Primary Catchment Area Research Articles

Modeling intrinsic vulnerability of complex karst aquifers: modifying the COP method to account for sinkhole density and fault location

This study investigates a method of karst-aquifer vulnerability modeling that modifies the concentration-overburden-precipitation (COP) method to better account for structural recharge pathways through noncarbonate rocks, and applies advancements in remote-sensing sinkhole identification. Karst aquifers are important resources for human and agricultural needs worldwide, yet they are often highly complex and have high vulnerability to contamination. While many methods of estimating intrinsic vulnerability of karst aquifers have been developed, few methods acknowledge the complication of layered karst aquifer systems, which may include interactions between carbonate and noncarbonate rocks. This paper describes a modified version of the COP method applied to the Kaibab Plateau, Arizona, USA, the primary catchment area supplying springs along the north side of the Grand Canyon. The method involves two models that, together, produce higher resolution and greater differentiation of vulnerability for both the deep and perched aquifers beneath the Kaibab Plateau by replacing the original sinkhole distance parameter with sinkhole density. Analyses indicate that many karst regions would benefit from the methodology developed for this study. Regions with high-resolution elevation data would benefit from the incorporation of sinkhole density data in aquifer vulnerability assessments, and deeper semi-confined karst aquifers would benefit greatly from the consideration of fault location.

Factors associated with maternity waiting home use among women in Jimma Zone, Ethiopia: a multilevel cross-sectional analysis

ObjectiveTo identify individual-, household- and community-level factors associated with maternity waiting home (MWH) use in Ethiopia.DesignCross-sectional analysis of baseline household survey data from an ongoing cluster-randomised controlled trial using multilevel...

A Population-Based Study of Incidence, Presentation, Management and Outcome of Primary Thromboembolic Ischemia in the Upper Extremity.

To investigate the epidemiology of acute upper limb thromboembolism in a well-defined Norwegian population. This study was a retrospective, single-center, observational population-based cohort study of acute upper limb thromboembolism. The study included all patients from the hospital's primary catchment area from January 2000 to December 2015. Age- and gender-adjusted incidence rates were calculated using population demographics from Statistics Norway. A total of 54 patients were identified, of which 49 were included in the analyses: 27 (55%) females (median age 83years, range 40-96) and 22 (45%) males (median age 70years, range 42-95) (P = .053). The adjusted incidence rate for the period was 1.6 patients per 100,000 inhabitants per year (95% confidence interval 1.2-2.2) and did not change significantly during the period studied. Atrial fibrillation was detected by electrocardiography in 30 (61%) patients; in this group, 10 patients were on warfarin but only two had an international normalized ratio > 1.9 and the remaining 20 were not anticoagulated. Altogether, 38 (78%) patients underwent surgery, 1 (2%) was treated with thrombolysis, and the remaining patients were treated conservatively; no amputations were performed. Four patients (8%) died within 30days, and 12 of the surviving 45 patients (27%) had recurrent thromboembolism. The incidence rate was stable during the study period. Patients with upper limb thromboembolism due to atrial fibrillation were inadequately anticoagulated. One in four patients experienced a recurrent thromboembolic event. Lifelong anticoagulation should be considered in all patients with upper limb thromboembolism.

The prevalence and determinants of glaucoma among 40 years and older Saudi residents in the Riyadh Governorate (except the Capital) – A community based survey

