Low Socioeconomic Status Areas Research Articles

School-based dental sealant programmes may be effective in caries prevention.

DesignSplit-mouth randomised controlled clinical trial.InterventionSchool-based dental sealant (SBDS) programme. The study population that was selected from 67-year-old pupils of 16 elementary schools in areas of low socioeconomic status within Nice, France. Children with first permanent molar pairs sufficiently erupted for sealing with no caries (ICDAS [International Caries Detection and Assessment System] 0) or initial enamel lesions (ICDAS 1-2) were included. Children were randomised to either the intervention group (light polymerised resin-based sealant with fluoride) or the control group (no treatment).Outcome measureThe primary outcome measure was caries with sealant retention as a secondary outcome.ResultsFour hundred and fifty-seven pairs of permanent first molars belonging to 276 school children were randomised. At three years 378 pairs in 228 children were available for analysis. The overall retention rate was 32.3%. Sealed molars had 67% less risk of new carious lesions, adjusted hazard ratio = 0.33(95%CI; 0.24-0.46).ConclusionsSBDS programmes can be effective in preventing the development of carious lesions in school children, particularly those who come from low socioeconomic backgrounds and may, as a result, be unable to receive adequate oral healthcare in other settings outside the school. ICR should determine the selection of at-risk sub-groups for which the intervention could be considered.

Treatment delays among women with breast cancer in a low socio-economic status region in Brazil

BackgroundConsidering the inequalities and the areas of low socioeconomic status in Brazil, access to health services is a challenge and the delay between diagnosis and treatment represents an important factor of worse prognosis in patients with breast cancer. Herein, we describe the clinical and epidemiological profiles of women with breast cancer and evaluate their access to health services, as well as treatment delays, at a reference centre of the Cariri region, Ceará, Brazil.MethodsThis is a retrospective study that included 473 women treated with breast cancer between 2009 and 2011 at the Oncology Centre of the Cariri.ResultsThe majority of these patients were aged between 40 and 69 years old (65.7%), without a completed high school degree (89.2%). They were married (62.9%) and were already diagnosed but had not yet been subjected to any previous treatment (77.8%). It was observed that 91.8% were referred from the public health service, and treatment was paid for by the public health service in 92.9% of the cases. The patients whose source of referral was the public system waited longer between diagnosis and the treatment initiation (p = 0.031; Mann–Whitney’s test), with a median waiting time of 71.5 days versus 39 days for those receiving referrals from private services. In addition, those with public referrals prior to diagnosis also experienced a longer waiting time between the first medical visit and treatment initiation (77 days vs. 37 days; p = 0.036; Mann–Whitney’s test), with the waiting time for the biopsy being an important factor in this delay.ConclusionsLate diagnosis was often the result of inefficiency of the prevention policies coupled with difficulty accessing the public health network. It was commonly observed that, even after diagnosis, the patients needed to wait too long before entering the Oncology Service because of long waiting queues in the public health system.

Assessing the health impact of transnational corporations: a case study on McDonald\u2019s Australia

BackgroundThe practices of transnational corporations affect population health through production methods, shaping social determinants of health, or influencing the regulatory structures governing their activities. There has been limited research on community exposures to TNC policies and practices. Our pilot research used McDonald’s Australia to test methods for assessing the health impacts of one TNC within Australia.MethodsWe adapted existing Health Impact Assessment methods to assess McDonald’s activities. Data identifying potential impacts were sourced through document analysis, including McDonald’s corporate literature; media analysis and semi-structured interviews. We commissioned a spatial and socioeconomic analysis of McDonald’s restaurants in Australia through Geographic Information System technology. The data was mapped against a corporate health impact assessment framework which included McDonald’s Australia’s political and business practices; products and marketing; workforce, social, environmental and economic conditions; and consumers’ health related behaviours.ResultsWe identified both positive and detrimental aspects of McDonald’s Australian operations across the scope of the CHIA framework. We found that McDonald’s outlets were slightly more likely to be located in areas of lower socioeconomic status. McDonald’s workplace conditions were found to be more favourable than those in many other countries which reflects compliance with Australian employment regulations. The breadth of findings revealed the need for governments to strengthen regulatory mechanisms that are conducive to health; the opportunity for McDonald’s to augment their corporate social responsibility initiatives and bolster reputational endorsement; and civil society actors to inform their advocacy towards health and equity outcomes from TNC operations.ConclusionOur study indicates that undertaking a corporate health impact assessment is possible, with the different methods revealing sufficient information to realise that strong regulatory frameworks are need to help to avoid or to mediate negative health impacts.

