Neighborhood Socioeconomic Circumstances and the Co-Occurrence of Unhealthy Lifestyles: Evidence from 206,457 Australians in the 45 and Up Study

Background

Research on the co-occurrence of unhealthy lifestyles has tended to focus mainly upon the demographic and socioeconomic characteristics of individuals. This study investigated the relevance of neighborhood socioeconomic circumstance for multiple unhealthy lifestyles.

Method

An unhealthy lifestyle index was constructed for 206,457 participants in the 45 and Up Study (2006–2009) by summing binary responses on smoking, alcohol, physical activity and five diet-related variables. Higher scores indicated the co-occurrence of unhealthy lifestyles. Association with self-rated health, quality of life; and risk of psychological distress was investigated using multilevel logistic regression. Association between the unhealthy lifestyle index with neighborhood characteristics (local affluence and geographic remoteness) were assessed using multilevel linear regression, adjusting for individual-level characteristics.

Results

Nearly 50% of the sample reported 3 or 4 unhealthy lifestyles. Only 1.5% reported zero unhealthy lifestyles and 0.2% had all eight. Compared to people who scored zero, those who scored 8 (the ‘unhealthiest’ group) were 7 times more likely to rate their health as poor (95%CI 3.6, 13.7), 5 times more likely to report poor quality of life (95%CI 2.6, 10.1), and had a 2.6 times greater risk of psychological distress (95%CI 1.8, 3.7). Higher scores among men decreased with age, whereas a parabolic distribution was observed among women. Neighborhood affluence was independently associated with lower scores on the unhealthy lifestyle index. People on high incomes scored higher on the unhealthy lifestyle index if they were in poorer neighborhoods, while those on low incomes had fewer unhealthy lifestyles if living in more affluent areas.

Interpretation

Residents of deprived neighborhoods tend to report more unhealthy lifestyles than their peers in affluent areas, regardless of their individual demographic and socioeconomic characteristics. Future research should investigate the trade-offs of population-level versus geographically targeted multiple lifestyle interventions.     

Social, environmental and psychological factors associated with objective physical activity levels in the over 65s

Objective

To assess physical activity levels objectively using accelerometers in community dwelling over 65 s and to examine associations with health, social, environmental and psychological factors.

Design

Cross sectional survey.

Setting

17 general practices in Scotland, United Kingdom.

Participants

Random sampling of over 65 s registered with the practices in four strata young-old (65–80 years), old-old (over 80 years), more affluent and less affluent groups.

Main Outcome Measures

Accelerometry counts of activity per day. Associations between activity and Theory of Planned Behaviour variables, the physical environment, health, wellbeing and demographic variables were examined with multiple regression analysis and multilevel modelling.

Results

547 older people (mean (SD) age 79(8) years, 54% female) were analysed representing 94% of those surveyed. Accelerometry counts were highest in the affluent younger group, followed by the deprived younger group, with lowest levels in the deprived over 80 s group. Multiple regression analysis showed that lower age, higher perceived behavioural control, the physical function subscale of SF-36, and having someone nearby to turn to were all independently associated with higher physical activity levels (R² = 0.32). In addition, hours of sunshine were independently significantly associated with greater physical activity in a multilevel model.

Conclusions

Other than age and hours of sunlight, the variables identified are modifiable, and provide a strong basis for the future development of novel multidimensional interventions aimed at increasing activity participation in later life.     

Elevated C-Reactive Protein in Children from Risky Neighborhoods: Evidence for a Stress Pathway Linking Neighborhoods and Inflammation in Children

Background

Childhood socioeconomic status is linked to adult cardiovascular disease and disease risk. One proposed pathway involves inflammation due to exposure to a stress-inducing neighborhood environment. Whether CRP, a marker of systemic inflammation, is associated with stressful neighborhood conditions among children is unknown.

Methods and Results

The sample included 385 children 5–18 years of age from 255 households and 101 census tracts. Multilevel logistic regression analyses compared children and adolescents with CRP levels >3 mg/L to those with levels ≤3 mg/L across neighborhood environments. Among children living in neighborhoods (census tracts) in the upper tertile of poverty or crime, 18.6% had elevated CRP levels, in contrast to 7.9% of children living in neighborhoods with lower levels of poverty and crime. Children from neighborhoods with the highest levels of either crime or poverty had 2.7 (95% CI: 1.2–6.2) times the odds of having elevated CRP levels when compared to children from other neighborhoods, independent of adiposity, demographic and behavioral differences.