PurposeTo evaluate the prevalence of glaucoma and its determinants among adult Saudi Residents aged 40 years and older in the Riyadh Governorate (except the Capital). MethodsA cluster-based sample of randomly selected citizens from six primary health center catchment areas were examined between 2014 and 2015. Data were collected on their glaucoma management. Assessment included measurement of intraocular pressure, optic nerve head evaluation and gonioscopy. Glaucoma suspects were referred for visual field testing. ResultA total of 940 citizens were examined and 124 had glaucoma. The prevalence of glaucoma was 5.6% [95% Confidence interval (CI): 5.43–5.75] with an estimated 3758 cases of glaucoma in study area. Males had a significantly higher prevalence (7.62%) than females (3.48%). Glaucoma was not significantly associated to diabetes [Odds ratio (OR) = 1.1; (95% CI: 0.8–1.7); P = 0.5]. The variation in the prevalence of glaucoma by age group was not significant (P = 0.2). Open angle of anterior chamber was in 78% of glaucoma cases. The coverage of glaucoma management was 27.8%. Among known glaucoma patients were 69% were treatment-complaint. Of 124 glaucoma patients, 29 (23.5%) were aware of their diagnosis. Mild and moderate visual impairment was in 67% and 8 (6.5%) glaucoma patients while one (0.8%) patient was bilateral blind. ConclusionThe prevalence of glaucoma was high. Identified determinants should be noted and accordingly a public health approach for early detection and adequate management is recommended.

Choice as a duty? The abolition of primary school catchment areas in North Rhine-Westphalia/Germany and its impact on parent choice strategies

In 2008, primary school catchment areas were abolished in the federal state of North Rhine-Westphalia (NRW)/Germany. Written several years later, this article’s main aim is to provide insights into the impact of the policy reform on parent choice practices and subsequently on educational segregation. Based on a mixed-methods approach, it seeks to understand how being raised in and accustomed to a catchment area system affects parents’ understanding of the policy reform and impacts their choice strategies. We demonstrate that the (socially selective) choice of a school outside the former catchment area increased significantly after 2008, leading to a higher level of school segregation, though affecting schools to very different extents. The study clearly reveals that the differences in choice strategies are shaped by the dissimilar conclusions parents from different educational backgrounds draw from the policy reform. While less-educated parents attribute less significance to this early stage of schooling, many well-educated ones interpret the introduction of free choice as an instigation to choose – a perception triggered and intensified by the policy reform. For them, choice is no longer only perceived as an opportunity; through its formalisation it rather seems to become a duty. Thus, by one-sidedly favouring well-educated parents’ interests and benefiting their abilities to play the game, the reform seems to perpetuate existing inequalities in choice rather than to alleviate them.

Models of care for co-morbid diabetes and chronic kidney disease.

Diabetes and chronic kidney disease (CKD) are two of the most prevalent co-morbid chronic diseases in Australia. The increasing complexity of multi-morbidity, and current gaps in health-care delivery for people with co-morbid diabetes and CKD, emphasize the need for better models of care for this population. Previously, proposed published models of care for co-morbid diabetes and CKD have not been co-designed with stake-holders or formally evaluated. Particular components of health-care shown to be effective in this population are interventions that: are structured, intensive and multifaceted (treating diabetes and multiple cardiovascular risk factors); involve multiple medical disciplines; improve self-management by the patient; and upskill primary health-care. Here we present an integrated patient-centred model of health-care delivery incorporating these components and co-designed with key stake-holders including specialist health professionals, general practitioners and Diabetes and Kidney Health Australia. The development of the model of care was informed by focus groups of patients and health-professionals; and semi-structured interviews of care-givers and health professionals. Other distinctives of this model of care are routine screening for psychological morbidity; patient-support through a phone advice line; and focused primary health-care support in the management of diabetes and CKD. Additionally, the model of care integrates with the patient-centred health-care home currently being rolled out by the Australian Department of Health. This model of care will be evaluated after implementation across two tertiary health services and their primary care catchment areas.

Characteristics, Stratification and Time to Death in a Population-Based Cohort of Patients with Ruptured Abdominal Aortic Aneurysms Not Undergoing Surgery.

