objectives: The paper describes the creation of a new scale to measure intimate partner violence (IPV) among gay and bisexual men. Methods: Seven focus group discussions were held with gay and bisexual men, focusing on defining intimate partner violence: 30 forms of IPV were identified. A venue-recruited sample of 912 gay and bisexual men was surveyed, examining definitional understanding and recent experiences of each of the 30 forms of IPV. Participants were also asked questions from the CDC definition of intimate partner violence and the short-form of the Conflicts Tactics Scale (CTS2S). Factor analysis of responses to the definitional questions was used to create the IPV-GBM scale, and the prevalence of intimate partner violence was compared with that identified by the CDC and CTS2S measures of intimate partner violence. Results: A 23-item scale, with 5 unique domains, was created, with strong internal reliability (Cronbach Alpha >.90). The IPV-GBM scale mirrored both the CDC and CTS2S definitions of intimate partner violence, but contained additional domains such as controlling violence, monitoring behaviors, emotional violence, and HIV-related violence. The new scale identified a significantly higher prevalence of IPV than either of the more commonly used measures. Conclusions: The results presented here provide encouraging evidence for a new, more accurate measure of intimate partner violence among gay and bisexual men in the U.S. [ABSTRACT FROM AUTHOR]

Background: Unhappiness at school is one of the main reasons for truancy among adolescents. In order to assess this problem more thoroughly in the context of Japanese adolescents, the present study examined the associations between feelings of unhappiness at school and lifestyle habits, school life realities, and mental health status. Method: This study was designed as a cross-sectional survey. A self-administered questionnaire was provided to students enrolled in randomly selected junior and senior high schools throughout Japan. We calculated the percentages of both junior and senior high school students who felt unhappy at school based on factors related to school life, lifestyle habits, and mental health status. Multiple logistic regression analyses were performed in order to examine the associations between those factors and students' feelings of unhappiness at school. Results: A total of 98,867 valid responses were analysed, 7.9% (Boys: 8.4%, Girls: 7.4%) of which came from students who responded that they felt unhappy at school. For both junior and senior high school students, the percentages of those who felt unhappy at school were significantly higher among those who had not yet decided on their future life course, who did not participate in extracurricular activities, did not eat breakfast every day, went to bed late, had used tobacco or alcohol in the previous 30 days, and had poor mental health compared with others. The results of multiple logistic regression analyses indicated that the adjusted odds ratios for feeling unhappy at school with regard to the above-mentioned factors were significantly high for both junior and senior high school students. Conclusions: The present results suggest that school employees and administrators must provide health guidance to students, considering that irregular lifestyle habits, lower school engagement, smoking, drinking alcohol, and poor mental health status are all associated with maladaptation to school among adolescents. [ABSTRACT FROM AUTHOR]

Objective: To design interventions that target energy balance-related behaviours, knowledge of primary schoolchildren's perceptions regarding soft drink intake, fruit juice intake, breakfast consumption, TV viewing and physical activity (PA) is essential. The current study describes personal beliefs and attitudes, home- and friend-related variables regarding these behaviours across Europe. Design: Cross-sectional study in which personal, family and friend -related variables were assessed by validated questionnaires, and dichotomized as favourable versus unfavourable answers. Logistic regression analyses were conducted to estimate proportions of children giving unfavourable answers and test between-country differences. Setting: A survey in eight European countries. Subjects: A total of 7903 10–12 year old primary schoolchildren. Results: A majority of the children reported unfavourable attitudes, preferences and subjective norms regarding soft drink, fruit juice intake and TV viewing accompanied with high availability and accessibility at home. Few children reported unfavourable attitudes and preferences regarding breakfast consumption and PA. Many children reported unfavourable health beliefs regarding breakfast consumption and TV viewing. Substantial differences between countries were observed, especially for variables regarding soft drink intake, breakfast consumption and TV viewing. Conclusion: The surveyed children demonstrated favourable attitudes to some healthy behaviours (PA, breakfast intake) as well as to some unhealthy behaviours (soft drink consumption, TV viewing). Additionally, many children across Europe have personal beliefs and are exposed to social environments that are not supportive to engagement in healthy behaviours. Moreover, the large differences in personal, family and friend-related variables across Europe argue for implementing different strategies in the different European countries. [ABSTRACT FROM AUTHOR]

Background: Proposed payment reforms in the US healthcare system would hold providers accountable for the care delivered to an assigned patient population. Annual hemoglobin A1c (HbA1c) tests are recommended for all diabetics, but some patient populations may face barriers to high quality healthcare that are beyond providers' control. The magnitude of fine-grained variations in care for diabetic Medicare beneficiaries, and their associations with local population characteristics, are unknown. Methods: HbA1c tests were recorded for 480,745 diabetic Medicare beneficiaries. Spatial analysis was used to create ZIP code-level estimated testing rates. Associations of testing rates with local population characteristics that are outside the control of providers – population density, the percent African American, with less than a high school education, or living in poverty – were assessed. Results: In 2009, 83.3% of diabetic Medicare beneficiaries received HbA1c tests. Estimated ZIP code-level rates ranged from 71.0% in the lowest decile to 93.1% in the highest. With each 10% increase in the percent of the population that was African American, associated HbA1c testing rates were 0.24% lower (95% CI −0.32–−0.17); for identical increases in the percent with less than a high school education or the percent living in poverty, testing rates were 0.70% lower (−0.95–−0.46) and 1.6% lower (−1.8–−1.4), respectively. Testing rates were lowest in the least and most densely populated ZIP codes. Population characteristics explained 5% of testing rate variations. Conclusions: HbA1c testing rates are associated with population characteristics, but these characteristics fail to explain the vast majority of variations. Consequently, even complete risk-adjustment may have little impact on some process of care quality measures; much of the ZIP code-related variations in testing rates likely result from provider-based differences and idiosyncratic local factors not related to poverty, education, or race. [ABSTRACT FROM AUTHOR]

Background: In most countries of Sub-Saharan Africa, control of lymphatic filariasis (LF) is based on annual mass drug administration (MDA) with a combination of ivermectin and albendazole. Treatment coverages are however often suboptimal for programmes to reach the goal of transmission interruption within reasonable time. The present study aimed to identify predictors and barriers to individual drug uptake during MDA implementation by the National LF Elimination Programme in Tanzania. Methods: A questionnaire based cross sectional household survey was carried out in two rural and two urban districts in Lindi and Morogoro regions shortly after the 2011 MDA. 3279 adults (≥15 years) were interviewed about personal characteristics, socio-economic status, MDA drug uptake among themselves and their children, reasons for taking/not taking drugs, and participation in previous MDA activities for LF control. Findings: The overall drug uptake rate was 55.1% (range of 44.5–75.6% between districts). There was no overall major difference between children (54.8%) and adults (55.2%) or between females (54.9%) and males (55.8%), but the role of these and other predictors varied to some extent between study sites. Major overall predictors of drug uptake among the interviewed adults were increasing age and history of previous drug uptake. Being absent from home during drug distribution was the main reason for not taking the drugs (50.2%) followed by clinical contraindications to treatment (10.8%), missing household visits of drug distributors (10.6%), and households not being informed about the distribution (9.0%). Conclusion: Drug uptake relied more on easily modifiable provider-related factors than on individual perceptions and practices in the target population. Limited investments in appropriate timing, dissemination of accurate timing information to recipients and motivation of drug distributors to visit all households (repeatedly when residents are absent) are likely to have considerable potential for increasing drug uptake, in support of successful LF transmission elimination. [ABSTRACT FROM AUTHOR]

Background: Recent commentary on the health consequences of natural disasters has suggested a dearth of research on understanding the antecedents prior to the disaster that are associated with health consequences after the disaster. Utilizing data from a two-wave panel survey of Port-au-Prince, Haiti, conducted just prior to and six weeks after the January 2010 earthquake, we test factors prior to the quake hypothesized to be associated with food insecurity after the quake. Methods: Using random Global Positioning System (GPS) sampling, we re-interviewed 93.1% (N = 1732) of the original 1,800 households interviewed in 2009. Respondents were queried with regard to mortalities, injuries, food security, housing, and other factors after the quake. Findings: Child food insecurity was found to be common on all three indices of food security (17.2%–22.6%). Additionally, only 36.5% of school-aged children were attending school prior to the quake. Findings suggest that prior schooling was associated with a substantial reduction on food insecurity indices (OR 0.62–0.75). Findings further suggest that several household characteristics were associated with food insecurity for children. Prior chronic/acute illnesses, poor living conditions, remittances from abroad, primary respondent mental health, and histories of criminal and other human rights violations committed against family members prior to the quake were associated with food insecurity after the earthquake. Earned household income after the quake was only associated with one of the measures of food insecurity. Interpretation: Food insecurity for children was common after the quake. Those households vulnerable on multiple dimensions prior to the quake were also vulnerable to food insecurity after the quake. Remittances from abroad were leading protective factors for food security. Because Haiti is well known for the potentiality of both hurricanes and earthquakes, reconstruction and redevelopment should focus on ameliorating potential vulnerabilities to poor outcomes in these natural disasters. [ABSTRACT FROM AUTHOR]