Assessing disparities in colorectal cancer mortality by socioeconomic status using new tools: health disparities calculator and socioeconomic quintiles

PurposeColorectal cancer mortality rates dropped by half in the past three decades, but these gains were accompanied by striking differences in colorectal cancer mortality by socioeconomic status (SES). Our research objective is to examine disparities in colorectal cancer mortality by SES, using a scientifically rigorous and reproducible approach with publicly available online tools, HD*Calc and NCI SES Quintiles.MethodsAll reported colorectal cancer deaths in the United States from 1980 to 2010 were categorized into NCI SES quintiles and assessed at the county level. Joinpoint was used to test for significant changes in trends. Absolute and relative concentration indices (CI) were computed with HD*Calc to graph change in disparity over time.ResultsDisparities by SES significantly declined until 1993–1995, and then increased until 2010, due to a mortality drop in populations living in high SES areas that exceeded the mortality drop in lower SES areas. HD*Calc results were consistent for both absolute and relative concentration indices. Inequality aversion parameter weights of 2, 4, 6 and 8 were compared to explore how much colorectal cancer mortality was concentrated in the poorest quintile compared to the richest quintile. Weights larger than 4 did not increase the slope of the disparities trend.ConclusionsThere is consistent evidence for a significant crossover in colorectal cancer disparity from 1980 to 2010. Trends in disparity can be accurately and readily summarized using the HD*Calc tool. The disparity trend, combined with published information on the timing of screening and treatment uptake, is concordant with the idea that introduction of medical screening and treatment leads to lower uptake in lower compared to higher SES populations and that differential uptake yields disparity in population mortality.

Impact of medical student origins on the likelihood of ultimately practicing in areas of low vs high socio-economic status

IntroductionMedical schools are in general over-represented by students from high socio-economic status backgrounds. The University of Western Australia Medical School has been progressively widening the participation of students from a broader spectrum of the community both through expanded selection criteria and quota-based approaches for students of rural, indigenous and other socio-educationally disadvantaged backgrounds. We proposed that medical students entering medical school from such backgrounds would ultimately be more likely to practice in areas of increased socio-economic disadvantage.MethodsThe current practice address of 2829 medical students who commenced practice from 1980 to 2011 was ascertained from the Australian Health Practitioner Regulation Agency (AHPRA) Database. Logistic regression was utilised to determine the predictors of the likelihood of the current practice address being in the lower 8 socio-economic deciles versus the top 2 socio-economic deciles.ResultsThose who were categorised in the lower 8 socio-economic deciles at entry to medical school had increased odds of a current practice address in the lower 8 socio-economic deciles 5 or more years after graduation (OR 2.05, 95% CI 1.72, 2.45, P < 0.001). Other positive univariate predictors included age at medical degree completion (for those 25 years or older vs those 24 years or younger OR 1.53, 95% CI 1.27, 1.84, P < 0.001), being female (OR 1.26, 95% CI 1.07, 1.48, P = 0.005) and having a general practice versus specialist qualification (OR 4.16, 95% CI 3.33, 5.19, P < 0.001). Negative predictors included having attended an independent school vs a government school (OR 0.77, 95% CI 0.64, 0.92, P < 0.001) or being originally from overseas vs being born in Oceania (OR 0.80, 95% CI 0.67, 0.96, P = 0.017). After adjustment for potential confounders in multivariate logistic regression, those in the lower 8 socio-economic deciles at entry to medical school still had increased odds of having a current practice address in the lower 8 socio-economic deciles (OR 1.63, 95% CI 1.34, 1.99, P < 0.001).ConclusionWidening participation in medical school to students from more diverse socio-educational backgrounds is likely to increase the distribution of the medical workforce to ultimate service across areas representative of a broader socio-economic spectrum.