The available literature on ruptured abdominal aortic aneurysms (rAAA) centers on survival after operation and commonly, reasons why some patients do not undergo surgery are not addressed. The aim of the present study is to examine, in a population-based cohort, the characteristics, stratification and time to death of patients admitted to hospital, but not undergoing operation for rAAA. A retrospective, single-center study. All patients admitted to Stavanger University Hospital from the primary catchment area with rAAA on admission or in-hospital from 2000 to 2014 were included. Altogether 214 patients with rAAA were identified; 57 (27%) patients did not undergo surgery. The proportion of women was significantly higher (37 vs. 14%; p<.001) in patients not having surgery. The reasons for not undergoing operation were patient 'not fit for surgery' (30%), 'dying or agonal' at time of diagnosis (26%), 'did not want operation' (21%) and 'diagnosed at autopsy' (23%). Of the non-operated patients, 45 had rAAA on arrival to hospital, 12 had in-hospital rupture and 21 patients had previously been diagnosed with an abdominal aortic aneurysm. Non-operative treatment was uniformly fatal. The 45 patients with rAAA on arrival were scored using four scoring systems, the predicted mortality varied widely, and the median time from admission to death was 7.4h (range 0-1337). In about half of patients, a decision not to operate was made by the consultant vascular surgeon or the patient. In the subgroup of patients not diagnosed until autopsy or having an in-hospital rupture, an earlier diagnosis might have altered the outcome.

A new generation of Primary Care Service Areas or general practice catchment areas

AbstractPrimary Care is fundamental to a well‐functioning health system. Various geographical small areas including specialized geographies such as Primary Care Service Areas (PCSAs) are used to measure primary care relevant outcomes and services, or to target interventions. PCSAs are small areas, the majority of patients resident in which obtain their primary care services from within the geography. The extent of this self‐sufficiency of use is measured by the Localization Index (LI). PCSAs have been built in the US, Australia and Switzerland using an allocation algorithm, which, while simple and easy to implement, may require the use of various ad‐hoc parameters. In this article we propose an optimization based approach to creating PCSAs, ‐ an approach which has previously been used to generate labour flow regions in Ireland. The approach is data driven, thus requiring a minimal number of ad‐hoc parameters. We compared the resulting PCSAs (or `rPCSAs') with PCSAs generated using the traditional allocation algorithm. We found that rPCSAs were generally larger, offered greater LIs and reflected patient travel patterns better than traditional PCSAs. Accounting for the larger size of rPCSAs showed that rPCSAs offered better LIs than similar sized traditional PCSAs.

A virtual tumor board-driven synaptic knowledge network.

89 Background: In 2006, Tahoe Forest Hospital District—a 25-bed hospital in Truckee, CA, a mountain resort community one hour from regional and two hours from academic cancer services—designed and implemented an oncology program utilizing effective telecommunications with a committed academic partner, the UC Davis Comprehensive Cancer Center in Sacramento. Methods: The UC Davis Cancer Care Network was established with four remote cancer programs, enabling participation in daily virtual tumor boards, clinical trial enrollment, and quality assurance assistance. (Richard J. Bold, et. al., Virtual tumor boards: community-university collaboration to improve quality of care. Community Oncol 10(11):310-315, November 2013.; Laurence J. Heifetz, MD, et. al., A Model for Rural Oncology. J Oncol Pract, 7:168-171, May 2011.). An increasing number of patients were observed to in-migrate to Truckee from even more remote rural areas in the mountains. In 2013, the now Gene Upshaw Memorial Tahoe Forest Cancer Center developed four remote telemedicine clinics to allow even more physically distant patients the capacity to be followed locally. Results: Since we opened the remote telemedicine clinics, our Sullivan-Luallin patient satisfaction scores have averaged 4.82/5.00 for “overall satisfaction with the practice” and 4.90/5.00 for “recommending your provider to others”; our in-migration rate of patients from outside our primary catchment area increased from 43% to 52%: and clinical trial accrual rate averaged 10%. Conclusions: Reducing cancer health disparities is an ASCO mission. (cover, ASCO Connection, July 2014; Laurence J. Heifetz, MD. Country Docs with City Technology Can Address Rural Cancer Care Disparities. Oncol, 29(9):641-644, September 2015.). We believe this synaptic knowledge network effectively addresses that mission for rural communities. This model can be scaled in many configurations to address the inherent degradation of quality care as a function of physical distance to an academic center that rural doctors and patients deal with on a daily basis. The key is to insist on a cultural shift – Do something smart at lunch every day. Attend a virtual tumor board.