Objective: In East Asia the recently increased number of marriages in response to pregnancy is an important social issue. This study evaluated the association of marriage preceded by pregnancy (bridal pregnancy) with obstetric outcomes among live births in Korea. Methods: In this population-based study, 1,152,593 first singleton births were evaluated from data registered in the national birth registration database from 2004 to 2008 in Korea. In the study population, the pregnancy outcomes among live births from the bridal pregnancy group (N = 62,590) were compared with the outcomes of the post-marital pregnancy group (N = 564,749), composed of women who gave birth after 10 months but before 24 months of marriage. The variables preterm birth (PTB; <37 weeks gestation) and low birth weight (LBW; <2.5 kg) were used to determine the primary outcome. The adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated after controlling for socio-demographic factors. Results: The socio-demographic factors among the bridal pregnancy group were associated with a social disadvantage and particular risk factors. In the subgroup analyses of maternal age, differences in adverse pregnancy outcomes from bridal pregnancy were identified between women in the following age group: (i) ≤19, (ii) 20–39, and (iii) ≥40 years. After the multivariate analysis, the aORs for each age group were 1.47 (95% CI: 1.15–1.89), 1.76 (1.70–1.83), and 1.13 (0.77–1.66), respectively, for PTB and 0.92 (0.70–1.21), 1.60 (1.53–1.66), and 1.11 (0.71–1.74), respectively, for LBW. In the adjusted logistic regression models, bridal pregnancy was associated with PTB (1.76, 1.69–1.82) and LBW (1.53, 1.48–1.59). Conclusion: Pregnancy outcomes among live births from bridal pregnancies are associated with higher risks for PTB and LBW in Korea. [ABSTRACT FROM AUTHOR]

Introduction: Multimorbidity is a major concern in primary care. Nevertheless, evidence of prevalence and patterns of multimorbidity, and their determinants, are scarce. The aim of this study is to systematically review studies of the prevalence, patterns and determinants of multimorbidity in primary care. Methods: Systematic review of literature published between 1961 and 2013 and indexed in Ovid (CINAHL, PsychINFO, Medline and Embase) and Web of Knowledge. Studies were selected according to eligibility criteria of addressing prevalence, determinants, and patterns of multimorbidity and using a pretested proforma in primary care. The quality and risk of bias were assessed using STROBE criteria. Two researchers assessed the eligibility of studies for inclusion (Kappa  = 0.86). Results: We identified 39 eligible publications describing studies that included a total of 70,057,611 patients in 12 countries. The number of health conditions analysed per study ranged from 5 to 335, with multimorbidity prevalence ranging from 12.9% to 95.1%. All studies observed a significant positive association between multimorbidity and age (odds ratio [OR], 1.26 to 227.46), and lower socioeconomic status (OR, 1.20 to 1.91). Positive associations with female gender and mental disorders were also observed. The most frequent patterns of multimorbidity included osteoarthritis together with cardiovascular and/or metabolic conditions. Conclusions: Well-established determinants of multimorbidity include age, lower socioeconomic status and gender. The most prevalent conditions shape the patterns of multimorbidity. However, the limitations of the current evidence base means that further and better designed studies are needed to inform policy, research and clinical practice, with the goal of improving health-related quality of life for patients with multimorbidity. Standardization of the definition and assessment of multimorbidity is essential in order to better understand this phenomenon, and is a necessary immediate step. [ABSTRACT FROM AUTHOR]

Background: An HIV vaccine could substantially impact the epidemic. However, risk compensation (RC), or post-vaccination increase in risk behavior, could present a major challenge. The methodology used in previous studies of risk compensation has been almost exclusively individual-level in focus, and has not explored how increased risk behavior could affect the connectivity of risk networks. This study examined the impact of anticipated HIV vaccine-related RC on the structure of high-risk drug users' sexual and injection risk network. Methods: A sample of 433 rural drug users in the US provided data on their risk relationships (i.e., those involving recent unprotected sex and/or injection equipment sharing). Dyad-specific data were collected on likelihood of increasing/initiating risk behavior if they, their partner, or they and their partner received an HIV vaccine. Using these data and social network analysis, a "post-vaccination network" was constructed and compared to the current network on measures relevant to HIV transmission, including network size, cohesiveness (e.g., diameter, component structure, density), and centrality. Results: Participants reported 488 risk relationships. Few reported an intention to decrease condom use or increase equipment sharing (4% and 1%, respectively). RC intent was reported in 30 existing risk relationships and vaccination was anticipated to elicit the formation of five new relationships. RC resulted in a 5% increase in risk network size (n = 142 to n = 149) and a significant increase in network density. The initiation of risk relationships resulted in the connection of otherwise disconnected network components, with the largest doubling in size from five to ten. Conclusions: This study demonstrates a new methodological approach to studying RC and reveals that behavior change following HIV vaccination could potentially impact risk network connectivity. These data will be valuable in parameterizing future network models that can determine if network-level change precipitated by RC would appreciably impact the vaccine's population-level effectiveness. [ABSTRACT FROM AUTHOR]

In recent years there has been an increasing interest in overprotective parenting and the potential role it plays in child development. While some have argued that a trend towards increased parental fear and reduced opportunity for independent mobility may be linked to increasing rates of child overweight and obesity, there is limited empirical information available to support this claim. Using data from the Longitudinal Study of Australian Children, this study aimed to examine the longitudinal relationships between maternal protectiveness and child overweight and obesity. A cohort of 4–5 year old children was followed up at 6–7, 8–9 and 10–11 years of age (n  =  2596). Measures included a protective parenting scale administered when children were 6–7 and 8–9 years of age, child body mass index (BMI), family characteristics including household income, neighbourhood disadvantage, child's position amongst siblings, and maternal BMI, education, employment, mental health and age at first birth. International Obesity Taskforce age- and sex-specific BMI cut points were used to determine if children were in the normal, overweight or obese BMI range. There was no association between maternal protectiveness and the odds of children being overweight or obese at age 4–5, 6–7 or 8–9 years. However at age 10–11 years, a 1 standard deviation increase in maternal protectiveness was associated with a 13% increase in the odds of children being overweight or obese. The results provide evidence of a relationship between maternal protectiveness and child overweight and obesity, however further research is required to understand the mechanism(s) that links the two concepts. [ABSTRACT FROM AUTHOR]

Background: The epidemiological profile and trends of road traffic injuries (RTIs) in Peru have not been well-defined, though this is a necessary step to address this significant public health problem in Peru. The objective of this study was to determine trends of incidence, mortality, and fatality of RTIs in Peru during 1973–2008, as well as their relationship to population trends such as economic growth. Methods and Findings: Secondary aggregated databases were used to estimate incidence, mortality and fatality rate ratios (IRRs) of RTIs. These estimates were standardized to age groups and sex of the 2008 Peruvian population. Negative binomial regression and cubic spline curves were used for multivariable analysis. During the 35-year period there were 952,668 road traffic victims, injured or killed. The adjusted yearly incidence of RTIs increased by 3.59 (95% CI 2.43–5.31) on average. We did not observe any significant trends in the yearly mortality rate. The total adjusted yearly fatality rate decreased by 0.26 (95% CI 0.15–0.43), while among adults the fatality rate increased by 1.25 (95% CI 1.09–1.43). Models fitted with splines suggest that the incidence follows a bimodal curve and closely followed trends in the gross domestic product (GDP) per capita Conclusions: The significant increasing incidence of RTIs in Peru affirms their growing threat to public health. A substantial improvement of information systems for RTIs is needed to create a more accurate epidemiologic profile of RTIs in Peru. This approach can be of use in other similar low and middle-income settings to inform about the local challenges posed by RTIs. [ABSTRACT FROM AUTHOR]