Expanding the scope beyond mortality: burden and missed opportunities in maternal morbidity in Indonesia

ABSTRACT Background: Indonesia still faces challenges in maternal health. Specifically, the lack of information on community-level maternal morbidity. The relatively high maternal healthcare non-utilization in Indonesia intensifies this problem. Objective: To describe the burden of community-level maternal morbidity in Indonesia. Additionally, to evaluate the extent and determinants of missed opportunities in women with maternal morbidity. Methods: We used three cross-sectional surveys (Indonesian Demographic and Health Survey, IDHS 2002, 2007 and 2012). Crude and adjusted proportions of maternal morbidity burden were estimated from 43,782 women. We analyzed missed opportunities in women who experienced maternal morbidity during their last birth (n = 19,556). Multilevel mixed-effects logistic regressions were used to evaluate the determinants of non-utilization in IDHS 2012 (n = 6762). Results: There were significant increases in the crude and adjusted proportion of maternal morbidity from IDHS 2002 to IDHS 2012 (p < 0.05). In 2012, the crude proportion of maternal morbidity was 53.7%, with adjusted predicted probability of 51.4%. More than 90% of these morbidities happened during labor. There were significant decreases in non-utilization of maternal healthcare among women with morbidity. In 2012, 20.0% of these women did not receive World Health Organization (WHO) standard antenatal care. In addition, 7.1% did not have a skilled provider at birth, and 25.0% delivered outside of health facilities. Higher proportions of non-utilization happened in women who were younger, multiparous, of low socioeconomic status (SES), and living in less-developed areas. In multilevel analyses, missed opportunities in healthcare utilization were strongly related to low SES and low-resource areas in Indonesia. Conclusion: The prevalence of maternal morbidity in Indonesia is relatively high, especially during labor. This condition is amplified by the concerning missed opportunities in maternal healthcare. Efforts are needed to identify risk factors for maternal morbidity, as well as increasing healthcare coverage for the vulnerable population.

Integrating Primary Health and Social Care in the Australian setting: an initial approach to risk stratification

Internationally, sophisticated risk stratification models have been developed using routinely collected data from large organisations that provide care in both community and hospital settings. This paper outlines a simple approach in the Australian context, where federal and state governments have separate data for community and hospital care, with limited opportunities for data linkage.On the NSW Central Coast, just north of Sydney, the Central Coast Local Health District, CCLHD, is embarking on a 10 year program to integrate primary health and social care for vulnerable older people in the community. A key action is to provide integrated care for people at greatest risk of some deterioration in their health state.Practice changeAim: To assess the utility of routinely collected hospital data for risk stratification. In the first year of the program, the risk is defined as a person with a high risk of being hospitalised in the next 12 months.Target Population: The Central Coast area of New South Wales, Australia, has a population of about 330,000 people, with 19% aged 65 years and over. Each year, about 10,000 people of this age have at least one unplanned hospital admission to a CCLHD hospital.There are over 400 General Practitioners, GPs, on the Central Coast, working from about 100 practice locations - with some solo practices to large group practices, operating as separate small business entities. People do not register for a GP, though nearly all people by 75 years of age have a regular GP. General practices also vary by the number and age profile of the patients they see in a year.Key Findings: The analysis of 5 years of hospital data demonstrated patterns in service delivery for the older age group eg for each year’s cohort of 10,000 people with at least one admission, about 2700 people (27%) have at least one hospital admission in the following year.Knowing each person’s nominated GP allowed some exploration of patterns of service use by GP. Some GPs had few patients admitted each year, and some GPs had many. It is likely this variability reflects differences in practice profiles of age distribution. There was consistency in these patterns of service use by GP over time, and also by general practice.The analysis of comorbidities allowed categorisation of the age group into those with 2 or more comorbidities - about 3500 people from a one year cohort have 2 or more chronic diseases. For this group of 3500 people, about 1500 people, or 40%, have a hospital admission in the following year.This approach was used to identify a small number of general practices in a low socio-economic status area, with an initial total cohort of about 600 people for a proof of concept of integrated care.Discussion: A risk stratification model needs to be linked with an effective intervention to improve the health of a population.Regression to the mean, when assessing whether a trial worked – it is important to have an understanding of patterns of service delivery over time, if they exist. Analysing hospital data, by general practice, allows contemporaneous analyses of other practices with similar activity and socio-economic profiles for comparison.Risk stratification models and c-statistics – the c-statistic is a useful measure of goodness of fit available for some regression models. It is not the only measure, and others should be considered. This approach using hospital data does not have a goodness of fit measure per se.Positive Predictive Value – Of equal importance is how well the model works when it is applied to the population of interest. If a model selects 100 people considered at high risk of hospitalisation, and 25 people are actually admitted to hospital, this represents a positive predictive value, PPV, of 25%. The PPV is influenced by the underlying risk of hospitalisation in your target population. Our 40% prediction of hospitalisation can be compared with the PPV of other risk stratification models.Conclusion: Further work is underway to apply a regression model to hospital data to facilitate comparisons with other risk stratification models reported in the literature, and quantify the incremental gains from increasingly sophisticated approaches to patient selection.Further work will also explore the gains from linking hospital data with primary care data.Using hospital data compares well with other models, and is an easily transferable, low tech approach to patient selection. A series of criteria for patient selection is a familiar way of doing business in many clinical settings.