Respiratory Viruses Associated Hospitalization among Children Aged

BackgroundWe combined hospital-based surveillance and health utilization survey data to estimate the incidence of respiratory viral infections associated hospitalization among children aged < 5 years in Bangladesh.MethodsSurveillance physicians collected respiratory specimens from children aged <5 years hospitalized with respiratory illness and residing in the primary hospital catchment areas. We tested respiratory specimens for respiratory syncytial virus, parainfluenza viruses, human metapneumovirus, influenza, adenovirus and rhinoviruses using rRT-PCR. During 2013, we conducted a health utilization survey in the primary catchment areas of the hospitals to determine the proportion of all hospitalizations for respiratory illness among children aged <5 years at the surveillance hospitals during the preceding 12 months. We estimated the respiratory virus-specific incidence of hospitalization by dividing the estimated number of hospitalized children with a laboratory confirmed infection with a respiratory virus by the population aged <5 years of the catchment areas and adjusted for the proportion of children who were hospitalized at the surveillance hospitals.ResultsWe estimated that the annual incidence per 1000 children (95% CI) of all cause associated respiratory hospitalization was 11.5 (10–12). The incidences per 1000 children (95% CI) per year for respiratory syncytial virus, parainfluenza, adenovirus, human metapneumovirus and influenza infections were 3(2–3), 0.5(0.4–0.8), 0.4 (0.3–0.6), 0.4 (0.3–0.6), and 0.4 (0.3–0.6) respectively. The incidences per 1000 children (95%CI) of rhinovirus-associated infections among hospitalized children were 5 (3–7), 2 (1–3), 1 (0.6–2), and 3 (2–4) in 2010, 2011, 2012 and 2013, respectively.ConclusionOur data suggest that respiratory viruses are associated with a substantial burden of hospitalization in children aged <5 years in Bangladesh.

Maternal metabolic risk factors for autism spectrum disorder-An analysis of electronic medical records and linked birth data.

Past studies have suggested that conditions experienced by women during pregnancy (e.g. obesity and gestational diabetes mellitus (GDM)) may be associated with having a child with autism spectrum disorder (ASD). Our objective was to compare mothers who had a child diagnosed with ASD to mothers of children with a non-ASD developmental disorder (DD) or without any reported DD (controls). To accomplish the objective we collected medical record data from patients who resided in the Cincinnati Children's Hospital Medical Center's (CCHMC) primary catchment area and linked those data to data from birth certificates (to identify risk factors). Two comparison groups were analyzed; one with DD; and the other, controls without a reported ASD or DD. Descriptive statistics and regression analyses evaluated differences. Differences were greater comparing mothers of ASD to controls than comparing ASD to DD. Maternal obesity and GDM were associated with a statistically significant approximately 1.5-fold increased odds of having a child with an ASD. For mothers with both GDM and obesity, the association was twofold for having a child with ASD compared with controls. Maternal obesity and GDM might be associated with an increased risk of ASD in the offspring; however, no difference in risk of ASD according to BMI and GDM was seen when comparing to DD. Autism Res 2016, 9: 829-837,. © 2016 International Society for Autism Research, Wiley Periodicals, Inc.

The changing face of Crohn’s disease: a population-based study of the natural history of Crohn’s disease in Örebro, Sweden 1963–2005