Objectives: Oral diseases are associated with adverse pregnancy outcomes. The routine utilization of dental care (RUDC) during pregnancy is an effective way to improve pregnant women’s oral health, and thus safeguard the health of their babies. As China has one fifth of the world’s population, it is especially meaningful to encourage RUDC there. However, the status of RUDC in China and the key underlying factors are largely unknown. Methods: This cross-sectional survey investigated the current status of RUDC during pregnancy and the key underlying factors in Hangzhou City, Zhejiang Province, eastern China. We collected participants’ demographics, individual oral-hygiene behaviors, individual lifestyle, oral-health conditions and attitudes, and also their RUDC during pregnancy. Binary Logistic Regression Analysis was used to analyze the key underlying factors. Results: Only 16.70% of the participants reported RUDC during pregnancy. The percentage of RUDC was significantly lower among pregnant women with the following characteristics: aged 30 or less, an annual household income under $8,000, brushing once a day or less, never flossing or rinsing the mouth, paying no attention to pregnancy-related oral-health knowledge, and being dissatisfied with one’s individual dental hygiene behavior. Conclusions: RUDC during pregnancy is very low in eastern China and is greatly influenced not only by a woman’s age, annual income, individual hygiene behavior, but also by her attention and attitudes to oral health. To improve this population’s access to and use of dental care during pregnancy, appropriate programs and policies are urgently needed. [ABSTRACT FROM AUTHOR]

Background: Consistent evidence has demonstrated that smoking ban policies save lives, but impacts on health inequalities are uncertain as few studies have assessed post-ban effects by socioeconomic status (SES) and findings have been inconsistent. The aim of this study was to assess the effects of the national Irish smoking ban on ischemic heart disease (IHD), stroke, and chronic obstructive pulmonary disease (COPD) mortality by discrete and composite SES indicators to determine impacts on inequalities. Methods: Census data were used to assign frequencies of structural and material SES indicators to 34 local authorities across Ireland with a 2000–2010 study period. Discrete indicators were jointly analysed through principal component analysis to generate a composite index, with sensitivity analyses conducted by varying the included indicators. Poisson regression with interrupted time-series analysis was conducted to examine monthly age and gender-standardised mortality rates in the Irish population, ages ≥35 years, stratified by tertiles of SES indicators. All models were adjusted for time trend, season, influenza, and smoking prevalence. Results: Post-ban mortality reductions by structural SES indicators were concentrated in the most deprived tertile for all causes of death, while reductions by material SES indicators were more equitable across SES tertiles. The composite indices mirrored the results of the discrete indicators, demonstrating that post-ban mortality decreases were either greater or similar in the most deprived when compared to the least deprived for all causes of death. Conclusions: Overall findings indicated that the national Irish smoking ban reduced inequalities in smoking-related mortality. Due to the higher rates of smoking-related mortality in the most deprived group, even equitable reductions across SES tertiles resulted in decreases in inequalities. The choice of SES indicator was influential in the measurement of effects, underscoring that a differentiated analytical approach aided in understanding the complexities in which structural and material factors influence mortality. [ABSTRACT FROM AUTHOR]

Background: Despite evidence that neighbourhood conditions affect residents' health, no prospective studies of the association between neighbourhood socio-demographic factors and all-cause mortality have been conducted in non-Western societies. Thus, we examined the effects of areal deprivation and population density on all-cause mortality in Japan. Methods: We employed census and survival data from the Japan Public Health Center-based Prospective Study, Cohort I (n = 37,455), consisting of middle-aged residents (40 to 59 years at the baseline in 1990) living in four public health centre districts. Data spanned between 1990 and 2010. A multilevel parametric proportional-hazard regression model was applied to estimate the hazard ratios (HRs) of all-cause mortality by two census-based areal variables —areal deprivation index and population density—as well as individualistic variables such as socioeconomic status and various risk factors. Results: We found that areal deprivation and population density had moderate associations with all-cause mortality at the neighbourhood level based on the survival data with 21 years of follow-ups. Even when controlling for individualistic socio-economic status and behavioural factors, the HRs of the two areal factors (using quartile categorical variables) significantly predicted mortality. Further, this analysis indicated an interaction effect of the two factors: areal deprivation prominently affects the health of residents in neighbourhoods with high population density. Conclusions: We confirmed that neighbourhood socio-demographic factors are significant predictors of all-cause death in Japanese non-metropolitan settings. Although further study is needed to clarify the cause-effect relationship of this association, the present findings suggest that health promotion policies should consider health disparities between neighbourhoods and possibly direct interventions towards reducing mortality in densely populated and highly deprived neighbourhoods. [ABSTRACT FROM AUTHOR]

Undernutrition among HIV-positive children can be ameliorated if they are given adequate foods in the right frequency and diversity. Food insecurity is known to undermine such efforts, but even in food rich areas, people have undernutrition. As yet no study has examined feeding practices and their associations with nutrition status among as HIV-positive children in regions with high food production. We therefore examined the magnitude of undernutrition and its association with feeding practices among HIV-positive children in a high food production region in Tanzania. Methods: We conducted this mixed-method study among 748 children aged 6 months-14 years attending 9 of a total of 32 care and treatment centers in Tanga region, Tanzania. We collected quantitative data using a standard questionnaire and qualitative data through seven focus group discussions (FGDs). Results: HIV-positive children had high magnitudes of undernutrition. Stunting, underweight, wasting, and thinness were prevalent among 61.9%, 38.7%, 26.0%, and 21.1% of HIV-positive children, respectively. They also had poor feeding practices: 88.1% were fed at a frequency below the recommendations, and 62.3% had a low level of dietary diversity. Lower feeding frequency was associated with stunting (β = 0.11, p = 0.016); underweight (β = 0.12, p = 0.029); and thinness (β = 0.11, p = 0.026). Lower feeding frequency was associated with low wealth index (β = 0.06, p<0.001), food insecurity (β = −0.05, p<0.001), and caregiver's education. In the FGDs, participants discussed the causal relationships among the key associations; undernutrition was mainly due to low feeding frequency and dietary diversity. Such poor feeding practices resulted from poor nutrition knowledge, food insecurity, low income, and poverty. Conclusion: Feeding practices and nutrition status were poor among HIV-positive children even in food rich areas. Improving feeding frequency may help to ameliorate undernutrition. To improve it, tailored interventions should target children of poor households, the food insecure, and caregivers who have received only a low level of education. [ABSTRACT FROM AUTHOR]

Background: The evidence on alcohol use disorder among conflict-affected civilian populations remains extremely weak, despite a number of potential risk-factors. The aim of this study is to examine patterns of alcohol use disorder among conflict-affected persons in the Republic of Georgia. Methods: A cross-sectional survey of 3600 randomly selected internally displaced persons (IDPs) and former IDPs. Two alcohol use disorder outcomes were measured: (i) having at least hazardous alcohol use (AUDIT score ≥8); (ii) episodic heavy drinking (consuming >60 grams of pure alcohol per drinking session at least once a week). Individual level demographic and socio-economic characteristics were also recorded, including mental disorders. Community level alcohol environment characteristics relating to alcohol availability, marketing and pricing were recorded in the respondents' communities and a factor analysis conducted to produce a summary alcohol environment factor score. Logistic regression analyses examined associations between individual and community level factors with the alcohol use disorder outcomes (among men only). Results: Of the total sample, 71% of men and 16% of women were current drinkers. Of the current drinkers (N = 1386), 28% of men and 1% of women were classified as having at least hazardous alcohol use; and 12% of men and 2% of women as episodic heavy drinkers. Individual characteristics significantly associated with both outcomes were age and experiencing a serious injury, while cumulative trauma events and depression were also associated with having at least hazardous alcohol use. For the community level analysis, a one unit increase in the alcohol environment factor was associated with a 1.27 fold increase in episodic heavy drinking among men (no significant association with hazardous alcohol use). Conclusion: The findings suggest potential synergies for treatment responses for alcohol use disorder and depression among conflict-affected populations in Georgia, as well as the need for stronger alcohol control policies in Georgia. [ABSTRACT FROM AUTHOR]

Objectives: To quantify the independent roles of geography and Indigenous status in explaining disparities in Potentially Preventable Hospital (PPH) admissions between Indigenous and non-Indigenous Australians. Design, setting and participants: Analysis of linked hospital admission data for New South Wales (NSW), Australia, for the period July 1 2003 to June 30 2008. Main outcome measures: Age-standardised admission rates, and rate ratios adjusted for age, sex and Statistical Local Area (SLA) of residence using multilevel models. Results: PPH diagnoses accounted for 987,604 admissions in NSW over the study period, of which 3.7% were for Indigenous people. The age-standardised PPH admission rate was 76.5 and 27.3 per 1,000 for Indigenous and non-Indigenous people respectively. PPH admission rates in Indigenous people were 2.16 times higher than in non-Indigenous people of the same age group and sex who lived in the same SLA. The largest disparities in PPH admission rates were seen for diabetes complications, chronic obstructive pulmonary disease and rheumatic heart disease. Both rates of PPH admission in Indigenous people, and the disparity in rates between Indigenous than non-Indigenous people, varied significantly by SLA, with greater disparities seen in regional and remote areas than in major cities. Conclusions: Higher rates of PPH admission among Indigenous people are not simply a function of their greater likelihood of living in rural and remote areas. The very considerable geographic variation in the disparity in rates of PPH admission between Indigenous and non-Indigenous people indicates that there is potential to reduce unwarranted variation by characterising outlying areas which contribute the most to this disparity. [ABSTRACT FROM AUTHOR]