An epidemiological study of clinic attendees at the first specialised clinic for individuals with intellectual disability in Sri Lanka

Background Intellectual disability (ID) is diagnosed when both intellectual and adaptive functioning deficits are shown in conceptual, social and practical domains during the developmental period. A higher prevalence of ID in areas of lower socioeconomic status and developing countries is noted. No published studies of ID were found for Sri Lanka. Aims To describe the epidemiology and pattern of health seeking behaviour of individuals with ID attending a specialised clinic. Methods Data were extracted from the records of all individuals registered at the specialised clinic for mentally retarded individuals at Teaching Hospital, Peradeniya, from 1984 to 2013. Results One thousand three hundred and thirty five patient records were perused. The mean age at first presentation was 11.7 years. The majority (60.7%) were males. Mild, moderate and severe ID was diagnosed in 78.9%, 15.6% and 5.5% respectively. The main presenting problem was poor scholastic abilities (54.8%). Epilepsy was the main associated medical condition. Activities of daily living (ADLs) were impaired in 31.8% of subjects. A majority-received no behavioural interventions. Conclusion There was a 33-fold increase in help seeking behaviour, over the 29 year study period. The findings of this study highlight the epidemiology of ID in Sri Lanka, and the need for more clinics and a national policy for ID.

The Selection of ECEC Programs by Australian Families: Quality, Availability, Usage and Family Demographics

HIGH-QUALITY EARLY CHILDHOOD education and care (ECEC) programs have the potential to ameliorate socioeconomic status (SES) gradients. In the Australian ECEC market, however, there is no guarantee that children from low SES backgrounds access high-quality ECEC programs. This study tested the influence of family SES on the selection of ECEC program quality. Participants were 2494 children enrolled in up to 1427 ECEC classrooms (mean age at entry = 43 months, SD = eight months). The study controlled for a range of child, family, home and community-level background factors. Both cross-sectional (linear regression) and longitudinal (growth models) methods are used. The study confirmed that children from lower SES families were more likely to attend lower quality programs. Longitudinal modelling showed the largest quality gap before kindergarten. To narrow SES-related achievement gaps there is a need to significantly improve aspects of program quality that influence children's development, and specifically to do so in programs for younger children. There is a particular need to target ECEC programs in lower SES areas to ameliorate the observed SES quality gradient. The findings further challenge current policy directions from the Productivity Commission inquiry into child care and early learning.

Who do you think you are? Medical student socioeconomic status and intention to work in underserved areas.

A frequently cited rationale for increasing the participation of students from low socioeconomic status (SES) backgrounds is that it will create a workforce who will choose to work in low SES and medically underserviced communities. Two theoretical arguments, one that supports and one that contradicts this assumption, are proposed to explain the practice location intentions of medical students which we examine in a longitudinal analysis. SES background and future intentions of 351 applicants to an undergraduate medical degree were assessed at Time 1, with intentions re-assessed one year later for 96% of those who were enrolled as medical students. Students from very low (and very high) SES backgrounds indicated lower intention to practice in low SES or medically underserviced areas than those from mid-range SES backgrounds. Males and students from non-English speaking backgrounds indicated less desire to work in low SES areas, perhaps explained by high aspirational motivation. SES accounted for a relatively small amount of variance in practice intentions. Alternate predictors of practice location, including individual values and training effects, and their implications for selection practice, are discussed.

