Intermediate Educational Level Research Articles

A sibling study of whether maternal exposure to different types of natural space is related to birthweight.

BackgroundBirthweight is an important determinant of health across the life course. Maternal exposure to natural space has been linked to higher birthweight, but stronger evidence of a causal link is needed. We use a quasi-experimental sibling study design to investigate if change in the mother’s exposure to natural space between births was related to birthweight, in urban Scotland.MethodsAmount (% area) of total natural space, total accessible (public) natural space, parks, woodlands and open water within 100 m of the mother’s postcode was calculated for eligible births (n = 40 194; 1991–2010) in the Scottish Longitudinal Study (a semi-random 5.3% sample of the Scottish population). Associations between natural space and birthweight were estimated, using ordinary least squares and fixed effects models.ResultsBirthweight was associated with the total amount of natural space around the mother’s home (+8.2 g for interquartile range increase), but was unrelated to specific types of natural space. This whole-sample relationship disappeared in the sibling analysis, indicating residual confounding. The sibling models showed effects for total natural space with births to women who already had children (+20.1 g), and to those with an intermediate level of education (+14.1 g).ConclusionsThe importance of total natural space for birthweight suggests that benefits can be experienced near to as well as within natural space. Ensuring expectant mothers have good access to high quality neighbourhood natural space has the potential to improve the infant’s start in life, and consequently their health trajectory over the life course.

Medication adherence among cardiac patients in Khartoum State, Sudan: a cross-sectional study.

SummaryIntroduction:Non-adherence to medication among cardiac patients is often the major risk factor for poor clinical outcomes, increased mortality rates and higher healthcare costs. The literature evaluating the prevalence of and reasons for non-adherence in resource-poor settings is extremely limited compared to resource-rich settings. There is a scarcity of data about medication adherence in Sudan hence this study was performed to identify prevalence, predictors and barriers of non-adherence to medication among cardiac patients in Khartoum State.Methods:A descriptive, cross-sectional survey was performed using a pre-tested, self-administered questionnaire on a sample of 433 randomly selected cardiac patients attending the largest three cardiac centres located in Khartoum State. Descriptive and multivariate logistic regression analyses were used for data analysis.Results:The response rate was 89.1%. The mean (± SD) number of chronic diseases among respondents was 2.3 (± 1.3) and that of medication use was 4.2 (± 1.9). The mean (± SD) duration of medication use among participants was 6.4 (± 5.4) years. Optimal adherence was defined as having a score of greater than six on the eight-item Morisky medication adherence scale. Using this cut-off point, 49% (95% CI: 43.9–54.1) of respondents had optimal adherence and 51% (95% CI: 45.9–56.1) had poor adherence. Respondents with a high level of education, low and middle income levels, and those taking five or more medications daily were found to be significantly more non-adherent to medication use than those with low to intermediate education levels (p < 0.001), those with high income levels (p < 0.001), and those taking one to four medications daily (p = 0.039). The top four barriers for poor medication adherence among the study participants were the high cost of drugs, polypharmacy and lack of pharmacist and physician communication with patients about their drug therapy.Conclusions:The current findings highlight the need for urgent, multifaceted interventions, given the burden of cardiovascular diseases and the clinical and economic consequences of medication non-adherence. These interventions include affordable medications, easy-to-use medication regimens with fewer daily doses, ongoing communication between patients and healthcare providers, and improvement of the patient– provider partnership.

Maternal education and age: inequalities in neonatal death.

ABSTRACTOBJECTIVE Evaluate the interaction between maternal age and education level in neonatal mortality, as well as investigate the temporal evolution of neonatal mortality in each stratum formed by the combination of these two risk factors.METHODS A nonconcurrent cohort study, resulting from a probabilistic relationship between the Mortality Information System and the Live Birth Information System. To investigate the risk of neonatal death we performed a logistic regression, with an odds ratio estimate for the combined variable of maternal education and age, as well as the evaluation of additive and multiplicative interaction. The neonatal mortality rate time series, according to maternal education and age, was estimated by the Joinpoint Regression program.RESULTS The neonatal mortality rate in the period was 8.09‰ and it was higher in newborns of mothers with low education levels: 12.7‰ (adolescent mothers) and 12.4‰ (mother 35 years old or older). Low level of education, without the age effect, increased the chance of neonatal death by 25% (OR = 1.25, 95%CI 1.14–1.36). The isolated effect of age on neonatal death was higher for adolescent mothers (OR = 1.39, 95%CI 1.33–1.46) than for mothers aged ≥ 35 years (OR = 1.16, 95%CI 1.09–1.23). In the time-trend analysis, no age group of women with low education levels presented a reduction in the neonatal mortality rate for the period, as opposed to women with intermediate or high levels of education, where the reduction was significant, around 4% annually.CONCLUSIONS Two more vulnerable groups – adolescents with low levels of education and older women with low levels of education – were identified in relation to the risk of neonatal death and inequality in reducing the mortality rate.