Background: Epidemiological data from South Africa demonstrate that risk of human immunodeficiency virus (HIV) infection in males increases dramatically after adolescence. Targeting adolescent HIV-negative males may be an efficient and cost-effective means of maximising the established HIV prevention benefits of voluntary medical male circumcision (VMMC) in high HIV prevalence–, low circumcision practice–settings. This study assessed the feasibility of recruiting male high school students for VMMC in such a setting in rural KwaZulu-Natal. Methods and Findings: Following community and key stakeholder consultations on the acceptability of VMMC recruitment through schools, information and awareness raising sessions were held in 42 high schools in Vulindlela. A three-phase VMMC demand-creation strategy was implemented in partnership with a local non-governmental organization, ZimnadiZonke, that involved: (i) community consultation and engagement; (ii) in-school VMMC awareness sessions and centralized HIV counselling and testing (HCT) service access; and (iii) peer recruitment and decentralized HCT service access. Transport was provided for volunteers to the Centre for the AIDS Programme of Research in South Africa (CAPRISA) clinic where the forceps-guided VMMC procedure was performed on consenting HIV-negative males. HIV infected volunteers were referred to further care either at the CAPRISA clinic or at public sector clinics. Between March 2011 and February 2013, a total of 5165 circumcisions were performed, the majority (71%) in males aged between 15 and 19 years. Demand-creation strategies were associated with an over five-fold increase in VMMC uptake from an average of 58 procedures/month in initial community engagement phases, to an average of 308 procedures/month on initiation of the peer recruitment–decentralized service phase. Post-operative adverse events were rare (1.2%), mostly minor and self-resolving. Conclusions: Optimizing a high volume, adolescent-targeted VMMC program was feasible, acceptable and safe in this setting. Adaptive demand-creation strategies are required to sustain high uptake. [ABSTRACT FROM AUTHOR]

Background: In 2009 the state government of Madhya Pradesh, India launched an emergency obstetric transportation service, Janani Express Yojana (JEY), to support the cash transfer program that promotes institutional delivery. JEY, a large scale public private partnership, lowers geographical access barriers to facility based care. The state contracts and pays private agencies to provide emergency transportation at no cost to the user. The objective was to study (a) the utilization of JEY among women delivering in health facilities, (b) factors associated with usage, (c) the timeliness of the service. Methods: A cross sectional facility based study was conducted in facilities that carried out > ten deliveries a month. Researchers who spent five days in each facility administered a questionnaire to all women who gave birth there to elicit socio-demographic characteristics and transport related details. Results: 35% of women utilised JEY to reach a facility, however utilization varied between study districts. Uptake was highest among women from rural areas (44%), scheduled tribes (55%), and poorly educated women (40%). Living in rural areas and belonging to scheduled tribes were significant predictors for JEY usage. Almost 1/3 of JEY users (n = 104) experienced a transport related delay. Discussion: The JEY service model complements the cash transfer program by providing transport to a facility to give birth. A study of the distribution of utilization in population subgroups suggests the intervention was successful in reaching the most vulnerable population, promoting equity in access. While 1/3 of women utilized the service and it saved them money; 30% experienced significant transport related delays in reaching a facility, which is comparable to women using public transportation. Further research is needed to understand why utilization is low, to explore if there is a need for service expansion at the community level and to improve the overall time efficiency of JEY. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to explore the racial and ethnic disparities in initiation of antiretroviral treatment (ARV treatment or ART) among HIV-infected Medicaid enrollees 18–64 years of age in 14 southern states which have high prevalence of HIV/AIDS and high racial disparities in HIV treatment access and mortality. Methods: We used Medicaid claims data from 2005 to 2007 for a retrospective cohort study. We compared frequency variances of HIV treatment uptake among persons of different racial- ethnic groups using univariate and multivariate methods. The unadjusted odds ratio was estimated through multinomial logistic regression. The multinomial logistic regression model was repeated with adjustment for multiple covariates. Results: Of the 23,801 Medicaid enrollees who met criteria for initiation of ARV treatment, only one third (34.6%) received ART consistent with national guideline treatment protocols, and 21.5% received some ARV medication, but with sub-optimal treatment profiles. There was no significant difference in the proportion of people who received ARV treatment between black (35.8%) and non-Hispanic whites (35.7%), but Hispanic/Latino persons (26%) were significantly less likely to receive ARV treatment. Conclusions: Overall ARV treatment levels for all segments of the population are less than optimal. Among the Medicaid population there are no racial HIV treatment disparities between Black and White persons living with HIV, which suggests the potential relevance of Medicaid to currently uninsured populations, and the potential to achieve similar levels of equality within Medicaid for Hispanic/Latino enrollees and other segments of the Medicaid population. [ABSTRACT FROM AUTHOR]

Background: Intimate partner violence (IPV) is a serious global public health issue. Acceptance of wife beating is known to be associated with IPV, but few studies have analysed the acceptance of wife beating from both women and men’s points of view. The objective of this study was to examine whether acceptance of wife beating among couples is associated with lifetime and past one-year physical IPV perpetration towards wives in Nepal. Methods: A cross-sectional study was conducted from August to September 2011, with 717 randomly selected couples with wives aged 18 to 49 years old from the Kirtipur municipality and Bhaktapur district of Nepal. Wives’ and husbands’ acceptance of wife beating was measured by six scale items, while physical IPV experience among wives was measured by seven physical assault scale items. To assess the association between acceptance of wife beating and physical IPV, multiple logistic regression analysis was used. Results: Nearly 30% of wives and husbands indicated that beating of wives is acceptable under certain circumstances. Statistically, no significant difference was detected between wives’ and husbands’ level of acceptance of wife beating. However, husbands’ acceptance of wife beating was positively associated with lifetime and past one-year perpetration of physical IPV, whereas wives’ acceptance of wife beating was neither associated with lifetime nor past one-year victimization of physical IPV. The positive association for husbands remained even after controlling for their partner’s factors. Conclusions: Acceptance of wife beating is an important risk factor, which must be considered to prevent perpetration of physical IPV towards wives in Nepal. Future studies should include men to better understand the structure and dynamics of IPV in Nepal, and prevention programs should also target men to change their attitudes or to identify which couples are at more risk of physical IPV occurring toward wives. [ABSTRACT FROM AUTHOR]

Background: Human Immunodeficiency Virus (HIV) status disclosure has been shown to provide several benefits, both at the individual and societal levels. Aim: To determine risk factors associated with disclosing HIV status among antiretroviral therapy (ART) recipients in South Africa. Setting: A cross-sectional study on risk factors for viremia and drug resistance took place at two outpatient HIV clinics in 2008, at a large hospital located in Soweto, South Africa. Methods: We conducted a secondary data analysis on socio-economic characteristics and HIV status disclosure to anyone, focusing on gender differences. Descriptive and multivariable logistic regression analyses were performed to model the associations between risk factors and HIV status disclosure. Additionally, descriptive analysis was conducted to describe gender differences of HIV status disclosure to partner, parents, parents in law, partner, child, family, employer, and other. Patients: A total of 883 patients were interviewed. The majority were women (73%) with median age of 39 years. Results: Employed patients were less likely to disclose than unemployed (odds ratio (OR) 0.36; 95% confidence interval (CI) 0.1–1.0; p = 0.05)). Women with higher income were more likely to disclose (OR 3.25; 95% CI 0.90–11.7; p = 0.07) than women with lower income, while men with higher income were less likely (OR 0.20; 95% CI 0.02–1.99; p = 0.17) than men with lower income. Men were more likely than women to disclose to their partner (p<0.01), and to partner and family (p<0.01), women were more likely than men to disclose to child and family (p<0.01), to child, family and others (p = 0.01). Conclusion: Being employed imposed a risk factor for HIV status disclosure, additionally we found an interaction effect of gender and income on disclosure. Interventions designed to reduce workplace discrimination and gender-sensitive interventions promoting disclosure are strongly recommended. [ABSTRACT FROM AUTHOR]

