Teenagers' knowledge of emergency contraception: questionnaire survey in south east Scotland.

OBJECTIVE--To determine the level of knowledge of emergency contraception among 14 and 15 year olds. DESIGN--Confidential questionnaire survey. SETTING--10 secondary schools in Lothian, south east Scotland. SUBJECTS--1206 pupils predominantly (98.7%) aged 14 and 15 in the fourth year of secondary school. MAIN OUTCOME MEASURES--Knowledge of the existence of emergency contraception; of its safety, efficacy, and time limits; and of where to obtain it. RESULTS--1121 (93.0%) fourth year pupils aged 14-16 had heard of emergency contraception. 194 girls (32.7%) and 168 boys (27.5%) had experienced sexual intercourse. Of girls who had experienced sexual intercourse, 61 (31.4%) had used emergency contraception. Knowledge of correct time limits was poor, sexually active girls being the most knowledgeable. Pupils attending schools ranked lower than the national average for academic attainment were less likely to have heard of emergency contraception and more likely to have been sexually active. 861 (76.8%) pupils knew they could obtain emergency contraception from their doctor. 925 (82.5%) pupils believed emergency contraception to be effective but 398 (35.5%) thought it more dangerous than the oral contraceptive pill. CONCLUSIONS--One third of sexually active girls aged under 16 in Lothian have used emergency contraception. This may help explain the fairly constant teenage pregnancy rates despite increasing sexual activity. Scottish teenagers are well informed about the existence of emergency contraception. However, many do not know when and how to access it properly. Health education initiatives should target teenagers from less academic schools as they are more likely to be sexually active at a young age and are less well informed about emergency contraception.     

Travel to school and physical activity levels in 9-10 year-old UK children of different ethnic origin; Child Heart and Health Study in England (CHASE)

Background

Travel to school may offer a convenient way to increase physical activity levels in childhood. We examined the association between method of travel to school and physical activity levels in urban multi-ethnic children.

Methods and Findings

2035 children (aged 9–10 years in 2006–7) provided data on their usual method of travel to school and wore an Actigraph-GT1M activity monitor during waking hours. Associations between method of travel and mean level of physical activity (counts per minute [CPM], steps, time spent in light, moderate or vigorous activity per day) were examined in models adjusted for confounding variables. 1393 children (69%) walked or cycled to school; 161 (8%) used public transport and 481 (24%) travelled by car. White European children were more likely to walk/cycle, black African Caribbeans to travel by public transport and South Asian children to travel by car. Children travelling by car spent less time in moderate to vigorous physical activity (−7 mins, 95%CI-9,-5), and had lower CPM (−32 CPM, 95%CI-44,-19) and steps per day (−813 steps, 95%CI,-1043,-582) than walkers/cyclists. Pupils travelling by public transport had similar activity levels to walkers/cyclists. Lower physical activity levels amongst car travellers'' were especially marked at travelling times (school days between 8–9 am, 3–5 pm), but were also evident on weekdays at other times and at weekends; they did not differ by gender or ethnic group.

Conclusion

Active travel to school is associated with higher levels of objectively measured physical activity, particularly during periods of travel but also at other times. If children travelling by car were to achieve physical activity levels (steps) similar to children using active travel, they would increase their physical activity levels by 9%. However, the population increase would be a modest 2%, because of the low proportion of car travellers in this urban population.     

National cross sectional study of views on sexual violence and risk of HIV infection and AIDS among South African school pupils

Objective To investigate the views of school pupils on sexual violence and on the risk of HIV infection and AIDS and their experiences of sexual violence.Design National cross sectional study.Setting 5162 classes in 1418 South African schools.Participants 269 705 school pupils aged 10-19 years in grades 6-11.Main outcome measure Answers to questions about sexual violence and about the risk of HIV infection and AIDS.Results Misconceptions about sexual violence were common among both sexes, but more females held views that would put them at high risk of HIV infection. One third of the respondents thought they might be HIV positive. This was associated with misconceptions about sexual violence and about the risk of HIV infection and AIDS. Around 11% of males and 4% of females claimed to have forced someone else to have sex; 66% of these males and 71% of these females had themselves been forced to have sex. A history of forced sex was a powerful determinant of views on sexual violence and risk of HIV infection.Conclusions The views of South African youth on sexual violence and on the risk of HIV infection and AIDS were compatible with acceptance of sexual coercion and “adaptive” attitudes to survival in a violent society. Views differed little between the sexes.     