Periconceptional Folic Acid Supplementation in Chinese Women: A Cross-sectional Study

ObjectiveTo investigate the status of folic acid (FA) supplementation and determinants of its use in pregnant Chinese women. MethodsIn this cross-sectional study, questionnaires were used to collect information of participants and FA supplementation. Women were recruited between 6 and 12 weeks postpartum in Tianjin, China, between July 2015 and July 2016. ResultsA total of 1,921 women were recruited in the study. Approximately 93.1% of the study participants used FA, while 14.4% of the women taking FA from three months prior to preconception to three months post-conception. Women who took FA for three months prior to preconception through at least three months into their pregnancy were more likely to be between 30 and 34 years old (OR = 2.91, 95% CI: 1.15, 7.33), employed (OR = 2.07, 95% CI: 1.17, 3.67), primigravida (OR = 5.20, 95% CI: 3.02, 8.96), married to spouses with an intermediate education level (OR = 2.92, 95% CI: 1.45, 5.89), and earn a high family income (OR = 3.19, 95% CI: 1.57, 6.49). ConclusionThe prevalence of periconceptional FA intake was far below the requirements of the National Health and Family Planning Commission of China; therefore, knowledge of FA supplementation should be strengthened among women who are or planning to become pregnant.

Gender and educational differences in the association between smoking and health-related quality of life in Belgium

Previous studies have shown that smoking has a significant and negative association with health-related quality of life (HRQOL). A question remains, however, as to whether this association between smoking and HRQOL differs by gender or educational level. To examine this question, we extracted data from the 2013 Belgian Health Interview Survey (n=5668). HRQOL was assessed using the descriptive system of the EuroQol 5D-5L that consists of 5 dimensions and the resulting index score. Linear and logistic multivariable regression models were fitted to estimate the association between HRQOL and smoking for each educational level and gender. Also, interaction terms were introduced in the full regression models and the Wald test was used to assess model fit. Our findings show that among men, there is no significant association between smoking and HRQOL, and no effect modification by educational level. Among women, however, daily smokers have shown significantly lower HRQOL scores compared with never smokers, but only among females with a low and intermediate educational level. The lower EQ-5D index scores among female daily smokers with lower education was due to higher odds of reporting problems in anxiety/depression, mobility, pain, and usual activities. To conclude, information on the association between HRQOL and smoking is useful for the development of smoking cessation interventions. Our findings suggest the importance of tailoring these interventions to the needs of the women with lower education.

Public perception of dermatology and dermatologists in Italy: results from a population-based national survey.

The public perception of dermatology and dermatologists may be very relevant in guiding strategies for improving dermatologic care but it has been poorly investigated in Europe. To investigate the public's perception of dermatology and dermatologists in Italy. A representative sampling of Italian adults (n = 1500, aged 18-70 years), residing throughout the national territory was interviewed through a population-based telephone survey using a structured questionnaire. The majority of interviewed aged between 35 and 54 years (45%) and had an intermediate educational level (57%), were employed (56%), and had at least one child in the family (68%). 70% of the interviewed knew at least one skin disease, particularly psoriasis, dermatitis, urticaria, skin tumours and nevi. The general practitioner resulted to be the first healthcare provider to consult in the case of skin problems for 73% of surveyed, with only 27% referring directly the private dermatologist. The dermatologist was the main referral specialist for psoriasis, pruritus and skin tumours by 66%, 54% and 53% of the sample, respectively. The most common reason for dermatological consultation was the control of nevi. In the case of childhood dermatitis, 52% indicated the paediatrician and 38% the dermatologist as the reference specialist. Almost half of the surveyed turned out to have a trusted dermatologist to consult in the case of skin problems. Finally, among those visited at least one time by a dermatologist, 46% were promoters, that is, they would recommend their dermatologist to a friend (net promoter score, 27). The general population has a wide-ranging understanding of skin diseases and the central role of dermatologists in skin care. Patients are looking for technical competence and loyalty, because this lead to more trusted and satisfactory physician-patient relationship. Public campaigns may be relevant in increasing awareness on curability of common skin diseases.