Objectives: We used insurance claims of a nationally representative population-based cohort to assess the longitudinal treated prevalence and incidence of attention-deficit/hyperactivity disorder (ADHD) in children, adolescents and adults. Methods: Participants were identified from among National Health Insurance enrollees in Taiwan from 1999 to 2005. We identified study subjects who had at least one service claim during these years with a principal diagnosis of ADHD. A total of 6,173 patients were recorded in the treated ADHD cohort during the 6-year study. Results: There was a significant increase in the treated prevalence rate of ADHD during the study period, from 64.65 per 100,000 in 2000 to 145.40 per 100,000 in 2005 (p = .001). An increase in the treated incidence rate of ADHD, from 44.67 per 100,000 in 2000 to 81.20 per 100,000 in 2005, was also observed (p = .013). However, the treated prevalence of ADHD was still lower than that of the community data in Taiwan. The peak treated prevalence of ADHD was at age 7–12 years for both males and females, and the peak treated incidence of ADHD was at age 0–6 for females and age 7–12 for males. Overall, the treated incidence and prevalence rates dropped abruptly after age 13–18 (both p<.001) for males and females (p<.001 for both). Male vs. female ratios of treated prevalence and incidence were both above 1 before age 25–30 years, but below 1 thereafter. Conclusion: Although an increasing number of people with ADHD sought treatment during 1999–2005 in Taiwan, the treated prevalence of ADHD was still lower than that of the community data. The treated incidence and prevalence of ADHD fell dramatically after age 13–18. However, more women than men sought treatment in adulthood. There may be under-diagnosis and under-treatment of ADHD, especially among females and adults. [ABSTRACT FROM AUTHOR]

Background: We aimed to assess medical students' empathy and its associations with gender, stage of medical school, quality of life and burnout. Method: A cross-sectional, multi-centric (22 medical schools) study that employed online, validated, self-reported questionnaires on empathy (Interpersonal Reactivity Index), quality of life (The World Health Organization Quality of Life Assessment) and burnout (the Maslach Burnout Inventory) in a random sample of medical students. Results: Out of a total of 1,650 randomly selected students, 1,350 (81.8%) completed all of the questionnaires. Female students exhibited higher dispositional empathic concern and experienced more personal distress than their male counterparts (p<0.05; d≥0.5). There were minor differences in the empathic dispositions of students in different stages of their medical training (p<0.05; f<0.25). Female students had slightly lower scores for physical and psychological quality of life than male students (p<0.05; d<0.5). Female students scored higher on emotional exhaustion and lower on depersonalization than male students (p<0.001; d<0.5). Students in their final stage of medical school had slightly higher scores for emotional exhaustion, depersonalization and personal accomplishment (p<0.05; f<0.25). Gender (β = 0.27; p<0.001) and perspective taking (β = 0.30; p<0.001) were significant predictors of empathic concern scores. Depersonalization was associated with lower empathic concern (β = −0.18) and perspective taking (β = −0.14) (p<0.001). Personal accomplishment was associated with higher perspective taking (β = 0.21; p<0.001) and lower personal distress (β = −0.26; p<0.001) scores. Conclusions: Female students had higher empathic concern and personal distress dispositions. The differences in the empathy scores of students in different stages of medical school were small. Among all of the studied variables, personal accomplishment held the most important association with decreasing personal distress and was also a predicting variable for perspective taking. [ABSTRACT FROM AUTHOR]

Background: Management of chronic diseases requires patients to adhere to recommended health behavior change and complete tests for monitoring. While studies have shown an association between low income and lack of adherence, the reasons why people with low income may be less likely to adhere are unclear. We sought to determine the association between household income and receipt of health behavior change advice, adherence to advice, receipt of recommended monitoring tests, and self-reported reasons for non-adherence/non-receipt. Methods: We conducted a population-weighted survey, with 1849 respondents with cardiovascular-related chronic diseases (heart disease, hypertension, diabetes, stroke) from Western Canada (n = 1849). We used log-binomial regression to examine the association between household income and the outcome variables of interest: receipt of advice for and adherence to health behavior change (sodium reduction, dietary improvement, increased physical activity, smoking cessation, weight loss), reasons for non-adherence, receipt of recommended monitoring tests (cholesterol, blood glucose, blood pressure), and reasons for non-receipt of tests. Results: Behavior change advice was received equally by both low and high income respondents. Low income respondents were more likely than those with high income to not adhere to recommendations regarding smoking cessation (adjusted prevalence rate ratio (PRR): 1.55, 95%CI: 1.09–2.20), and more likely to not receive measurements of blood cholesterol (PRR: 1.72, 95%CI 1.24–2.40) or glucose (PRR: 1.80, 95%CI: 1.26–2.58). Those with low income were less likely to state that non-adherence/non-receipt was due to personal choice, and more likely to state that it was due to an extrinsic factor, such as cost or lack of accessibility. Conclusions: There are important income-related differences in the patterns of health behavior change and disease monitoring, as well as reasons for non-adherence or non-receipt. Among those with low income, adherence to health behavior change and monitoring may be improved by addressing modifiable barriers such as cost and access. [ABSTRACT FROM AUTHOR]

Objectives: To adapt the Assessing Care of Vulnerable Elders Quality Indicators (ACOVE QIs) for use in Italy, to assess the adherence to these indicators as reported in the medical records of residents in a nursing home (NH), to compare this adherence for general medical and geriatric conditions, and eventually, to identify the relationships between patients' characteristics and reported processes of care. Methods: Two physicians collected the data by reviewing medical records of all NH residents in the previous 5 years, for a period of one year. Patients aged <65 years were excluded. A total of 245 patients were reviewed during the study period. The ACOVE QIs set, developed for NH processes of care, was used to assess the quality of care. Multivariate analysis was performed to identify and to assess the role of patients' characteristics on quality of processes of care by several domains of care in general medical and geriatric conditions. Results: With the exception of diabetes management, quality of processes of care for general medical conditions approached adequate adherence. Care falls substantially short of acceptable levels for geriatric conditions (pressure ulcers, falls, dementia). On the contrary, the recommended interventions for urinary incontinence were commonly performed. Adherence to indicators varied for the different domains of care and was proven worse for the screening and prevention indicators both for geriatric and general medical conditions. Statistical analysis showed disparities in provision of appropriate processes of care associated with gender, age, co-morbidities, level of function and mobility, length of stay and modality of discharge by NHs. Conclusions: Adherence to recommended processes of care delivered in NH is inadequate. Substantial work lies ahead for the improvement of care. Efforts should focus particularly on management of geriatric conditions and on preventive healthcare. [ABSTRACT FROM AUTHOR]

Background: Health-seeking behaviour lies on the direct pathway between socio-economic position (SEP) and health outcomes. The objective of this systematic review is to identify and synthesise evidence of socio-economic gradients in health-seeking behaviours related to maternal and child health in Egypt. Methods: Four databases (Medline, Embase, Global Health and Web of Science) were searched in September 2013 for material published in English from 1992 to 2013 for a combination of terms describing health-seeking behaviours, indicators of socio-economic position and geographical limitation to Egypt. Findings of studies were described and synthesised in a narrative format as meta-analysis was not possible. Findings: Among the 786 references identified, 10 articles met the inclusion criteria. Six studies examined maternal and five studies child health-seeking behaviours (one study examined both). For maternal health, three dimensions of health-seeking behaviour (receipt of any care, type of care and intensity of care) were covered by studies of ante-natal and one dimension (type of care) by analyses of delivery care. For child health, two dimensions of preventive care (coverage of and intensity of immunisation) and three dimensions of curative care (receipt of any care, type and cost of care) were analysed. Conclusions: Based on two studies of time trends in nationally-representative surveys, socio-economic inequalities in seeking care for basic preventive and curative interventions in maternal and child health appear to have narrowed. Limited evidence of gradients in intensity of maternal preventive and provider selection in child curative care showed that inequalities may have widened. In studies of more geographically and socially homogeneous samples, fewer gradients were identified. Current body of evidence contains numerous limitations and gaps and is insufficient to draw a conclusive summary of such gradients. Improved understanding of SEP gradients is crucial in designing and prioritising interventions to equitably improve maternal and child health outcomes. [ABSTRACT FROM AUTHOR]