Relationship between physical activity levels and body fat of children aged 8–9, from UK schools in low socioeconomic areas

Relevance: Increasing levels of obesity, sedentary lifestyles and lower levels of physical activity (PA) in children is concerning both in the UK and globally. This is particularly important in low socioeconomic status (SES) areas, where lower levels of engagement with public health initiatives have been identified. Health behaviour patterns in childhood are important for long-term health and well-being. It is therefore important to understand PA behaviours in children from low SES areas and to explore possible relationships with obesity.

The changing pattern of contraceptive use and pregnancies in four generations of young women.

The aim of this study was to describe contraceptive use and pregnancies and their relationship to socio-economic status (SES) in four generations of young Swedish women. Questionnaires regarding contraceptive use and pregnancies were sent to random samples of 19-year-old women in 1981, 1991, 2001 and 2011 (n=4732). Current contraceptive use was higher in 2001 (78%) (p<0.01) and 2011 (69%) (p<0.05) compared with 1981 (60%) and 1991 (62%). Combined hormonal contraception (CHC) was the most common form of contraception throughout (p<0.0001). The use of long-acting reversible contraception (LARC=implants, intrauterine contraception) and progestogen-only pills increased over time (p<0.01). Mental side effects as a reason for CHC cessation increased over time and was the most common reason for cessation of CHC in 2011 (p<0.001). Contraceptive use was lower in women from low SES areas (p<0.05) in 2011. The percentage of young women who had been pregnant at ≤19years of age was lower (p<0.05) in the assessment from 2001 (7%) than in that in 1991 (13%) and 2011 (12%). The proportion of teenage mothers decreased from 4.4% (1981) to 1.6% (2011) (p<0.01). More women had been pregnant at ≤19years of age in low SES areas than in middle and high SES areas (p<0.05). The lowest pregnancy rate was in the cohort with the highest contraceptive use. Term pregnancies declined over time. A greater number of pregnancies in low SES areas and a change towards lower contraceptive use in low SES areas was recorded in 2011.

P.7.d.008 - Differences in utilization patterns among medications in children and adolescents with attention-deficit hyperactivity disorder: a 36-month naturalistic retrospective study using the Korean health insurance review and assessment claims database

To investigate the patterns and the determinants of mental health service use by children and adolescents in Australia.Data from Young Minds Matter (YMM): The Second Australian Child and Adolescent Survey of Mental Health and Wellbeing is used in this study. YMM is a face-to-face household survey conducted in 2013–2014 that collected information from 6310 parents/carers of children aged 4–17 years (55% of eligible households). A self-reported survey of 2967 (89% of eligible youth) 11- to 17-year-olds from these households was also conducted. Bivariate analyses are used in this study to examine the variables and their distributions over the outcome variables. Binary logit models are used to investigate the determinants of mental health service use.Parent reported data shows that among children aged 4–17 years, 12%, 1.2% and 0.6% utilised health services, school services and telephone services, respectively. Youth reported data reveals that approximately 7.2%, 2% and 4% and 23.5% of children aged 11–17 years used health services, school services, telephone services and online services, respectively. Youth reported data further shows that online services were the most popular type of mental health service among adolescents. Those with anxiety or ADHD constituted the highest proportion of children that used any type of mental health services. Logistic analysis of parent reported data shows that children from step, blended and sole-parent households compared to original parent households were more likely to use any type of mental health service, and the same trend was seen for children living in inner regional areas compared to those living in major cities. Children of parents with lower education or unemployed parents were also more likely to utilise health services.From the findings, it is concluded that age-relevant mental health services should be improved and made available for children and adolescents. Secondly, school and health services should have a particular focus on complex disorders like ADHD, anxiety and conduct disorders, as these are the services most used by children who suffer from these conditions. Finally, areas of low socio-economic status should focus on improving their school and health services as these are the services used most by children from these backgrounds.

Adolescents' ratings of features of parks that encourage park visitation and physical activity.