The malaise of the squeezed middle: Challenging the narrative of the ‘left behind’ Brexiter

The result of the referendum in the United Kingdom in 2016 to leave the European Union sparked much interest on the socio-economic characteristics of ‘Brexiters’. In this article, we challenge the popularized view of the Leave voter as an outsider and find that individuals from an intermediate class, whose malaise is due to a declining financial position, represent an important segment of the Brexit vote. We use individual-level data from a post-Brexit survey based on the British Election Study. Our analysis tests three predictive models. First, although our analysis confirms the negative association between education and Leave vote, we find that voting Leave is associated more with intermediate levels of education than with low or absent education, in particular in the presence of a perceived declining economic position. Secondly, we find that Brexiters hold distinct psycho-social features of malaise due to declining economic conditions, rather than anxiety or anger. Thirdly, our exploratory model finds voting Leave associated with self-identification as middle class, rather than with working class. We also find that intermediate levels of income were not more likely to vote for remain than low income groups. Overall our analysis of the Brexit vote underlines the importance of considering the political behaviour of the declining middle.

Socioeconomic inequalities in activities of daily living limitations and in the provision of informal and formal care for noninstitutionalized older Brazilians: National Health Survey, 2013.

BackgroundThis study assesses the association between socioeconomic factors and living arrangements with activity of daily living limitations (ADL) and the receipt of informal and formal care among non-institutionalized Brazilians aged ≥ 60 years.MethodsData come from a nationally representative survey (the Brazilian National Health Survey), conducted in 2013. Outcomes examined include the number of ADL tasks performed with limitations and number of tasks for which the individual received informal care (provided by unpaid relatives or friends), formal care, or no care. Key exposure variables were years of education and household assets.ResultsFunctioning limitations were reported by 7,233 (30.1 %) of 23,815 survey participants. Of these, 5,978 reported needing help to perform at least one ADL task. There was a strong inverse gradient between physical functioning and both education and household assets that was independent of confounders. The provision of care showed an opposite trend, with the wealthiest being more likely to receive help for performing ADL tasks. The receipt of formal care was strongly correlated with highest education (Fully adjusted prevalence ratio [PR] = 1.64; 95 % CI 1.05, 2.58) and with the highest assets level (PR = 2.24; 95 % CI 1.38, 3.64). Living with someone else was associated with provision of care (formal or informal) for those at the lowest and intermediate educational and assets levels, but not for the wealthiest.ConclusionDespite worse physical functioning, older Brazilians in worse socioeconomic conditions are much less likely to receive needed help in performing ADL tasks.

Topical Corticosteroid Concerns in Dermatological Outpatients: A Cross-Sectional and Interventional Study

Background/Aims: Topical corticosteroid concerns (TCC) are an important issue in patients with atopic dermatitis, leading to non-adherence with poor disease control and increased health care costs. However, neither the prevalence of TCC in a more comprehensible dermatological population nor the impact of patient information on topical corticosteroids given by clinicians is known. Therefore, we assessed the prevalence, characteristics, and sources of TCC in a dermatological population and the impact of written and oral patient information on TCC. Methods: A total of 643 outpatients with various skin diseases answered a 12-item questionnaire while waiting for the doctor's visit. Patients with TCC quantified their concerns on a discrete visual analogue scale before and after patient information, which consisted of written and oral information about topical corticosteroids (TCS) given by dermatologists. Results: The prevalence of TCC was 41.5%, and that of TCC-related non-adherence was 28.3%. TCC was positively associated with age <60 years, female gender, use of complementary and alternative medicine (CAM) and non-physician health care profession. The leading concerns were skin atrophy, systemic effects, and impairment of the immune system. The most frequent sources of TCC were negative reports by media, family, or friends. Both written and oral patient information significantly reduced TCC. The number needed to benefit from patient information was approximately 2. Non-responders were more often female, TCS-inexperienced, and users of CAM with an intermediate level of education. Conclusions: TCC are highly prevalent in dermatological patients. Patient information may lower TCC in almost every second patient.