Background: Prevalence of childhood overweight/obesity has increased considerably in recent years. The transition to higher rates of overweight/obesity has been well documented in high income countries; however, consistent or representative data from lower income countries is scarce. It is therefore pertinent to assess if rates of overweight/obesity are also increasing in lower income countries, to inform public health efforts. Objective: This systematic review aimed to investigate the evidence for an overweight/obesity transition occurring in school-aged children and youth in Sub Saharan Africa. Methods: Studies were identified by searching the MEDLINE, Embase, Africa Index Medicus, Global Health, Geobase, and EPPI-Centre electronic databases. Studies that used subjective or objective metrics to assess body composition in apparently healthy or population-based samples of children and youth aged 5 to 17 years were included. Results: A total of 283 articles met the inclusion criteria, and of these, 68 were used for quantitative synthesis. The four regions (West, Central, East, and South) of Sub Saharan Africa were well represented, though only 11 (3.9%) studies were nationally representative. Quantitative synthesis revealed a trend towards increasing proportions of overweight/obesity over time in school-aged children in this region, as well as a persistent problem of underweight. Weighted averages of overweight/obesity and obesity for the entire time period captured were 10.6% and 2.5% respectively. Body composition measures were found to be higher in girls than boys, and higher in urban living and higher socioeconomic status children compared to rural populations or those of lower socioeconomic status. Conclusions: This review provides evidence for an overweight/obesity transition in school-aged children in Sub Saharan Africa. The findings of this review serve to describe the region with respect to the growing concern of childhood overweight/obesity, highlight research gaps, and inform interventions. PROSPERO Registration Number: CRD42013004399 [ABSTRACT FROM AUTHOR]

There has been little work that comprehensively compared the relationship between prenatal care and infant health across multiple countries using similar data sources and analytical models. Such comparative analyses are useful for understanding the background of differences in infant health between populations. We evaluated the association between prenatal care visits and fetal growth measured by birth weight (BW) in grams or low birth weight (<2500 grams; LBW) adjusted for gestational age in eight South American countries using similarly collected data across countries and the same analytical models. OLS and logistic regressions were estimated adjusting for a large set of relevant infant, maternal, and household characteristics and birth year and hospital fixed effects. Birth data were acquired from 140 hospitals that are part of the Latin American Collaborative Study of Congenital Malformations (ECLAMC) network. The analytical sample included 56,014 live-born infants (∼69% of total sample) with complete data born without congenital anomalies in the years 1996–2011 in Brazil, Argentina, Chile, Venezuela, Ecuador, Colombia, Bolivia, and Uruguay. Prenatal care visits were significantly (at p<.05) and positively associated with BW and negatively associated with LBW for all countries. The OLS coefficients ranged from 9 grams per visit in Bolivia to 36 grams in Uruguay. The association with LBW was strongest for Chile (OR = 0.87 per visit) and lowest for Argentina and Venezuela (OR = 0.95). The association decreased in the recent decade compared to earlier years. Our findings suggest that estimates of association between prenatal care and fetal growth are population-specific and may not be generalizable to other populations. Furthermore, as one of the indicators for a country’s healthcare system for maternal and child health, prenatal care is a highly variable indicator between countries in South America. [ABSTRACT FROM AUTHOR]

Objectives: Depression is experienced by a large proportion of the workforce and associated with high costs to employers and employees. There is little research on how the social costs of depression vary by social and cultural context. This study investigates individual, workplace and societal factors associated with greater perceived discomfort regarding depression in the workplace, greater likelihood of employees taking time off of work as a result of depression and greater likelihood of disclosure of depression to one's employer. Methods: Employees and managers (n = 7,065) were recruited from seven European countries to participate in the IDEA survey. Multivariable logistic regression models were used to examine associations between individual characteristics and country contextual characteristics in relation to workplace perceptions, likelihood of taking time off work and disclosing depression to an employer. Results: Our findings suggest that structural factors such as benefit systems and flexible working hours are important for understanding workplace perceptions and consequences for employees with depression. However, manager responses that focus on offering help to the employee with depression appear to have stronger associations with positive perceptions in the workplace, and also with openness and disclosure by employees with depression. Conclusion: This study highlights the importance of individual, workplace and societal factors that may be associated with how people with depression are perceived and treated in the workplace, and, hence, factors that may be associated with openness and disclosure among employees with depression. Some responses, such as flexible working hours, may be helpful but are not necessarily sufficient, and our findings also emphasise the importance of support and openness of managers in addition to flexible working hours. [ABSTRACT FROM AUTHOR]

Objective: To identify patterns of perception of front-of-pack (FOP) nutrition labels and determine dietary, lifestyle and health profiles related to such patterns. Design: Cross-sectional. Participants/Setting: 28,952 French adults participating in the web-based Nutrinet-Santé cohort. Outcome measures: Perception was measured using indicators of understanding and acceptability for three simple FOP labels (“green tick”, the logo of the French Nutrition and Health Program and “simple traffic lights” (STL)), and two detailed FOP formats (“multiple traffic lights” (MTL) and “color range” logo (CR)), placed on ready-to-eat soup packages. Dietary intake data were collected using three web-based 24 h records. Statistical analyses: Associations of perception patterns with individual characteristics, including diet, lifestyle and health status, were examined using analysis of covariance and logistic regression, adjusted for socio-demographic and economic factors. Results: No clear trend emerged concerning differences in dietary intake between perception groups. Low physical activity and obesity were more frequent in the ‘favorable to STL’ group (respectively, 20.7% and 10.7%). The ‘favorable to MTL’ group included the highest percentage of individuals who declared type 2 diabetes (2.2%). Persons with hypertension were proportionally more numerous in the ‘favorable to MTL’ and the ‘favorable to CR logo’ groups (respectively, 9.5% and 9.3%). Conclusions: After adjustment for socio-demographic and economic factors, no FOP label stood out as being more suitable than another for reaching populations with poor diet. However, both STL and MTL may be most appropriate for increasing awareness of healthy eating among groups at higher risk of nutrition-related chronic diseases. [ABSTRACT FROM AUTHOR]

Background: Depression and suicidal thinking occur frequently alongside HIV/AIDS, triggering profound detrimental impacts on quality of life, treatment adherence, disease progression, and mortality. Yet the psychosocial factors contributing to these psychiatric comorbidities remain underexplored, particularly in the developing country context. This study thus examined different dimensions of perceived family support in relation to depression and suicidal ideation among people living with HIV/AIDS (PLWHA) in Nepal. Methods: A cross-sectional survey of 322 adult PLWHA residing in the Kathmandu Valley, Nepal was conducted. Data were analyzed using multiple logistic regressions for correlates of Beck Depression Inventory (BDI)-Ia-defined depressive symptoms and suicidal ideation in the past 2 weeks. Perceived family support, measured using the 10-item Nepali Family Support and Difficulty Scale, was entered into separate models, in turn, as a composite score, for each sub-scale (emotional, instrumental, and negative support), and for each individual item. Results: Overall, 25.5% of participants registered BDI-Ia-defined depression, with significantly lower rates among those with perceived family support scores in the highest (AOR = 0.19; 95% CI = 0.07, 0.55) and middle (AOR = 0.38; 95% CI = 0.17, 0.86) tertiles relative to those with lowest-tertile scores. Meanwhile, 14.0% reported suicidal thinking, with significantly lower rates among those in the highest perceived family support tertile relative to the lowest (AOR = 0.25; 95% CI = 0.07, 0.91). Broken down by support sub-scale, only negative support (i.e. family difficulty) was significant in its correlations with both outcomes – a trend similarly reflected in the item-wise analyses. Conclusions: Our findings highlight an important role for family support in determining experiences of depression and suicidality among PLWHA. Incorporating family counseling and support services – with special focus on ameliorating negative interaction and bolstering emotional support – into HIV care and treatment services may help to improve mental health along with overall wellness and treatment outcomes for HIV-positive populations in Nepal and similar settings. [ABSTRACT FROM AUTHOR]

Background: Education and wealth may have different associations with female obesity but this has not been investigated in detail outside high-income countries. This study examines the separate and inter-related associations of education and household wealth in relation to obesity in women in a representative sample of low- and middle-income countries (LMICs). Methods: The seven largest national surveys were selected from a list of Demographic and Health Surveys (DHS) ordered by decreasing sample size and resulted in a range of country income levels. These were nationally representative data of women aged 15–49 years collected in the period 2005–2010. The separate and joint effects, unadjusted and adjusted for age group, parity, and urban/rural residence using a multivariate logistic regression model are presented Results: In the four middle-income countries (Colombia, Peru, Jordan, and Egypt), an interaction was found between education and wealth on obesity (P-value for interaction <0.001). Among women with no/primary education the wealth effect was positive whereas in the group with higher education it was either absent or inverted (negative). In the poorer countries (India, Nigeria, Benin), there was no evidence of an interaction. Instead, the associations between each of education and wealth with obesity were independent and positive. There was a statistically significant difference between the average interaction estimates for the low-income and middle-income countries (P<0.001). Conclusions: The findings suggest that education may protect against the obesogenic effects of increased household wealth as countries develop. Further research could examine the factors explaining the country differences in education effects. [ABSTRACT FROM AUTHOR]