BackgroundThe neighbourhood environment such as the availability of parks are a key, but under-researched, influence on adolescents’ physical activity. In addition to overall physical activity levels, park-based physical activity and park visitation is low in this age group. Thus, it is critical to identify park features that may encourage or discourage adolescents from visiting parks. This study used a novel methodology to identify key physical characteristics of parks that are perceived to be important for park visitation and park-based physical activity among adolescents.MethodsFour secondary schools located in low, mid and high socio-economic status areas of Victoria, Australia were recruited. Using a purpose-built computer application, students in years 8–10 were presented with 44 original photographic images of park features. Participants rated each image (range 1–10) on how likely the feature would be to encourage them to visit a park and to engage in park-based physical activity, and placed symbols (‘thumbs up’/‘thumbs down’) on aspects of the image that had a positive or negative influence on their ratings.ResultsParticipants (n = 99) had a mean age of 13.3 years (SD = 0.87) and 53 % were female. Overall, the top three rated images prompting park visitation by adolescents were: a long steep slide, a flying fox and a table tennis table. These first two features were also reported as being likely to promote physical activity in the park. Differences in ratings were observed for boys and girls. The images that received the greatest number of “thumbs-up” symbols included large swings and slides, table tennis tables, no-smoking signs, flying foxes and BMX tracks. The images that received the greatest number of “thumbs-down” symbols included signage about rules, graffiti, toilets, concrete steps, and skate bowls.ConclusionPhysically challenging play equipment is likely to encourage adolescents to visit and be active in parks. Rules, graffiti, toilets and skate bowls may discourage visitation. It is important for park designers, planners and policy makers to consider adolescents’ views of what park design features are important so that parks are created that support and encourage visitation and optimise levels of physical activity when in the park.Electronic supplementary materialThe online version of this article (doi:10.1186/s12966-016-0391-9) contains supplementary material, which is available to authorized users.

Implementation of an Educational Cartoon (“the Patchbook”) and Other Compliance-Enhancing Measures by Orthoptists in Occlusion Treatment of Amblyopia

ABSTRACTPurpose: This implementation study evaluated orthoptists’ use of an educational cartoon (“the Patchbook”) and other measures to improve compliance with occlusion therapy for amblyopia.Methods: Participating orthoptists provided standard orthoptic care for one year, adding the Patchbook in the second year. They attended courses on compliance and intercultural communication by communication skills training. Many other compliance-enhancing measures were initiated. Orthoptists’ awareness, attitude, and activities regarding noncompliance were assessed through interviews, questionnaires, and observations. Their use of the Patchbook was measured. The study was performed in low socio-economic status (SES) areas and in other areas in the Netherlands. It was attempted to integrate education on compliance into basic and continuing orthoptic training.Results: The Patchbook was used by all 9 orthoptists who participated in low-SES areas and 17 of 23 orthoptists in other areas. Courses changed awareness and attitude about compliance, but this was not sustained. Although orthoptists estimated compliance during patching at 70%, three-quarters never suspected noncompliance during a full day of observation in any of their patients. Explanations to parents who spoke Dutch poorly were short. In the second year, explanations to children were longer. Implementation of all 7 additional compliance-enhancing measures failed. Education on compliance was not integrated into orthoptists’ training.Conclusion: Almost all orthoptists used the Patchbook and, as another study demonstrated, it proved to be very effective, especially in low-SES areas. Duration of explanation was inversely proportional to parents’ fluency in Dutch. Noncompliance was rarely suspected by orthoptists. Although 7 additional compliance-enhancing measures had been conceived and planned with the best intentions, they were not realized. These required extra, unpaid time from the orthoptists, which is especially scarce in hospitals in low-SES areas where the educational cartoon is most needed.

Clusters of suicides and suicide attempts: detection, proximity and correlates.