Brief intervention to prevent hazardous drinking in young people aged 14--15 in a high school setting (SIPS JR-HIGH): study protocol for a randomized controlled trial

ABSTRACT: BACKGROUND: Whilst the overall proportion of young people drinking alcohol in the United Kingdom has decreased in recent years, those who do drink appear to drink a larger amount, and more frequently. Early and heavy drinking by younger adolescents is a significant public health problem linked to intellectual impairment, increased risk of injuries, mental health issues, unprotected or regretted sexual experience, violence, and sometimes accidental death, which leads to high social and economic costs. This feasibility pilot trial aims to explore the feasibility of delivering brief alcohol intervention in a school setting with adolescents aged 14 and 15 and to examine the acceptability of study measures to school staff, young people and parents.Methods and designSeven schools across one geographical area in the North East of England will be recruited. Schools will be randomly allocated to one of three conditions: provision of an advice leaflet (control condition, n = 2 schools); a 30-minute brief interactive session, which combines structured advice and motivational interviewing techniques delivered by the school learning mentor (level 1 condition, n = 2 schools); and a 60-minute session involving family members delivered by the school learning mentor (level 2 condition, n = 3 schools). Participants will be year 10 school pupils (aged 14 and 15) who screen positively on a single alcohol screening question and who consent to take part in the trial. Year 10 pupils in all seven schools will be followed up at 6 and 12 months. Secondary outcome measures include the ten-question Alcohol-Use Disorders Identification Test. The EQ-5D-Y and a modified short service use questionnaire will inform the health and social resource costs for any future economic evaluation.Young people recruited into the trial will also complete a 28-day timeline follow back questionnaire at 12-month follow-up. A qualitative evaluation (with young people, school staff, learning mentors, and parents) will examine facilitators and barriers to the use of screening and brief intervention approaches in the school setting in this age group.Trial registrationTrial reference number ISRCTN07073105.     

Joint and limb symptoms in children after immunisation with measles,mumps, and rubella vaccine.

OBJECTIVE--To assess whether the combined measles, mumps, and rubella vaccine increases the incidence of joint and limb symptoms in young children. DESIGN--Comparison of six week recalled incidence of symptoms in two groups of children: children who had been immunised at the start of the six weeks, and children eligible for immunisation but who had not received it. SETTING--South Manchester Health Authority. SUBJECTS--2658 children immunised during July 1989-February 1990 and 2359 not yet immunised. Questionnaires were returned for 1846 immunised children and 1075 not immunised. MAIN OUTCOME MEASURE--Recalled rate of joint and limb episodes determined by postal questionnaire and later by clinical follow up. RESULTS--Compared with non-immunised children the immunised group had an increased incidence of new episodes (relative risk 1.6 (95% confidence interval (1.2 to 2.1)) and first ever episodes, though this was not significant (1.7 (0.3 to 3.5)). The risk of first episodes was increased in girls (3.5 (1.1 to 12.2)) but not in boys (1.0 (0.4 to 2.6)). Similarly, an increased risk was seen in children aged under 5 (12.0 (1.6 to 92.3)) but not in older children (0.7 (0.3 to 1.5)). Most episodes were mild and self limiting, but three immunised children required hospital referral. CONCLUSION--Measles, mumps, and rubella vaccine is associated with an increased risk of episodes of joint and limb symptoms, especially in girls and children under 5. The risk of frank arthritis is substantially less than after wild rubella infection.     

How Combined Trip Purposes Are Associated with Transport Choice for Short Distance Trips. Results from a Cross-Sectional Study in the Netherlands

Background

One way to increase physical activity is to stimulate a shift from car use to walking or cycling. In single-purpose trips, purpose was found to be an important predictor of transport choice. However, as far as known, no studies have been conducted to see how trips with combined purposes affect this decision. This study was designed to provide insight into associations between combined purposes and transport choice.

Methods

An online questionnaire (N = 3,663) was used to collect data concerning transport choice for four primary purposes: shopping, going to public natural spaces, sports, and commuting. Per combination of primary trip purpose and transport choice, participants were asked to give examples of secondary purposes that they combine with the primary purpose. Logistic regression analyses were used to model the odds of both cycling and walking versus car use.