Although there are great changes of dietary in the past few decades in China, few are known about the aluminium exposure in Chinese diet. The aim of this study is to systematically evaluate the dietary aluminium intake level in residents of Shenzhen, China. A total of 853 persons from 244 household were investigated their diet by three days food records. Finally, 149 kinds of foods in 17 food groups were selected to be the most consumed foods. From them, 1399 food samples were collected from market to test aluminium concentration. High aluminium levels were found in jellyfish (median, 527.5 mg/kg), fried twisted cruller (median, 466.0 mg/kg), shell (median, 107.1 mg/kg). The Shenzhen residents' average dietary aluminium exposure was estimated at 1.263 mg/kg bw/week which is lower than the PTWI (provisional tolerable weekly intake). But 0–2 and 3–13 age groups have the highest aluminium intake exceeding the PTWI (3.356 mg/kg bw/week and 3.248 mg/kg bw/week) than other age groups. And the main dietary aluminium exposure sources are fried twisted cruller, leaf vegetables and bean products. Our study suggested that even three decades rapid economy development, children in Shenzhen still have high dietary aluminium exposure risk. How to control high dietary aluminium exposure still is a great public health challenge in Shenzhen, China. [ABSTRACT FROM AUTHOR]

Background: Sexually transmitted infections (STIs), including Hepatitis B and C virus, are emerging public health risks in China, especially among men who have sex with men (MSM). This study aims to assess the magnitude and risks of STIs among Chinese MSM. Methods: Chinese and English peer-reviewed articles were searched in five electronic databases from January 2000 to February 2013. Pooled prevalence estimates for each STI infection were calculated using meta-analysis. Infection risks of STIs in MSM, HIV-positive MSM and male sex workers (MSW) were obtained. This review followed the PRISMA guidelines and was registered in PROSPERO. Results: Eighty-eight articles (11 in English and 77 in Chinese) investigating 35,203 MSM in 28 provinces were included in this review. The prevalence levels of STIs among MSM were 6.3% (95% CI: 3.5–11.0%) for chlamydia, 1.5% (0.7–2.9%) for genital wart, 1.9% (1.3–2.7%) for gonorrhoea, 8.9% (7.8–10.2%) for hepatitis B (HBV), 1.2% (1.0–1.6%) for hepatitis C (HCV), 66.3% (57.4–74.1%) for human papillomavirus (HPV), 10.6% (6.2–17.6%) for herpes simplex virus (HSV-2) and 4.3% (3.2–5.8%) for Ureaplasma urealyticum. HIV-positive MSM have consistently higher odds of all these infections than the broader MSM population. As a subgroup of MSM, MSW were 2.5 (1.4–4.7), 5.7 (2.7–12.3), and 2.2 (1.4–3.7) times more likely to be infected with chlamydia, gonorrhoea and HCV than the broader MSM population, respectively. Conclusion: Prevalence levels of STIs among MSW were significantly higher than the broader MSM population. Co-infection of HIV and STIs were prevalent among Chinese MSM. Integration of HIV and STIs healthcare and surveillance systems is essential in providing effective HIV/STIs preventive measures and treatments. Trial Registration: PROSPERO No: CRD42013003721 [ABSTRACT FROM AUTHOR]

Background: Most maternal deaths occur in developing countries and most maternal deaths are avoidable. China has made a great effort to reduce MMR by three quarters to meet the fifth Millennium Development Goal (MDG5). Methods: This retrospective study reviewed and analyzed maternal death data in Wuhan from 2001 to 2012. Joinpoint regression and multivariate Poisson regression was conducted using the log-linear model to measure the association of the number of maternal deaths with time, cause of death, where the death occurred, and cognitive factors including knowledge, attitude, resource, and management stratified. Results: The MMR declined from 33.41 per 100,000 live births in 2001 to 10.63 per 100,000 live births in 2012, with a total decline of 68.18% and an average annual decline of 9.89%. From 2001–2012, the four major causes of maternal death were obstetric hemorrhage (35.16%), pregnancy complications (28.57%), amniotic fluid embolism (16.48%) and gestational hypertension (8.79%). Multivariate Poisson regression showed on average the MMR decreased by.17% each year from 2001–2006 and stayed stagnant since 2007–2012. Conclusions: With the reduction in MMR in obstetric death (e.g. obstetric hemorrhage), there had been a remarkable reduction in MMR in Wuhan in 2001–2012, which may be due to (1) the improvement in the obstetric quality of perinatal care service on prevention and treatment of obstetric hemorrhage and emergency care skills, and (2) the improvement in the maternal health management and quality of prenatal care. Interventions to further reduce the MMR include several efforts such as the following: (1) designing community-based interventions, (2) providing subsidies to rural women and/hospitals for hospital delivery, (3) screening for pregnancy complications, and (4) establishing an emergency rescue system for critically ill pregnant women. [ABSTRACT FROM AUTHOR]

Background: Little is known about patterns of physical activity engaged in by youth after they immigrate to a new country. This study aims to investigate relationships between immigrant generation and ethnicity with physical activity, and to determine if the relationship between immigrant generation and physical activity was modified by ethnicity. Methods: The data sources were Cycle 6 (2009–2010) of the Canadian Health Behaviour in School-Aged Children Study and the 2006 Canada Census of Population. Participants (weighted n = 23,124) were young people from grades 6–10 in 436 schools. Students were asked where they were born, how long ago they moved to Canada, their ethnicity, and how many days a week they accumulated at least 60 minutes of moderate-to-vigorous physical activity (MVPA). Results: Youth born outside of Canada were less likely to be active than peers born in Canada; 11% vs 15% reported 7 days/week of at least 60 minutes of MVPA (p = .001). MVPA increased with time since immigration. Compared to Canadian-born youth, youth who immigrated within the last 1–2 years were less likely to get sufficient MVPA on 4–6 days/week (odds ratio: 0.66, 95% confidence interval: 0.53–0.82) and 7 days/week (0.62; 0.43–0.89). East and South-East Asian youth were less active, regardless of time since immigration: 4–6 days/week (0.67; 0.58–0.79) and 7 days/week (0.37; 0.29–0.48). Conclusion: Time since immigration and ethnicity were associated with MVPA among Canadian youth. Mechanisms by which these differences occur need to be uncovered in order to identify barriers to physical activity participation among youth. [ABSTRACT FROM AUTHOR]

Introduction: We investigate the links between health and injury in Thailand. This is important because of the high burden of injury in transitional countries and limited information for public health. Methods: We analyse 2005 baseline and 2009, 4-year follow-up data from distance learning students of Sukhothai Thammathirat Open University residing nationwide (n = 60569). Injury was reported for the past year in both periods. Medical Outcome Study Short-Form (SF-8™) health status was reported and Physical and Mental Component Summary Scores (PCS and MCS) were calculated. Analyses used covariate-adjusted multivariate linear regression. Results: In 2009, increasing numbers of traffic injuries (0, 1, 2, 3, 4+) associated with declining PCS scores (49.8, 48.4, 46.9, 46.2, 44.0), along with a similar monotonic decline for MCS scores (47.6, 46.0, 44.2, 42.7, 40.6). A similar (but smaller) dose-response gradient was found between non-traffic injuries and SF-8 scores. Longitudinal analyses showed those with incident injury (no injury 2005, injury 2009) had lower PCS and MCS scores compared to those with no injury in both periods. Individuals with reverting injury status (injury 2005, no injury 2009) reported improvement in PCS and MCS scores over the four-year period. Conclusion: We found significant and epidemiologically important associations between increasing injury frequency and worse health in the past year, especially traffic injuries. Longitudinal 2005–2009 results were supportive and revealed statistically significant adverse 4-year effects of incident injury on health. If injury reverted over four years, low initial scores improved greatly. Findings highlight the importance of injury prevention as a public health priority. [ABSTRACT FROM AUTHOR]