A suicide cluster is defined as a higher number of observed cases occurring in space and/or time than would typically be expected. Previous research has largely focused on identifying clusters of suicides, while there has been comparatively limited research on clusters of suicide attempts. We sought to identify clusters of both types of behaviour, and having done that, identify the factors that distinguish suicide attempts inside a cluster from those that were outside a cluster. We used data from Western Australia from 2000 to 2011. We defined suicide attempts as admissions to hospital for deliberate self-harm and suicides as deaths due to deliberate self-harm. Using an analytic strategy that accounted for the repetition of attempted suicide within a cluster, we performed spatial-temporal analysis using Poisson discrete scan statistics to detect clusters of suicide attempts and clusters of suicides. Logistic regression was then used to compare clustered attempts with non-clustered attempts to identify risk factors for an attempt being in a cluster. We detected 350 (1%) suicide attempts occurring within seven spatial-temporal clusters and 12 (0.6%) suicides occurring within two spatial-temporal clusters. Both of the suicide clusters were located within a larger but later suicide attempt cluster. In multivariate analysis, suicide attempts by individuals who lived in areas of low socioeconomic status had higher odds of being in a cluster than those living in areas of high socioeconomic status [odds ratio (OR) = 29.1, 95% confidence interval (CI) = 6.3-135.5]. A one percentage-point increase in the proportion of people who had changed address in the last year was associated with a 60% increase in the odds of the attempt being within a cluster (OR = 1.60, 95% CI = 1.29-1.98) and a one percentage-point increase in the proportion of Indigenous people in the area was associated with a 7% increase in the suicide being within a cluster (OR = 1.07, 95% CI = 1.00-1.13). Age, sex, marital status, employment status, method of harm, remoteness, percentage of people in rented accommodation and percentage of unmarried people were not associated with the odds of being in a suicide attempt cluster. Early identification of and responding to suicide clusters may reduce the likelihood of subsequent clusters forming. The mechanisms, however, that underlie clusters forming is poorly understood.

Physical activity pattern, cardiorespiratory fitness, and socioeconomic status in the SCAPIS pilot trial - A cross-sectional study.

Living in a low socioeconomic status (SES) area is associated with an increased risk of cardiovascular events and all-cause mortality. Previous studies have suggested a socioeconomic gradient in daily physical activity (PA), but have mainly relied on self-reported data, and individual rather than residential area SES. This study aimed to investigate the relationships between residential area SES, PA pattern, compliance with PA-recommendations and fitness in a Swedish middle-aged population, using objective measurements. We included 948 individuals from the SCAPIS pilot study (Gothenburg, Sweden, 2012, stratified for SES, 49% women, median age: 58 years), in three low and three high SES districts. Accelerometer data were summarized into intensity-specific categories: sedentary (SED), low (LIPA), and medium-to-vigorous PA (MVPA). Fitness was estimated by submaximal ergometer testing. Participants of low SES areas had a more adverse cardiovascular disease risk factor profile (smoking: 20% vs. 6%; diabetes: 9% vs. 3%; hypertension: 38% vs. 25%; obesity: 31% vs. 13%), and less frequently reached 150 min of MVPA per week (67% vs. 77%, odds ratio [OR] = 0.61; 95% confidence interval [95% CI] = 0.46–0.82), from 10-minute bouts (19% vs. 31%, OR = 0.53, 95% CI = 0.39–0.72). Individuals in low SES areas showed lower PA levels (mean cpm: 320 vs. 348) and daily average MVPA (29.9 vs. 35.5 min), and 12% lower fitness (25.1 vs. 28.5 mL × min− 1 × kg− 1) than did those in high SES areas. Reduced PA and fitness levels may contribute to social inequalities in health, and should be a target for improved public health in low SES areas.

Mo1148 Trends in Sociodemographic Disparities in Colorectal Cancer Staging and Survival: A SEER-Medicare Analysis

Introduction Race, ethnicity, and socioeconomic status are known to influence staging and survival in colorectal cancer (CRC). It is unclear how these relationships are affected by geographic factors and changes in insurance coverage for CRC screening. We examined the temporal trends in the association between sociodemographic and geographic factors and staging and survival among Medicare beneficiaries. Methods We identified patients 65 years or older with CRC using the 1991-2010 Surveillance, Epidemiology, and End Results-Medicare database and extracted area-level sociogeographic data. We constructed multinomial logistic regression models and the Cox proportional hazards models to assess factors associated with CRC stage and survival in 4 periods with evolving reimbursement and screening practices: (i) 1991-1997, (ii) 1998-June 2001, (iii) July 2001-2005, and (iv) 2006-2010. Results We observed 327,504 cases and 102,421 CRC deaths. Blacks were 24%-39% more likely to present with distant disease than whites. High-income areas had 7%-12% reduction in distant disease. Compared with whites, blacks had 16%-21% increased mortality, Asians had 32% lower mortality from 1991 to 1997 but only 13% lower mortality from 2006 to 2010, and Hispanics had 20% reduced mortality only from 1991 to 1997. High-education areas had 9%-12% lower mortality, and high-income areas had 5%-6% lower mortality after Medicare began coverage for screening colonoscopy. No consistent temporal trends were observed for the associations between geographic factors and CRC survival. Discussion Disparities in CRC staging and survival persisted over time for blacks and residents from areas of low socioeconomic status. Over time, staging and survival benefits have decreased for Asians and disappeared for Hispanics.