Results

Primary trip purposes combined with commuting, shopping, visiting private contacts or medical care were more likely to be made by car than by cycling or walking. Combinations with visiting catering facilities, trips to social infrastructure facilities, recreational outings, trips to facilities for the provision of daily requirements or private contacts during the trip were more likely to be made by walking and/or cycling than by car.

Conclusion

Combined trip purposes were found to be associated with transport choice. When stimulating active transport focus should be on the combined-trip purposes which were more likely to be made by car, namely trips combined with commuting, other shopping, visiting private contacts or medical care.     

A study of Nigerian pupils' understanding of selected biological concepts

120 Nigerian Secondary school biology pupils, mostly aged 16–18, were interviewed individually to assess their level of understanding of a range of biological concepts. The concepts were related to growth, reproduction, and transport mechanisms within living organisms. The responses of each pupil were scored and examined to determine whether they revealed concrete or formal operational thinking. Given 21 opportunities to do so, almost 50 per cent of pupils either failed to exhibit formal thinking at all, or revealed it on only one occasion. Fewer than 5 per cent exhibited formal thinking on ten or more occasions. There was no significant difference in the performance of boys as compared with girls, nor between pupils whose parents were from different socio-economic groups. Pupils from urban schools performed significantly better than those from rural schools. Pupils' common misconceptions were identified. The importance of ascertaining pupils' misconceptions and their levels of understanding of biological concepts is discussed from the viewpoint of the classroom teacher.     

A newly identified group of adolescents at “invisible” risk for psychopathology and suicidal behavior: findings from the SEYLE study

This study explored the prevalence of risk behaviors (excessive alcohol use, illegal drug use, heavy smoking, reduced sleep, overweight, underweight, sedentary behavior, high use of Internet/TV/videogames for reasons not related to school or work, and truancy), and their association with psychopathology and self‐destructive behaviors, in a sample of 12,395 adolescents recruited in randomly selected schools across 11 European countries. Latent class analysis identified three groups of adolescents: a low‐risk group (57.8%) including pupils with low or very low frequency of risk behaviors; a high‐risk group (13.2%) including pupils who scored high on all risk behaviors, and a third group (“invisible” risk, 29%) including pupils who were positive for high use of Internet/TV/videogames for reasons not related to school or work, sedentary behavior and reduced sleep. Pupils in the “invisible” risk group, compared with the high‐risk group, had a similar prevalence of suicidal thoughts (42.2% vs. 44%), anxiety (8% vs. 9.2%), subthreshold depression (33.2% vs. 34%) and depression (13.4% vs. 14.7%). The prevalence of suicide attempts was 5.9% in the “invisible” group, 10.1% in the high‐risk group and 1.7% in the low‐risk group. The prevalence of all risk behaviors increased with age and most of them were significantly more frequent among boys. Girls were significantly more likely to experience internalizing (emotional) psychiatric symptoms. The “invisible” group may represent an important new intervention target group for potentially reducing psychopathology and other untoward outcomes in adolescence, including suicidal behavior.     

Feeding of school children in a London borough.

A survey of 12 schools in a London borough showed that the protein and energy content of the average school meal was below the standard set by the Department of Health and Social Security for all age groups. Failure to meet the standards resulted from inadequate food purchases, poor menu planning and portion control, and several management problems. A 24-hour recall questionnaire showed that 5% of the pupils were "poorly" fed. These pupils were, however, no worse off than their "adequately" fed peers with regard to absences from school or academic attainment measured by reading quotient, but there was some slight difference in height and weight. The percentage of children having no breakfast increased from 4% in the infant schools to 21% in the senior schools. Two per cent of the senior pupils regularly ate no lunch.     

Cigarette advertising and onset of smoking in children: questionnaire survey.