Conclusions

Children living in neighborhoods with high levels of poverty or crime had elevated CRP levels compared to children from other neighborhoods. This result is consistent with a psychosocial pathway favoring early development of cardiovascular risk that involves chronic stress from exposure to socially- and physically-disordered neighborhoods characteristic of poverty.     

The Association of Neighborhood Social Capital and Ethnic (Minority) Density with Pregnancy Outcomes in the Netherlands

Background

Perinatal morbidity rates are relatively high in the Netherlands, and significant inequalities in perinatal morbidity and mortality can be found across neighborhoods. In socioeconomically deprived areas, ‘Western’ women are particularly at risk for adverse birth outcomes. Almost all studies to date have explained the disparities in terms of individual determinants of birth outcomes. This study examines the influence of neighborhood contextual characteristics on birth weight (adjusted for gestational age) and preterm birth. We focused on the influence of neighborhood social capital – measured as informal socializing and social connections between neighbors – as well as ethnic (minority) density.

Methods

Data on birth weight and prematurity were obtained from the Perinatal Registration Netherlands 2000–2008 dataset, containing 97% of all pregnancies. Neighborhood-level measurements were obtained from three different sources, comprising both survey and registration data. We included 3.422 neighborhoods and 1.527.565 pregnancies for the birth weight analysis and 1.549.285 pregnancies for the premature birth analysis. Linear and logistic multilevel regression was performed to assess the associations of individual and neighborhood level variables with birth weight and preterm birth.

Results

We found modest but significant neighborhood effects on birth weight and preterm births. The effect of ethnic (minority) density was stronger than that of neighborhood social capital. Moreover, ethnic (minority) density was associated with higher birth weight for infants of non-Western ethnic minority women compared to Western women (15 grams; 95% CI: 12,4/17,5) as well as reduced risk for prematurity (OR 0.97; CI 0,95/0,99).

Conclusions

Our results indicate that neighborhood contexts are associated with birth weight and preterm birth in the Netherlands. Moreover, ethnic (minority) density seems to be a protective factor for non-Western ethnic minority women, but not for Western women. This helps explain the increased risk of Western women in deprived neighborhoods for adverse birth outcomes found in previous studies.     

Where You Live May Make You Old: The Association between Perceived Poor Neighborhood Quality and Leukocyte Telomere Length

Background

Strong evidence supports that living in disadvantaged neighborhoods has direct unfavorable impact on mental and physical health. However, whether it also has direct impact on cellular health is largely unknown. Thus we examined whether neighborhood quality was associated with leukocyte telomere length, an indicator of cellular aging.

Methods

In May 2014, we extracted and analyzed baseline data from the Netherlands Study of Depression and Anxiety (NESDA), a large epidemiological study of individuals age between 18–65 years (n=2902). Telomere length was determined using quantitative polymerase chain reaction. Neighborhood quality was assessed using modified measures of perceived neighborhood disorder, fear of crime, and noise. We used multivariable linear regression models to examine association between perceived neighborhood quality and telomere length with comprehensive adjustment for individual and community characteristics related to socioeconomic and demographic status, urbanization level, mental and physical health, and lifestyle.

Results

Compared to individuals who reported good neighborhood quality, the mean telomere length of those who reported moderate neighborhood quality was approximately 69 base pair shorter (β =-69.33, 95% CI: -119.49, -19.17, p= 0.007), and that of those who reported poor neighborhood quality were 174 base pair shorter (β =-173.80, 95% CI: -298.80, -49.01, p=0.006). For illustrative purposes, one could extrapolate these outcomes to 8.7 and 11.9 years in chronological age, respectively.

Conclusion

We have established an association between perceived neighborhood quality and cellular aging over and above a range of individual attributes. Biological aging processes may be impacted by socioeconomic milieu.     

Neighborhood Deprivation Is Strongly Associated with Participation in a Population-Based Health Check

Background

We sought to examine whether neighborhood deprivation is associated with participation in a large population-based health check. Such analyses will help answer the question whether health checks, which are designed to meet the needs of residents in deprived neighborhoods, may increase participation and prove to be more effective in preventing disease. In Europe, no study has previously looked at the association between neighborhood deprivation and participation in a population-based health check.