Current status on management and needs related to education and training programs set for new employees at the provincial Centers for Disease Control and Prevention, in China

In order to understand the current management status on education/training and needs for training among new employees working at the provincial CDC in China during 2012-2014, so as to provide basis for setting up related programs at the CDC levels. Based on data gathered through questionnaire surveys run by CDCs from 32 provincial and 5 specifically-designated cities, microsoft excel was used to analyze the current status on management of education and training, for new employees. There were 156 management staff members working on education and training programs in 36 CDCs, with 70% of them having received intermediate or higher levels of education. Large differences were seen on equipment of training hardware in different regions. There were 1 214 teaching staff with 66 percent in the fields or related professional areas on public health, in 2014. 5084 new employees conducted pre/post training programs, from 2012 to 2014 with funding as 750 thousand RMB Yuan. 99.5% of the new employees expressed the needs for further training while. 74% of the new staff members expecting a 2-5 day training program to be implemented. 79% of the new staff members claimed that practice as the most appropriate method for training. Institutional programs set for education and training at the CDCs need to be clarified, with management team organized. It is important to provide more financial support on both hardware, software and human resources related to training programs which are set for new stuff members at all levels of CDCs.

Support for electronic cigarette regulations among California voters

Policies regulating the sale and use of electronic cigarettes (e-cigarettes) vary widely within the USA and worldwide. We assessed support for four proposed policies among a representative sample of California...

Less educated and older patients have reduced access to biologic DMARDs even in a country with highly developed social welfare (Norway): results from Norwegian cohort study NOR-DMARD

To explore whether age, gender or education influence the time until initiation of the first bDMARD in patients with RA. Data from the Norwegian Register of DMARDs collected between 2000 and 2012 were used. Only DMARD-naïve patients with RA starting their first conventional synthetic DMARD were included in the analyses. The start of the first bDMARD was the main outcome of interest. Cox regression analyses were used to explore the impact of education, age and gender on the start of a first bDMARD, adjusting for confounders, either at baseline or varying over time (time-varying model). Of 1946 eligible patients [mean (s.d.) age: 55 (14) years, 68% females], 368 (19%) received a bDMARD during follow-up (mean 2.6 years). In the baseline prediction model, older age [Hazard Ratio (HR) 0.97, 95% CI: 0.96, 0.98], lower education [HR = 0.76 and 0.68 for low and intermediate education levels vs college/university education, respectively (P = 0.01)] and female gender [only in the period 2000-03, HR = 0.61 (95% CI: 0.41, 0.91)] were associated with a lower hazard ratio to start a bDMARD. The time-varying model provided overall consistent results, but the effect of education was only relevant for older patients (>57 years) and became more pronounced by the end of the decade. Less educated and older patients have disadvantages with regard to access to costly treatments, even in a country with highly developed welfare like Norway. Females had lower access in the beginning of the 2000s, but access had improved by the end of the decade.

Prediction of Chlamydia trachomatis infection to facilitate selective screening on population and individual level: a cross-sectional study of a population-based screening programme

ObjectivesTo develop prediction models for Chlamydia trachomatis (Ct) infection with different levels of detail in information, that is, from readily available data in registries and from additional questionnaires.MethodsAll inhabitants of...

Which group of smokers is more vulnerable to the economic crisis?