OBJECTIVE: To investigate uptake of smoking in a cohort of 11 to 12 year olds related to awareness of advertised cigarette brands named. DESIGN: Self completed questionnaires administered to whole classes of schoolchildren in June 1993 and June 1994. SETTING: Primary, middle, and secondary schools in the north and south of England. SUBJECTS: 1450 pupils aged 11 and 12 years at the time of the first survey. MAIN OUTCOME MEASURES: Onset of smoking and brands smoked by the second survey related to cigarette brands named in the first one. Less advertised brands were used as the base for calculating odds ratios. RESULTS: Girls who named the most advertised brands-namely, Benson and Hedges alone (odds ratio = 2.50, 95% confidence interval = 1.18 to 5.30) or Benson and Hedges and Silk Cut (2.15, 1.04 to 4.42) in the first survey were at greatest risk of taking up smoking by the second one. The difference was similar but not significant for boys. Boys and girls who named the least advertised brands in the first survey were at no greater risk of taking up smoking by the second survey than those who named no brands (boys odds ratio = 0.49 (0.24 to 1.01); girls 0.79 (0.38 to 1.62)). New smokers were more likely to smoke any available brand (29.5%) or a less advertised brand such as Embassy (24.6%) than the most advertised ones, Benson and Hedges (19.7%) and Silk Cut (14.8%). Established smokers were more selective, only 15% smoking any available brand and 38.3% smoking Benson and Hedges. CONCLUSIONS: Cigarette advertising appears to increase children''s awareness of smoking at a generic level and encourages them to take up the behaviour, beginning with any cigarettes which are available and affordable.     

The relationship between violent video games,acculturation, and aggression among Latino adolescents

Multiple factors are involved in the occurrence of aggressive behavior. The purpose of this study was to evaluate the hypotheses that Latino middle school children exposed to higher levels of video game playing will exhibit a higher level of aggression and fighting compared to children exposed to lower levels and that the more acculturated middle school Latino children will play more video games and will prefer more violent video games compared to less acculturated middle school Latino children. This study involved 5,831 students attending eight public schools in Texas. A linear relationship was observed between the time spent playing video games and aggression scores. Higher aggression scores were significantly associated with heavier video playing for boys and girls (p < 0.0001). The more students played video games, the more they fought at school (p < 0.0001). As Latino middle school students were more acculturated, their preference for violent video game playing increased, as well as the amount of time they played video games. Students who reported speaking more Spanish at home and with their friends were less likely to spend large amounts of time playing video games and less likely to prefer violent video games (p < 0.05).     

London Education and Inclusion Project (LEIP): Exploring Negative and Null Effects of a Cluster-Randomised School-Intervention to Reduce School Exclusion—Findings from Protocol-Based Subgroup Analyses

This paper presents subgroup analyses from the London Education and Inclusion Project (LEIP). LEIP was a cluster-randomised controlled trial of an intervention called Engage in Education-London (EiE-L) which aimed to reduce school exclusions in those at greatest risk of exclusion. Pupils in the control schools attended an hour-long employability seminar. Minimisation was used to randomly assign schools to treatment and control following baseline data collection. The study involved 36 schools (17 in treatment—373 pupils; 19 in control—369 pupils) with >28% free school meal eligibility across London and utilised on pupil self-reports, teacher reports as well as official records to assess the effectiveness of EiE-L. Due to multiple data sources, sample sizes varied according to analysis. Analyses of pre-specified subgroups revealed null and negative effects on school exclusion following the intervention. Our findings suggest that the design and implementation of EiE-L may have contributed to the negative outcomes for pupils in the treatment schools when compared to those in the control schools. These findings call into question the effectiveness of bolt-on short-term interventions with pupils, particularly those at the highest risk of school exclusion and when they are faced with multiple problems. This is especially pertinent given the possibility of negative outcomes.Trial Registration: Controlled Trials: ISRCTN23244695     

Prevalence of the three categories of handedness among Malawian school children

A cross sectional study of prevalence of left, right and mixed handedness was made on 512 Malawian school children (240 boys and 272 girls) aged 6-17 years. Handedness was assessed using questionnaire incorporating questions on hand preferred for eight unimanual activities. Interviews with guardians, pupils and teachers were conducted to assess the pressure experienced by children to use right hand for unimanual activities. The overall prevalence of left-, right- and mixed-handers was 3.9%, 90.4% and 5.7%, respectively. Association between handedness and age or gender of children was nonsignificant. 96.2% of guardians and 92.7% of teachers were insistent upon use of right hand for unimanual tasks. Most of non-right handed children indicated that they had experienced pressure to use right hand for unimanual activities but they were still using left hand for one or more manual tasks. 28 pupils indicated that they stopped using left hand under the pressure from guardians and teachers.     

Special care and school difficulties in 8-year-old very preterm children: the Epipage cohort study

Objectives

To investigate school difficulties, special care and behavioral problems in 8 year-old very preterm (VPT) children.