Methods

The study population comprised 12,768 persons invited for a health check including screening for ischemic heart disease and lifestyle counseling. The study population was randomly drawn from a population of 179,097 persons living in 73 neighborhoods in Denmark. Data on neighborhood deprivation (percentage with basic education, with low income and not in work) and individual socioeconomic position were retrieved from national administrative registers. Multilevel regression analyses with log links and binary distributions were conducted to obtain relative risks, intraclass correlation coefficients and proportional change in variance.

Results

Large differences between neighborhoods existed in both deprivation levels and neighborhood health check participation rate (mean 53%; range 35-84%). In multilevel analyses adjusted for age and sex, higher levels of all three indicators of neighborhood deprivation and a deprivation score were associated with lower participation in a dose-response fashion. Persons living in the most deprived neighborhoods had up to 37% decreased probability of participating compared to those living in the least deprived neighborhoods. Inclusion of individual socioeconomic position in the model attenuated the neighborhood deprivation coefficients, but all except for income deprivation remained statistically significant.

Conclusion

Neighborhood deprivation was associated with participation in a population-based health check in a dose-response manner, in which increasing neighborhood deprivation was associated with decreasing participation. This suggests the need to develop preventive health checks tailored to deprived neighborhoods.     

Economic Valuation of Health Care Services in Public Health Systems: A Study about Willingness to Pay (WTP) for Nursing Consultations

Background

Identifying the economic value assigned by users to a particular health service is of principal interest in planning the service. The aim of this study was to evaluate the perception of economic value of nursing consultation in primary care (PC) by its users.

Methods and Results

Economic study using contingent valuation methodology. A total of 662 users of nursing consultation from 23 health centers were included. Data on demographic and socioeconomic characteristics, health needs, pattern of usage, and satisfaction with provided service were compiled. The validity of the response was evaluated by an explanatory mixed-effects multilevel model in order to assess the factors associated with the response according to the welfare theory. Response reliability was also evaluated. Subjects included in the study indicated an average Willingness to Pay (WTP) of €14.4 (CI 95%: €13.2–15.5; median €10) and an average Willingness to Accept [Compensation] (WTA) of €20.9 (CI 95%: €19.6–22.2; median €20). Average area income, personal income, consultation duration, home visit, and education level correlated with greater WTP. Women and older subjects showed lower WTP. Fixed parameters explained 8.41% of the residual variability, and response clustering in different health centers explained 4–6% of the total variability. The influence of income on WTP was different in each center. The responses for WTP and WTA in a subgroup of subjects were consistent when reassessed after 2 weeks (intraclass correlation coefficients 0.952 and 0.893, respectively).

Conclusions

The economic value of nursing services provided within PC in a public health system is clearly perceived by its user. The perception of this value is influenced by socioeconomic and demographic characteristics of the subjects and their environment, and by the unique characteristics of the evaluated service. The method of contingent valuation is useful for making explicit this perception of value of health services.     

Perceptions of Neighborhood Safety and Asthma among Children and Adolescents in Los Angeles: A Multilevel Analysis

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.     

Associations of supermarket characteristics with weight status and body fat: a multilevel analysis of individuals within supermarkets (RECORD study)

Purpose

Previous research on the influence of the food environment on weight status has often used impersonal measures of the food environment defined for residential neighborhoods, which ignore whether people actually use the food outlets near their residence. To assess whether supermarkets are relevant contexts for interventions, the present study explored between-residential neighborhood and between-supermarket variations in body mass index (BMI) and waist circumference (WC), and investigated associations between brands and characteristics of supermarkets and BMI or WC, after adjustment for individual and residential neighborhood characteristics.

Methods

Participants in the RECORD Cohort Study (Paris Region, France, 2007–2008) were surveyed on the supermarket (brand and exact location) where they conducted their food shopping. Overall, 7 131 participants shopped in 1 097 different supermarkets. Cross-classified multilevel linear models were estimated for BMI and WC.

Results

Just 11.4% of participants shopped for food primarily within their residential neighborhood. After accounting for participants'' residential neighborhood, people shopping in the same supermarket had a more comparable BMI and WC than participants shopping in different supermarkets. After adjustment for individual and residential neighborhood characteristics, participants shopping in specific supermarket brands, in hard discount supermarkets (especially if they had a low education), and in supermarkets whose catchment area comprised low educated residents had a higher BMI/WC.