ObjectivesStudies investigating whether smoking increases or decreases during economic downturn provided contrasting results. For the first time, we used direct questions to analyse changes in smoking behaviour due to the 2008 financial crisis, comparing socio-economic characteristics of smokers who changed with those who kept their smoking intensity. Study designCross-sectional survey. MethodsWe used data from three annual surveys conducted in Italy in 2012–2014 on representative samples of the Italian general population aged ≥15 years. ResultsA total of 1919 current smokers were asked specific questions on the influence of the economic crisis that started in 2008 on their smoking behaviour. Overall, 77.4% of 1919 current smokers reported not to have changed their smoking behaviour, 19.1% to have reduced, and 3.5% to have increased their smoking intensity as a consequence of the economic crisis. The reduction in cigarette smoking increased with age: compared to the respondents aged <25 years, the multivariate odds ratio (OR) for those aged 25–44, 45–64 and ≥65 years were 0.65, 0.46 and 0.33, respectively (P for trend<0.001). Reduction was significantly lower among intermediate (OR = 0.68 compared to low) and high education levels (OR = 0.28; P for trend<0.001). A significant inverse trend for increasing consumption was observed with age (P = 0.022), education (P = 0.003) and family income (P < 0.001). ConclusionsThe large majority of current smokers did not change their smoking habit following the economic crisis. However, there are specific vulnerable subgroups of smokers, constituted by the young and subjects with low socio-economic status, that were reactive to the global economic crisis. These groups are more prone to change their smoking behaviours, either for better or –, in a smaller proportion –, for worse.

Shifting the Beveridge Curve: What Affects Labor Market Matching?

This paper explores conditions and policies that could affect the matching between labor demand and supply. We identify shifts in the Beveridge curves for 12 OECD countries between 2000Q1 and 2013Q4 using three complementary methodologies and analyze the short-run determinants of these shifts by means of limited-dependent variable models. We find that labor force growth as well as employment protection legislation reduce the likelihood of an outward shift in the Beveridge curve,. Our findings also show that the matching process is more difficult the higher the share of employees with intermediate levels of education in the labor force and when long-term unemployment is more pronounced. Policies which could facilitate labor market matching include active labor market policies, such as incentives for start-up and job sharing programs. Passive labor market policies, such as unemployment benefits, as well as labor taxation render matching signficantly more difficult.

Shifting the Beveridge Curve: What Affects Labor Market Matching?

This paper explores conditions and policies that could affect the matching between labor demand and supply. We identify shifts in the Beveridge curves for 12 OECD countries between 2000Q1 and 2013Q4 using three complementary methodologies and analyze the short-run determinants of these shifts by means of limited-dependent variable models. We find that labor force growth as well as employment protection legislation reduce the likelihood of an outward shift in the Beveridge curve. Our findings also show that the matching process is more difficult the higher the share of employees with intermediate levels of education in the labor force and when long-term unemployment is more pronounced. Policies which could facilitate labor market matching include active labor market policies, such as incentives for start-up and job sharing programs. Passive labor market policies, such as unemployment benefits, as well as labor taxation render matching significantly more difficult.

Parental Decisional Regret after Primary Distal Hypospadias Repair: Family and Surgery Variables, and Repair Outcomes

Decisional regret is defined as distress after making a health care choice and can be an issue for parents electing distal hypospadias repair for their sons. We assessed the influence on decisional regret of variables related to the family, surgery and outcomes. Charts for 372 patients undergoing primary distal hypospadias repair between 2005 and 2012 were reviewed, and validated questionnaires, including the Decisional Regret Scale, Pediatric Penile Perception Score and Dysfunctional Voiding and Incontinence Scoring System, were administered to parents. Data were available for 172 of 372 families (response rate 46.2%). Of 323 parents 128 (39.6%) presented with moderately strong decisional regret, with good agreement within couples. Predictors of decisional regret included intermediate parental educational level (OR 3.19, 95% CI 1.52-6.69), patient not being the first born (OR 2.01, 95% CI 1.07-3.78), family history of hypospadias (OR 4.42, 95% CI 1.96-9.97), initial desire to avoid surgery (OR 2.07, 95% CI1.04-4.12), younger age at followup (OR 0.81, 95% CI 0.72-0.91), presence of lower urinary tract symptoms (OR 4.92, 95% CI 1.53-15.81) and lower Pediatric Penile Perception Score (OR 0.86, 95% CI 0.75-0.99). Decisional regret was unrelated to parental desire to avoid circumcision, surgical variables, development of complications and duration of followup. Decisional regret is a problem in a significant proportion of parents electing distal hypospadias repair for their sons. In our experience family variables seemed to be predictors of decisional regret, while surgical variables did not. Predictors of decisional regret included worse parental perception of penile appearance and the presence of lower urinary tract symptoms. However, the latter could be unrelated to surgery. Irrespective of the duration of followup, decisional regret seems decreased in parents of older patients.

Educational differences in trajectories of self-rated health before, during, and after entering or leaving paid employment in the European workforce.