Effect of Fee on Cervical Cancer Screening Attendance--ScreenFee, a Swedish Population-Based Randomised Trial.

BackgroundAttendance in the cervical cancer screening programme is one of the most important factors to lower the risk of contracting the disease. Attendance rates are often low in areas with low socioeconomic status. Charging a fee for screening might possibly decrease attendance in this population. Screening programme coverage is low in low socio-economic status areas in Gothenburg, Sweden, but has increased slightly after multiple interventions in recent years. For many years, women in the region have paid a fee for screening. We studied the effect of abolishing this fee in a trial emanating from the regular cervical cancer screening programme.MethodIndividually randomised controlled trial. All 3 124 women in three low-resource areas in Gothenburg, due for screening during the study period, were randomised to receive an offer of a free test or the standard invitation stating the regular fee of 100 SEK (≈11 €). The study was conducted during the first six months of 2013. Attendance was defined as a registered Pap smear within 90 days from the date the invitation was sent out.ResultsAttendance did not differ significantly between women who were charged and those offered free screening (RR 0.93; CI 0.85–1.02). No differences were found within the districts or as an effect of age, attendance after the most recent previous invitation or previous experience of smear taking.ConclusionAbolishment of a modest screening fee in socially disadvantaged urban districts with low coverage, after previous multiple systematic interventions, does not increase attendance in the short term. Other interventions might be more important for increasing attendance in low socio-economic status areas.Trial RegistrationClinicalTrials.gov NCT02378324

Response: Commentary: Control of Body Weight by Eating Behavior in Children.

To the Editor: We thank Dr. Tony Kuo for his valuable comments on our review. As Dr. Kuo correctly points out, interventions aiming at manipulating internal mechanisms related to body weight, e.g., ­pharmacology and diets, have had limited success in reversing the increase in pediatric body weight. We agree with him that the alternative suggestion that body weight is under external control is in line with many recent public health initiatives aiming at improving the food environment. Dr. Kuo listed many of the newer policies, some of which we were unaware of and so we learnt a great deal from reading Dr. Kuo’s commentary paper. Yet, we feel confident that Dr. Kuo agrees with us that the success of these initiatives in curbing further increase in body weight among children has also been limited. We beg to disagree, however, with Dr. Kuo that the hypothesis that body weight is under external control is “opposed to the viewpoint that cognition plays a predominant role,” and that our method is somehow related to “cognitive control.” We refer to the compelling work of Dr. Brian Wansink, showing that the role of cognition in eating behavior is negligible (1). Undesirable cognitions, including “dietary restraint,” among obese individuals are more likely the results of failed attempts at dieting than causes of their weight problem (2). Interestingly, a sustained reduction of body weight has been obtained with cognitive behavioral therapy (3), but it is clear from the protocol that the effect was obtained by behavioral intervention, i.e., establishing normal eating behavior; whatever effect the cognitive intervention exerted was less important (4). At the same time, we certainly agree with Dr. Kuo that our suggestion that body weight can increase among the underweight and decrease among the overweight if they learn how to eat normally by using feedback on a computer screen requires further investigation. However, the facts that this method has brought 75% of patients with eating disorders into remission, reduced the rate of relapse to 10% over 5 years of follow-up, and eliminated the mortality are encouraging (5). We have outlined the neurobiological mechanisms on which the method relies in detail (references in our review). The approach was adapted to the treatment of childhood obesity because anorexia and obesity are at the extreme opposites of the same behavioral and biochemical continuum (6). Dr. Kuo is right in suggesting that the success of this approach on a larger scale needs to be tested. And, of course, creating healthy environments, including advice on diets and physical activity, remains important not least “for those who live in low socioeconomic status areas.”