Conclusion

A public health strategy to reduce excess weight may be to intervene on specific supermarkets to change food purchasing behavior, as supermarkets are where dietary preferences are materialized into definite purchased foods.     

Resting Heart Rate and Risk of Cardiovascular Diseases and All-Cause Death: The Kailuan Study

Background

Resting heart rate (RHR) predicts both cardiovascular and noncardiovascular death in different populations. However, the results of the association between RHR and cardiovascular diseases (CVDs) are inconsistent, especially for each subtype of CVDs.

Objective

The aim of this study was to prospectively explore the relationship between RHR and CVDs including myocardial infarction (MI), ischemic stroke, and hemorrhagic stroke and all-cause death in a general population.

Methods

The Kailuan study is a prospective longitudinal cohort study on cardiovascular risk factors and cardiovascular or cerebrovascular events. Hazard ratio (HR) with 95% confidence intervals (CI) were calculated using Cox regression modeling.

Results

We analyzed 92,562 participants (18–98 years old) in the Kailuan Study. CVDs were developed in 1,903 people during follow-ups. In multivariate analysis with adjustment for major traditional cardiovascular risk factors, HRs of the highest quintile group compared with the lowest quintile group of RHR for all-cause CVDs, MI, any stroke, ischemic stroke, hemorrhagic stroke, and all-cause death were 1.03 (95% CI, 0.98–1.07), 1.10 (95% CI, 1.01–1.20), 1.01 (95% CI, 0.97–1.06), 1.02 (95% CI, 0.96–1.07), 1.01 (95% CI, 0.92–1.11) and 1.18, (95% CI, 1.13–1.23), respectively.

Conclusions

The elevated RHR was independently associated with the increased risk for MI and all-cause death, but not for all-cause CVDs, any stroke, ischemic stroke, nor hemorrhagic stroke. This indicates that the elevated RHR might be a risk marker for MI and all-cause death in general populations.     

Health Insurance Utilization and Its Impact: Observations from the Middle-Aged and Elderly in China

Objective

In China, despite a high coverage rate, health insurance is not used for all illness episodes. Our goal is to identify subjects’ characteristics associated with insurance utilization and the association between utilization and medical expenditure.

Methods

A survey was conducted in January and February of 2012. 2093 middle-aged and elderly subjects (45 years old and above) were surveyed.

Results

Heath insurance was not utilized for 12.6% (inpatient), 53.3% (outpatient), and 72.6% (self-treatment) of disease episodes. Subjects’ characteristics were associated with insurance utilization. Inpatient and outpatient treatments were expensive. In the multivariate analysis of outpatient treatment expenditure, insurance utilization was significantly associated with higher treatment cost, lost income, and gross total cost.

Conclusion

Utilization of health insurance may need to be improved. Insurance utilization can reduce out-of-pocket medical expenditure. However, the amount paid by the insured is still high. Policy intervention is needed to further improve the effectiveness of health insurance.     

Neighborhood Ethnic Diversity and Behavioral and Emotional Problems in 3 Year Olds: Results from the Generation R Study

Background

Studies suggest that neighborhood ethnic diversity may be important when it comes to understanding ethnic inequalities in mental health. The primary aim of this study was to investigate whether neighborhood ethnic diversity moderated the association between the ethnic minority status and child behavioral and emotional problems.

Methods

We included 3076 preschoolers participating in the Generation R Study, a birth cohort study in Rotterdam, the Netherlands. At child age 3-years, parents completed the Child Behavior Checklist (CBCL/1,5-5). Individual-level data, assessed with questionnaires, was combined with neighborhood-level data. Multi-level logistic regression models predicted the Odds Ratios for the CBCL total problems score as a function of maternal ethnic background and neighborhood ethnic diversity, computed with the Racial Diversity Index and categorized into tertiles. Interaction on the additive scale was assessed using Relative Access Risk due to Interaction.