This study aimed to investigate (i) the influence of entering or leaving paid employment on self-rated health trajectories before, during, and after this transition and (ii) educational differences in these health trajectories. In this prospective study, we used yearly measurements of self-rated health from the European Community Household Panel (ECHP) to establish how health is affected by employment transitions in or out of the workforce due to early retirement, unemployment or economic inactivity. Trajectories of self-rated health were analyzed among 136 556 persons with low, intermediate, or high educational level by repeated-measures logistic regression with generalized estimating equations. Among low-educated workers, ill-health partly prompted their voluntary labor force exit through early retirement and becoming economically inactive, but thereafter these exit routes seemed to prevent further deterioration of their health. In contrast, among higher educated workers, early retirement had an adverse effect on their self-rated health. Becoming unemployed had adverse effects on self-rated health among all educational levels. Entering paid employment was predetermined by self-rated health improvement in the preceding years among intermediate and high educated workers, whereas, among low-educated workers, self-rated health improved in the year of entering paid employed and continued to improve in the following years. Prolonging working life may have both adverse and beneficial effects on self-rated health. Health inequalities may increase when every person, independent of educational level, must perform paid employment until the same age before being able to retire.

Self-Reporting of Smoking Cessation in Cardiac Patients: How Reliable Is It and Is Reliability Associated With Patient Characteristics?

The objectives of this study were to determine the accuracy of smoking cessation self-reports by cardiac patients who participated in a smoking cessation program, and to determine which patient characteristics are associated with an inaccurate self-report during a follow-up interview 12 months after the start of the program. Smoking cessation self-reports (point prevalence abstinence) were validated against salivary cotinine levels. Using χ analyses, patients who reported accurately being a nonsmoker were compared with those who reported inaccurately being a nonsmoker (biochemically verified as smokers) on factors the literature has indicated to be associated with inaccurate self-report in smoking. Potential predictors of inaccurate self-report of smoking (P ≤ 0.20 in univariate analyses) were subsequently tested in a multivariate logistic regression analysis. Of the 95 patients tested, almost 25% inaccurately reported having quit smoking at a cutoff of 10-ng/mL cotinine in saliva. The data show more underreporting of smoking among patients who received a face-to-face counseling intervention and among patients with an intermediate education level. There was significantly less underreporting among patients characterized as having a Type D personality. These findings suggest that underreporting of smoking status in cardiac patients who participate in a smoking cessation program is high, especially in those who receive intensive face-to-face counseling. Having a Type D personality seems to be a protective factor, whereas having an intermediate level of education is a risk factor for inaccurate reporting. Biochemical validation in high-risk populations is highly needed, ideally accompanied by alternative forms of verification. Optimal validation testing in smoking cessation studies of cardiac patients is difficult because of high refusal rates, no-show, and organizational difficulties.

Epidemiological Characteristics of Suicidal Patients Hospitalized at the Psychiatric Clinic of the University Clinical Hospital Mostar in the Period 2004-2013

Despite the evident progress of medicine and psychiatry in recent decades there is an increase in the number of suicide attempts in psychiatric patients in outpatient and hospital settings. To determine the epidemiological characteristics of suicidal patients admitted at the Psychiatric Clinic of the University Clinical Hospital Mostar. We conducted a retrospective study in which we analyzed data from the medical history of 189 patients hospitalized after a suicide attempt at the Psychiatric Clinic of the University Clinical Hospital Mostar in the period from 2004 to 2013. Patients who attempted suicide were more often females (52.9%), unemployed (47.6%), with lower (31.7%) and intermediate level of education (52.4%), married (45.5%), without children (37.6%) and were more likely to come from urban areas (75.7%). Most of the subjects had already been in some kind of psychiatric treatment (65.1%) before. The most common method of attempting suicide was poisoning (54.0%) and when observed by gender it was significantly more frequent in females (p<0.001). Male subjects were significantly more frequently alcohol (p=0.001) and drug (p=0.001) abusers, and also more frequently were participants in the last Civil war (p<0.001) and wounded during it (p<0.001). Suicide attempts are more common in unemployed subjects, subjects with intermediate level of education, subjects who come from urban areas and in subjects who had previously received psychiatric treatment. The most common way of suicide attempts is by poisoning which was statistically significant in female subjects.