Objective: Changes in medical therapy and surgery might have influenced the natural history of Crohn’s disease (CD). Our aim was to explore the short-term outcome of CD and to specifically assess trends in disease phenotype, medications and surgery in the first five years from diagnosis. Material and methods: A population-based cohort comprising 472 CD patients diagnosed within the primary catchment area of Örebro University Hospital 1963–2005 were identified retrospectively and described. Data on medication, surgery, progression in disease location and behavior, were extracted from the medical records. Patients were divided into three cohorts based on year of diagnosis. Results: The proportion of patients with complicated disease behavior five years after diagnosis decreased from 54.4% (95%CI, 43.9–65.6) to 33.3% (27.4–40.0) in patients diagnosed 1963–1975 and 1991–2005, respectively (p = 0.002), whereas the proportion of patients progressing to complicated disease behavior was stable among those with non-stricturing, non-penetrating disease at diagnosis (p = 0.435). The proportion of patients undergoing surgery decreased from 65.8% (55.4–76.0) to 34.6% (28.6–41.5) in patients diagnosed 1963–1975 and 1991–2005, respectively (p < 0.001). The reduction in surgery preceded an increased use of immunomodulators and was explained by a decrease in surgery within three months from diagnosis (p = 0.001). Conclusions: We observed a striking decrease in complicated disease behavior and surgery five years after CD diagnosis, the latter largely due to a decrease in early surgery. Our findings suggest that the introduction of new treatments alone does not explain the reduction in surgery rates, the increasing proportion of patients with inflammatory disease at diagnosis also play an important role.

Population-Based Analysis of Hematologic Malignancy Referrals to a Comprehensive Cancer Center, Referrals for Blood and Marrow Transplantation, and Participation in Clinical Trial, Survey, and Biospecimen Research by Race

Racial and ethnic disparities have been reported in clinical trial/research participation, utilization of autologous and allogeneic blood and marrow transplantation (BMT), and availability of allogeneic donors. We performed a population-based cohort study to investigate adult hematologic malignancy referrals to a US tertiary cancer center, utilization of BMT, and participation in clinical trial, survey, and biospecimen research by race. US Census Data and the New York State Public Access Cancer Epidemiology Database identified the racial distribution of the general population and new hematologic malignancy cases in the primary catchment area. From 2005 to 2011, 1106 patients aged 18 to 75 years were referred for BMT consultation; although the rate of BMT among hematologic malignancy referrals did not differ by race, the reasons for not receiving a BMT did. Participation in biospecimen research did not vary by race; however, African Americans and other minorities were significantly less likely to participate in survey research than European Americans. Although rates of hematologic malignancy referrals and use of BMT for minorities appear to be low (<10%), they closely reflect the race distribution of all hematologic malignancy cases and the western New York population. African Americans are equally likely as other races to participate in biospecimen banking, but further study is needed to understand reasons for lower participation in survey research.

Analiza tržnih območij treh letališč v zgornjejadranski regiji

This article seeks to explain passengers’ choice of airport and analyse catchment areas of three airports in the Upper Adriatic region. The Upper Adriatic region is considered as a uniform, territorially and socio-economically integrated region – and as a single multi-airport and cross-border region. The analysed region is also specific in terms of its geographical, political, economic, and social characteristics, since it extends beyond the boundaries of four countries. The analysis of outbound passengers and catchment areas of the Ljubljana Jože Pucnik Airport (LJU), Venice Marco Polo Airport (VCE) and Trieste Ronchi dei Legionari Airport (TRS) draws on a survey conducted in 2011. The analysis includes the records of 1552 surveyed passengers with permanent residence in the region. Characteristics of outbound passengers were analysed separately in terms of sex, age, employment, purpose of travel and mode of transportation to the airport. A spatial analysis of airport catchment areas was conducted using the separate and total distances covered to the selected airport, and the purpose of travel in the empirical model of the relevant airport catchment area.The results suggest that small airports have small primary catchment areas, as over 70% of passengers originate in the immediate proximity of airports.