Results

Being from an ethnic minority was associated with child behavioral and emotional problems in unadjusted (OR 2.76, 95% CI 1.88–4.04) and adjusted models (OR 2.64, 95% CI 1.79–3.92). Residing in a high diversity neighborhood was associated with child behavioral and emotional problems in unadjusted (OR 2.03, 95% CI 1.13–3.64) but not in adjusted models (OR 0.89, 95% CI 0.51–1.57). When stratifying by the three levels of neighborhood ethnic diversity, ethnic inequalities in behavioral and emotional problems were greatest in low diversity neighborhoods (OR 5.24, 95%CI 2.47–11.14), smaller in high diversity neighborhoods (OR 3.15, 95% CI 1.66–5.99) and smallest in medium diversity neighborhoods (OR 1.59, 95% CI 0.90–2.82). Tests for interaction (when comparing medium to low diversity neighborhoods) trended towards negative on both the additive and multiplicative scale for the maternal-report (RERI: −3.22, 95% CI −0.70–0.59; Ratio of ORs: 0.30, 95% CI 0.12–0.76).

Conclusion

This study suggests that ethnic inequalities in child behavioral and emotional problems may be greatest in ethnically homogeneous neighborhoods.     

The combined effect of individual and neighborhood socioeconomic status on cancer survival rates

Background

This population-based study investigated the relationship between individual and neighborhood socioeconomic status (SES) and mortality rates for major cancers in Taiwan.

Methods

A population-based follow-up study was conducted with 20,488 cancer patients diagnosed in 2002. Each patient was traced to death or for 5 years. The individual income-related insurance payment amount was used as a proxy measure of individual SES for patients. Neighborhood SES was defined by income, and neighborhoods were grouped as living in advantaged or disadvantaged areas. The Cox proportional hazards model was used to compare the death-free survival rates between the different SES groups after adjusting for possible confounding and risk factors.

Results

After adjusting for patient characteristics (age, gender, Charlson Comorbidity Index Score, urbanization, and area of residence), tumor extent, treatment modalities (operation and adjuvant therapy), and hospital characteristics (ownership and teaching level), colorectal cancer, and head and neck cancer patients under 65 years old with low individual SES in disadvantaged neighborhoods conferred a 1.5 to 2-fold higher risk of mortality, compared with patients with high individual SES in advantaged neighborhoods. A cross-level interaction effect was found in lung cancer and breast cancer. Lung cancer and breast cancer patients less than 65 years old with low SES in advantaged neighborhoods carried the highest risk of mortality. Prostate cancer patients aged 65 and above with low SES in disadvantaged neighborhoods incurred the highest risk of mortality. There was no association between SES and mortality for cervical cancer and pancreatic cancer.

Conclusions

Our findings indicate that cancer patients with low individual SES have the highest risk of mortality even under a universal health-care system. Public health strategies and welfare policies must continue to focus on this vulnerable group.     

Metabolic Syndrome and Stroke Recurrence in Chinese Ischemic Stroke Patients – The ACROSS-China Study

Objective

Metabolic syndrome has emerged as a novel risk factor in cardiovascular disease due to its potential for predicting stroke in population-based studies. We investigated the relationship of metabolic syndrome with stroke recurrence.

Methods

This was a retrospective analysis of Chinese patients enrolled in the prospective Abnormal gluCose Regulation in patients with acute strOke acroSS China (ACROSS-China) study after their first ischemic stroke. Metabolic syndrome was defined using the International Diabetes Federation (IDF) criteria. Vascular risk factors were assessed. Outcome was defined as recurrence of stroke within one year after the index ischemic stroke. Cox proportional hazards regression was performed to identify potential predictors of stroke recurrence.

Results

The prevalence of metabolic syndrome among 2639 ischemic stroke patients was 51.35%. During the one-year follow-up, 195 strokes (7.4%) recurred. The multivariate hazard ratio (95% CI) of stroke recurrence was 1.94 (1.39–2.73) for metabolic syndrome. After adjustment for components, metabolic syndrome lost its association with stroke recurrence; in this model, high fasting plasma glucose (IDF definition) was a predictor for stroke recurrence.

Conclusion

Metabolic syndrome may not be predictive for stroke recurrence beyond its component individual factors for Chinese ischemic stroke patients.     

Why People Do,or Do Not,Immediately Contact Emergency Medical Services following the Onset of Acute Stroke: Qualitative Interview Study

Objectives

To identify the reasons why individuals contact, or delay contacting, emergency medical services in response to stroke symptoms.

Design

Qualitative interview study with a purposive sample of stroke patients and witnesses, selected according to method of accessing medical care and the time taken to do so. Data were analysed using the Framework approach.

Setting

Area covered by three acute stroke units in the north east of England.

Participants

Nineteen stroke patients and 26 witnesses who had called for help following the onset of stroke symptoms.