Dietary acculturation, specifically the adoption of western dietary habits, may result in adverse health effects such as obesity and type 2 diabetes. Therefore, it is necessary to explore the role of acculturation in dietary patterns as well as awareness and knowledge of healthy nutrition among South Asian immigrants. This is an especially important population to target as South Asians have higher prevalence rates of type 2 diabetes and cardiovascular disease, which may be magnified with immigration. The current investigation is a sub-study of the Multi-Cultural Community Health Assessment Trial (M-CHAT). There were 207 participants of South Asian origin included in the initial study, 129 were born outside of Canada and had immigrated after the age of 18. The length of residence in Canada was used as a marker for acculturation. A questionnaire addressing perceived changes in dietary patterns, food preparation, and nutrition knowledge and awareness since immigration was used to assess dietary practices. The association between length of residence and variables related to perceived changes in dietary patterns was explored with Spearman correlation and significant associations were subsequently analyzed with ordinal logistic regression analysis adjusted for age, sex, education and body mass index. South Asian immigrants in Canada reported a variety of positive dietary practices, including an increased consumption of fruits and vegetables and an improvement in food preparation (including an increase in grilling and a decrease in deep frying when cooking). However, there was a reported increase in the consumption of convenience foods, sugar-sweetened beverages, red meat and in dining out. South Asian immigrants in Canada reported a variety of positive dietary practices including an improvement in food preparation. Future health promotion strategies should encourage cultural sensitivity in efforts to reduce the consumption of sugar-sweetened beverage, convenience foods and to encourage eating at home rather than dining out. [ABSTRACT FROM AUTHOR]

Introduction: Worldwide, a minority of disordered children/adolescents receives mental health assistance. In order to improve service access, it is important to investigate factors that influence the process leading to receiving care. Data on frequency and barriers for mental health service use (MHSU) among Brazilian children/adolescents are extremely scarce and are needed to guide public policy. Objectives: To establish the frequency of MHSU among 6-to-16-year-old with psychiatric disorders from four Brazilian regions; and to identify structural/psychosocial/demographic barriers associated with child/adolescent MHSU. Methods: Multicenter cross-sectional-study involving four towns from four out of five Brazilian regions. In each town, a representative sample of elementary public school students was randomly selected (sample: 1,721). Child/adolescent MHSU was defined as being seen by a psychologist/psychiatrist/neurologist in the previous 12 months. Standardized instruments measured: (1) children/adolescent characteristics [(1.1) Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS-PL)-psychiatric disorders; (1.2) Ten Questions Screen-neurodevelopment problems; (1.3) two subtests of WISC-III-estimated IQ; (1.4) Academic Performance Test-school performance)], (2) factors related to mothers/main caregivers (Self-Reporting Questionnaire-anxiety/depression), (3) family (Brazilian Research-Companies-Association's Questionnaire-SES). Results: Only 19.8% of children/adolescents with psychiatric disorder have used mental health services in the previous 12 months. Multiple logistic regression modeling identified five factors associated with lower rates of MHSU (female gender, adequate school performance, mother/main caregiver living with a partner, lower SES, residing in deprived Brazilian regions) regardless of the presence of any psychiatric disorders/neurodevelopmental problems. Conclusions: Only a small proportion of children/adolescents with psychiatric disorders had been seen by a mental health specialist in the previous 12 months. Structural/psychosocial/demographic factors were associated with uneven access to service for certain groups of children/adolescents. These results call attention to the urgent need to implement programs to help reduce this large unmet mental health need; inequalities must be considered by policy makers when planning strategies to address barriers for care. [ABSTRACT FROM AUTHOR]

Background: A psychological disorder called ‘Internet addiction’ has newly emerged along with a dramatic increase of worldwide Internet use. However, few studies have used population-level samples nor taken into account contextual factors on Internet addiction. Methods and Findings: We identified 57,857 middle and high school students (13–18 year olds) from a Korean nationally representative survey, which was surveyed in 2009. To identify associated factors with addictive Internet use, two-level multilevel regression models were fitted with individual-level responses (1st level) nested within schools (2nd level) to estimate associations of individual and school characteristics simultaneously. Gender differences of addictive Internet use were estimated with the regression model stratified by gender. Significant associations were found between addictive Internet use and school grade, parental education, alcohol use, tobacco use, and substance use. Female students in girls' schools were more likely to use Internet addictively than those in coeducational schools. Our results also revealed significant gender differences of addictive Internet use in its associated individual- and school-level factors. Conclusions: Our results suggest that multilevel risk factors along with gender differences should be considered to protect adolescents from addictive Internet use. [ABSTRACT FROM AUTHOR]

Background: In many developing countries including Ethiopia, maternal morbidity and mortality still pose a substantial burden and thus progress towards the fifth Millennium Development Goal (MDG) remains slow. Raising awareness of women about the danger signs of pregnancy and childbirth is the first essential step in accepting appropriate and timely referral to obstetric care. However, in Ethiopia little is known about the knowledge level of mothers about obstetric danger signs. The objective of this study was to assess the status of knowledge of danger signs of pregnancy and childbirth among mothers who gave birth in the past two years prior to the survey in Tsegedie district, Tigray regional state, Ethiopia. Methods: A Community based cross-sectional study was conducted from November 20, 2012 to June 30, 2013 on a randomly selected sample of 485 women who had at least one delivery in the past two years. Multistage sampling technique was employed to select the study participants. A pre-tested structured questionnaire was used to collect quantitative data. Focus group discussion and in-depth interviews were utilized to supplement the Quantitative data. Bivariate and multivariate data analysis was performed using SPSS version 17.0 software. Result: Four hundred eighty five mothers participated in the study making a response rate of 100%. Vaginal bleeding was the most commonly mentioned danger signs of pregnancy (49.1%) and childbirth (52.8%). Two hundred eighty five (58.8%) and 299 (61.6%) of respondents mentioned at least two danger signs of pregnancy and childbirth respectively. One hundred seventy (35.1%) and 154 (31.8%) of respondents didn't know any danger signs of pregnancy and childbirth respectively. Educational status of the mother, place of delivery and having functional radio were found to be independent predictors of knowledge of women about the danger signs of pregnancy and childbirth. Conclusion: Educational status of the mother, place of delivery and having functional radio were independently associated with knowledge of women about obstetric danger signs. Thus, provision of information, education and communication targeting women, family and the general community on danger signs of pregnancy and childbirth and associated factors was recommended. [ABSTRACT FROM AUTHOR]

Background: Research examining the impact of neighborhoods on asthma has shown an increased interest in the role of the psychosocial environment. We examined the associations between various measures of neighborhood safety, individual and family characteristics, and asthma outcomes among children in Los Angeles. Methods: Multilevel logistic regression models were used to analyze data on 3,114 children across 65 neighborhoods from Wave 1 of the Los Angeles Family and Neighborhood Survey (2000 to 2002). Primary caregivers reported asthma outcome and all individual covariates; home environmental characteristics were observed by the interviewer. Results: In fully adjusted models, parents who reported their neighborhood fairly safe or somewhat dangerous had lower odds of reported lifetime asthma compared to those who reported their neighborhood completely safe (OR 0.71; 95% CI 0.52–0.96 and OR 0.60; 95% CI 0.42–0.88 respectively). Conversely, parents who reported they could not trust their neighbors to keep their children safe had a nearly 40% increase in lifetime asthma compared to those who reported they could trust their neighbors to keep their children safe (OR 1.39; 95% CI 1.07–1.81). Conclusions: The study demonstrates a complex pattern between various measures of neighborhood safety and asthma and suggests that these relationships may operate differently in Los Angeles. As an increasing proportion of children are growing up in newer Western and Southwestern cities, which have different physical layouts and residential segregation patterns compared to Northeast and Midwestern cities, future studies should continue to examine neighborhood psychosocial stressors and asthma in diverse contexts. [ABSTRACT FROM AUTHOR]

Objective: We validate an online, personalized mortality risk measure called “RealAge” assigned to 30 million individuals over the past 10 years. Methods: 188,698 RealAge survey respondents were linked to California Department of Public Health death records using a one-way cryptographic hash of first name, last name, and date of birth. 1,046 were identified as deceased. We used Cox proportional hazards models and receiver operating characteristic (ROC) curves to estimate the relative scales and predictive accuracies of chronological age, the RealAge score, and the Framingham ATP-III score for hard coronary heart disease (HCHD) in this data. To address concerns about selection and to examine possible heterogeneity, we compared the results by time to death at registration, underlying cause of death, and relative health among users. Results: The RealAge score is accurately scaled (hazard ratios: age 1.076; RealAge-age 1.084) and more accurate than chronological age (age c-statistic: 0.748; RealAge c-statistic: 0.847) in predicting mortality from hard coronary heart disease following survey completion. The score is more accurate than the Framingham ATP-III score for hard coronary heart disease (c-statistic: 0.814), perhaps because self-reported cholesterol levels are relatively uninformative in the RealAge user sample. RealAge predicts deaths from malignant neoplasms, heart disease, and external causes. The score does not predict malignant neoplasm deaths when restricted to users with no smoking history, no prior cancer diagnosis, and no indicated health interest in cancer (p-value 0.820). Conclusion: The RealAge score is a valid measure of mortality risk in its user population. [ABSTRACT FROM AUTHOR]