Patient and Methods

Longitudinal population-based cohort in nine regions of France of VPT children and a reference group born at 39–40 weeks of gestation (WG). The main outcome measures were information about school, special care and behavioral problems using Strengths and Difficulties Questionnaire from a questionnaire to parents.

Results

Among the 1439 VPT children, 5% (75/1439) were in a specialised school or class, 18% (259/1439) had repeated a grade in a mainstream class and 77% (1105/1439) were in the appropriate grade-level in mainstream class; these figures were 1% (3/327) , 5% (16/327) and 94% (308/327) , respectively, for the reference group. Also, 15% (221/1435) of VPT children in a mainstream class received support at school versus 5% (16/326) of reference group. More VPT children between the ages of five and eight years received special care (55% (794/1436)) than children born at term (38% (124/325)); more VPT children (21% (292/1387)) had behavioral difficulties than the reference group (11% (35/319)). School difficulties, support at school, special care and behavioral difficulties in VPT children without neuromotor or sensory deficits varied with gestational age, socioeconomic status, and cognitive score at the age of five.

Conclusions

Most 8-year-old VPT children are in mainstream schools. However, they have a high risk of difficulty in school, with more than half requiring additional support at school and/or special care. Referral to special services has increased between the ages of 5 and 8 years, but remained insufficient for those with borderline cognitive scores.     

Relation between cognitive impairment and early death in the elderly.

STUDY OBJECTIVE--To study the association between cognitive impairment and early death in elderly patients living in the community. DESIGN--Case-control study of 410 patients assessed by the mental status questionnaire and followed up after three years. SETTING--A general practice in Inverurie, Aberdeenshire, with 14,000 patients. PATIENTS--205 Patients aged greater than or equal to 65 with cognitive impairment according to the mental status questionnaire (score less than or equal to 8) and 205 patients scoring greater than 8 on the questionnaire matched for age and sex. MAIN OUTCOME MEASURE--Death. RESULTS--The relative risk of death in the cognitively impaired patients overall was 3.5. Those patients who scored less than or equal to 7 on the mental status questionnaire were five times more likely to die than their controls. There was no difference in risk of death between those with severe or moderate cognitive impairment. CONCLUSIONS--Cognitive impairment is associated with early death.     

Exposure-Based, ‘Like-for-Like’ Assessment of Road Safety by Travel Mode Using Routine Health Data

Background

Official reports on modal risk have not chosen appropriate numerators and denominators to enable like-for-like comparisons. We report age- and sex-specific deaths and injury rates from equivalent incidents in England by travel mode, distance travelled and time spent travelling.

Methods

Hospital admissions and deaths in England 2007–2009 were obtained for relevant ICD-10 external codes for pedestrians, cyclists, and car/van drivers, by age-group and sex. Distance travelled by age-group, sex and mode in England (National Travel Survey 2007–2009 data) was converted to time spent travelling using mean trip speeds. Fatality rates were compared with age-specific Netherlands data.

Results

All-age fatalities per million hours’ use (f/mhu) varied over the same factor-of-three range for both sexes (0.15–0.45 f/mhu by mode for men, 0.09–0.31 f/mhu for women). Risks were similar for men aged 21–49 y for all three modes and for female pedestrians and drivers aged 21–69 y. Most at risk were: males 17–20 y (1.3 f/mhu (95% CI 1.2–1.4)) for driving; males 70+ (2.2 f/mhu(1.6–3.0)) for cycling; and females 70+ (0.95 f/mhu (0.86–1.1)) for pedestrians. In general, fatality rates were substantially higher among males than females. Risks per hour for male drivers <30 y were similar or higher than for male cyclists; for males aged 17–20 y, the risk was higher for drivers (33/Bn km (30–36), 1.3 f/mhu (1.2–1.4)) than cyclists (20/Bn km (10–37), 0.24 f/mhu (0.12–0.45)) whether using distance or time. Similar age patterns occurred for cyclists and drivers in the Netherlands. Age-sex patterns for injuries resulting in hospital admission were similar for cyclists and pedestrians but lower for drivers.

Conclusions

When all relevant ICD-10 codes are used, fatalities by time spent travelling vary within similar ranges for walking, cycling and driving. Risks for drivers were highest in youth and fell with age, while for pedestrians and cyclists, risks increased with age. For the young, especially males, cycling is safer than driving.     