Results

Factors influencing who called emergency medical services and when they called included stroke severity, how people made sense of symptoms and their level of motivation to seek help. Fear of the consequences of stroke, including future dependence or disruption to family life, previous negative experience of hospitals, or involving a friend or relations in the decision to access medical services, all resulted in delayed admission. Lack of knowledge of stroke symptoms was also an important determinant. Perceptions of the remit of medical services were a major cause of delays in admission, with many people believing the most appropriate action was to telephone their GP. Variations in the response of primary care teams to acute stroke symptoms were also evident.

Conclusions

The factors influencing help-seeking decisions are complex. There remains a need to improve recognition by patients, witnesses and health care staff of the need to treat stroke as a medical emergency by calling emergency medical services, as well as increasing knowledge of symptoms of stroke among patients and potential witnesses. Fear, denial and reticence to impose on others hinders the process of seeking help and will need addressing specifically with appropriate interventions. Variability in how primary care services respond to stroke needs further investigation to inform interventions to promote best practice.

Trial Registration

UK Clinical Research Network UKCRN 6590     

A Prospective Study of the Incidence and Correlated Factors of Post-Stroke Depression in China

Background

Post-stroke depression (PSD) is commonly observed among stroke survivors. However, statistical analysis of such data is scarce in developing countries. The purpose of this study is to examine the incidence of PSD and its relationship with stroke characteristics in China.

Methods

This was a prospective hospital-based study. Stroke patients were assessed within two weeks after acute ischemic stroke onset and then reevaluated at three months. Hamilton Depression Scale (HAMD) was used for screening depression (PSD). Subjects with HAMD score of ≥7 were further assessed with the World Health Organization Composite International Diagnostic Interview. Stroke severity was measured by the National Institutes of Health Stroke Scale (NIHSS). Stroke outcome was measured by the modified Rankin Scale (mRS).

Results

One hundred and two stroke patients were recruited, only ninety-one patients completed del period (men = 53, 63.74%), with mean age 60.0±10.4 years (range, 34–82 years). The incidence of PSD was 27.47% two weeks after stroke. The occurrence of PSD was unrelated with age, stroke type, stroke lesion and the history of disease. In univariate analysis gender, PSD was correlated with female gender. In multivariate logistic regression analysis, poor stroke outcome (mRS≥3) (OR 12.113, CI 1.169 to 125.59, P<0.05) was the important predictors of PSD.

Conclusions

The study indicated that gender, functional dependence and stroke outcome are determinants of PSD occurrence during the first 2 weeks after stroke in China.     

Neighborhood Street Scale Elements,Sedentary Time and Cardiometabolic Risk Factors in Inactive Ethnic Minority Women

Background

Cardiometabolic risk factors such as obesity, excess percent body fat, high blood pressure, elevated resting heart rate and sedentary behavior have increased in recent decades due to changes in the environment and lifestyle. Neighborhood micro-environmental, street scale elements may contribute to health above and beyond individual characteristics of residents.

Purpose

To investigate the relationship between neighborhood street scale elements and cardiometabolic risk factors among inactive ethnic minority women.

Method

Women (N = 410) completed measures of BMI, percent body fat, blood pressure, resting heart rate, sedentary behavior and demographics. Trained field assessors completed the Pedestrian Environment Data Scan in participants’ neighborhoods. Data were collected from 2006–2008. Multiple regression models were conducted in 2011 to estimate the effect of environmental factors on cardiometabolic risk factors.

Results

Adjusted regression models found an inverse association between sidewalk buffers and blood pressure, between traffic control devices and resting heart rate, and a positive association between presence of pedestrian crossing aids and BMI (ps<.05). Neighborhood attractiveness and safety for walking and cycling were related to more time spent in a motor vehicle (ps<.05).

Conclusions

Findings suggest complex relationships among micro-environmental, street scale elements that may confer important cardiometabolic benefits and risks for residents. Living in the most attractive and safe neighborhoods for physical activity may be associated with longer times spent sitting in the car.     

Increased Risk of Ischemic Stroke in Young Patients with Ankylosing Spondylitis: A Population-Based Longitudinal Follow-Up Study

Background

Prospective data on the association between ischemic stroke and ankylosing spondylitis (AS) in the young are sparse. The purpose of this population-based, age- and sex-matched longitudinal follow-up study was to investigate the risk of developing ischemic stroke in young patients with AS.

Methods

A total of 4562 patients aged 18- to 45-year-old with at least two ambulatory visits in 2001 with a principal diagnosis of AS were enrolled in the AS group. The non-AS group consisted of 22810 age- and sex-matched, randomly sampled subjects without AS. The two-year ischemic stroke-free survival rate for each group were calculated using the Kaplan-Meier method. Cox proportional hazards regression analysis was used to estimate the hazard ratio of ischemic stroke after adjusting for demographic and clinical covariates.

Results

During follow-up, 21 patients in the AS group and 53 in the non-AS group developed ischemic stroke. The ischemic stroke-free survival rate over the 2 year follow-up was lower in the AS group than the non-AS group (p = 0.0021). The crude hazard ratio of ischemic stroke for the AS group was 1.98 (95% CI, 1.20–3.29; p = 0.0079) and the adjusted hazard ratio after controlling for demographic and comorbid medical disorders was 1.93 (95% CI, 1.16–3.20; p = 0.0110).

Conclusion

Our study showed an increased risk of developing ischemic stroke in young patients with AS.     

Anticoagulation after Anterior Myocardial Infarction and the Risk of Stroke

Background

Survivors of anterior MI are at increased risk for stroke with predilection to form ventricular thrombus. Commonly patients are discharged on dual antiplatelet therapy. Given the frequency of early coronary reperfusion and risk of bleeding, it remains uncertain whether anticoagulation offers additional utility. We examined the effectiveness of anticoagulation therapy for the prevention of stroke after anterior MI.

Methods and Findings

We performed a population-based cohort analysis of 10,383 patients who survived hospitalization for an acute MI in Ontario, Canada from April 1, 1999 to March 31, 2001. The primary outcome was four-year ischemic stroke rates compared between anterior and non-anterior MI patients. Risk factors for stroke were assessed by multivariate Cox proportional-hazards analysis. Warfarin use was determined at discharge and followed for 90 days among a subset of patients aged 66 and older (n = 1483). Among the 10,383 patients studied, 2,942 patients survived hospitalization for an anterior MI and 20% were discharged on anticoagulation therapy. Within 4 years, 169 patients (5.7%) were admitted with an ischemic stroke, half of which occurred within 1-year post-MI. There was no significant difference in stroke rate between anterior and non-anterior MI patients. The use of warfarin up to 90 days was not associated with stroke protection after anterior MI (hazard ratio [HR], 0.68; 95% confidence interval [CI], 0.37–1.26). The use of angiotensin-converting-enzyme inhibitors (HR, 0.65; 95% CI, 0.44–0.95) and beta-blockers (HR, 0.60; 95% CI, 0.41–0.87) were associated with a significant decrease in stroke risk. There was no significant difference in bleeding-related hospitalizations in patients who used warfarin for up to 90 days post-MI.

Conclusion

Many practitioners still consider a large anterior-wall MI as high risk for potential LV thrombus formation and stroke. Among a cohort of elderly patients who survived an anterior MI there was no benefit from the use of warfarin up to 90 days post-MI to prevent ischemic stroke. Our data suggests that routine anticoagulation of patients with anterior-wall MI may not be indicated. Prospective randomized trials are needed to determine the optimal antithrombin strategy for preventing this common and serious adverse outcome.     

Poverty in the Midst of Plenty: Unmet Needs and Distribution of Health Care Resources in South Korea

Background

The unmet needs for health care have been used as an alternative measurement to monitor equity in health services. We sought to examine contextual influences on unmet needs for health care whereas precedent studies have been focused on individual characteristics on them.

Methods and Findings

The current study conducted multilevel logistic regression analysis to assess the effects of individual- and contextual-level predictors in meeting individual health care needs in South Korea. We sampled 7,200 individuals over the age of 19 in the Fourth Korea National Health and Nutrition Examination Survey in 2009. Included in the regression model were individual predictors such as demographic variables, socio-economic status, and self-rated health; the density of beds and physicians in public and private sectors within different regions were used as contextual-level predictors. This study showed the inverse association between unmet needs and regional resources in private sectors after controlling for the effects of individual-level predictors.

Conclusion

Our findings suggest that increasing regional resources in private sectors might produce inefficiency in the health care system and inequity in access to health services, particularly where the competition in private health care sectors was highly stimulated under the fee-for-service reimbursement scheme. Policies for the reallocation of health care resources and for reduction of individual health care costs are needed in Korea.