School’s Out: Seasonal Variation in the Movement Patterns of School Children

School children are core groups in the transmission of many common infectious diseases, and are likely to play a key role in the spatial dispersal of disease across multiple scales. However, there is currently little detailed information about the spatial movements of this epidemiologically important age group. To address this knowledge gap, we collaborated with eight secondary schools to conduct a survey of movement patterns of school pupils in primary and secondary schools in the United Kingdom. We found evidence of a significant change in behaviour between term time and holidays, with term time weekdays characterised by predominately local movements, and holidays seeing much broader variation in travel patterns. Studies that use mathematical models to examine epidemic transmission and control often use adult commuting data as a proxy for population movements. We show that while these data share some features with the movement patterns reported by school children, there are some crucial differences between the movements of children and adult commuters during both term-time and holidays.     

Neighbourhood,Route and Workplace-Related Environmental Characteristics Predict Adults' Mode of Travel to Work

Objective

Commuting provides opportunities for regular physical activity which can reduce the risk of chronic disease. Commuters'' mode of travel may be shaped by their environment, but understanding of which specific environmental characteristics are most important and might form targets for intervention is limited. This study investigated associations between mode choice and a range of objectively assessed environmental characteristics.

Methods

Participants in the Commuting and Health in Cambridge study reported where they lived and worked, their usual mode of travel to work and a variety of socio-demographic characteristics. Using geographic information system (GIS) software, 30 exposure variables were produced capturing characteristics of areas around participants'' homes and workplaces and their shortest modelled routes to work. Associations between usual mode of travel to work and personal and environmental characteristics were investigated using multinomial logistic regression.

Results

Of the 1124 respondents, 50% reported cycling or walking as their usual mode of travel to work. In adjusted analyses, home-work distance was strongly associated with mode choice, particularly for walking. Lower odds of walking or cycling rather than driving were associated with a less frequent bus service (highest versus lowest tertile: walking OR 0.61 [95% CI 0.20–1.85]; cycling OR 0.43 [95% CI 0.23–0.83]), low street connectivity (OR 0.22, [0.07–0.67]; OR 0.48 [0.26–0.90]) and free car parking at work (OR 0.24 [0.10–0.59]; OR 0.55 [0.32–0.95]). Participants were less likely to cycle if they had access to fewer destinations (leisure facilities, shops and schools) close to work (OR 0.36 [0.21–0.62]) and a railway station further from home (OR 0.53 [0.30–0.93]). Covariates strongly predicted travel mode (pseudo r-squared 0.74).

Conclusions

Potentially modifiable environmental characteristics, including workplace car parking, street connectivity and access to public transport, are associated with travel mode choice, and could be addressed as part of transport policy and infrastructural interventions to promote active commuting.     

Loss of employment and mortality.

OBJECTIVE--To assess effect of unemployment and early retirement on mortality in a group of middle aged British men. DESIGN--Prospective cohort study (British Regional Heart Study). Five years after initial screening, information on employment experience was obtained with a postal questionnaire. SETTING--One general practice in each of 24 towns in Britain. SUBJECTS--6191 men aged 40-59 who had been continuously employed for at least five years before initial screening in 1978-80: 1779 experienced some unemployment or retired during the five years after screening, and 4412 remained continuously employed. MAIN OUTCOME MEASURE--Mortality during 5.5 years after postal questionnaire. RESULTS--Men who experienced unemployment in the five years after initial screening were twice as likely to die during the following 5.5 years as men who remained continuously employed (relative risk 2.13 (95% confidence interval 1.71 to 2.65). After adjustment for socioeconomic variables (town and social class), health related behaviour (smoking, alcohol consumption, and body weight), and health indicators (recall of doctor diagnoses) that had been assessed at initial screening the relative risk was slightly reduced, to 1.95 (1.57 to 2.43). Even men who retired early for reasons other than illness and who appeared to be relatively advantaged and healthy had a significantly increased risk of mortality compared with men who remained continuously employed (relative risk 1.87 (1.35 to 2.60)). The increased risk of mortality from cancer was similar to that of mortality from cardiovascular disease (adjusted relative risk 2.07 and 2.13 respectively). CONCLUSIONS--In this group of stably employed middle aged men loss of employment was associated with an increased risk of mortality even after adjustment for background variables, suggesting a causal effect. The effect was non-specific, however, with the increased mortality involving both cancer and cardiovascular disease.