Five National Cancer Institute–designated cancer centers' data collection on racial/ethnic minority participation in therapeutic trials

BACKGROUNDTo ensure that National Institutes of Health‐funded research is relevant to the population's needs, specific emphasis on proportional representation of minority/sex groups into National Cancer Institute (NCI) cancer centers' clinical research programs is reported to the NCI.METHODSEMPaCT investigators at 5 regionally diverse comprehensive cancer centers compared data reported to the NCI for their most recent Cancer Center Support Grant competitive renewal to assess and compare the centers' catchment area designations, data definitions, data elements, collection processes, reporting, and performance regarding proportional representation of race/ethnicity and sex subsets.RESULTSCancer centers' catchment area definitions differed widely in terms of their cancer patient versus general population specificity, levels of specificity, and geographic coverage. Racial/ethnic categories were similar, yet were defined differently, across institutions. Patients' socioeconomic status and insurance status were inconsistently captured across the 5 centers.CONCLUSIONSCatchment area definitions and the collection of patient‐level demographic factors varied widely across the 5 comprehensive cancer centers. This challenged the assessment of success by cancer centers in accruing representative populations into the cancer research enterprise. Accrual of minorities was less than desired for at least 1 racial/ethnic subcategory at 4 of the 5 centers. Institutions should clearly and consistently declare their primary catchment area and the rationale and should report how race/ethnicity and sex are defined, determined, collected, and reported. More standardized, frequent, consistent collection, reporting, and review of these data are recommended, as is a commitment to collecting socioeconomic data, given that socioeconomic status is a primary driver of cancer disparities in the United States. Cancer 2014;120(7 suppl):1113–21. © 2014 American Cancer Society.

Screening for people with glucose metabolism disorders within the framework of the DEMOJUAN project (DEMOnstration area for primary prevention of type 2 diabetes, JUAN Mina and Barranquilla, Colombia).

Until now, no systematic screening for T2D or prevention activities targeting T2D has been implemented in Colombia. The aims of this study were i) describe the feasibility of implementing the Finnish Diabetes Risk Score (FINDRISC) as a screening tool for glucose metabolism disorders (GMD) in the primary health care system in Barranquilla in Colombia during 2011 and 2012, and ii) to describe the risk factors for T2D in the population screened. This screening was opportunistic among people aged 34-60 years living in five primary health care catchment areas in Barranquilla, Colombia. People with 13 or more FINDRISC points were invited to an oral glucose tolerance test (OGTT). Out of 14193 participants with the FINDRISC completed, 35% (n=4915) had a score of 13 points or higher (men 23%, women 40%). Among those with FINDRISC completed, the percentage of people with BMI<25 kg/m2 was 46% in men and 35% in women. The prevalence of screen-detected T2D was 18% in men and 12% in women, respectively, among those with FINDRISC >12 attending an OGTT. In both sexes the prevalence of isolated IGT, isolated IFG, and IFG and IGT combined were 8%, 11%, and 8%, respectively. In total, 2% of all 14 193 screened participants had undetected T2D and 7% GMD. This figure would potentially be 4.6% (T2D), respectively 15% (GMD) if all with a FINDRISC>12 attend the OGTT. Thus, we found the FINDRISC to be a useful tool to identify people with GMD. This article is protected by copyright. All rights reserved.

Three days hospital stay after uncomplicated primary PCI is feasible and does not influence the readmission rate

Background: Fast discharge after primary PCI may save health care resources, but is logistically challenging. It is unclear whether forced early discharge after uncomplicated primary PCI (PPCI) leads to increased readmission rate compared to usual care. Methods: At a single PCI centre all consecutive PPCI patients over a two year study period were risk stratified with the Zwolle score. Patients with a score <5 were randomized to discharge within three days or usual care. All treatments, counseling and follow-up routines were identical in the two groups. Vital status and all readmissions at any hospital in the region were tracked during follow-up (median 466 days, minimum 31 days, maximum 821 days follow-up). Results: Of a total of 425 eligible PPCI patients from the primary catchment area, 215 (50.6%) were randomized to either early discharge (n=108) or usual routine discharge (n=107). Only 18 (8.6%) patients refused to participate in the study. The total number of in-hospital days during the index hospitalization was significant lower in the early discharge group (total 239 days) compared to the usual care group (262 days, p<0.001). During follow-up the number of total number of readmissions was 54 in the early group vs. 82 in the usual care group (p=0.045), and the total number of in-hospital days was 163 days in the early discharge group vs. 192 days in the usual care group (p=0.13) in the early discharge group. The excluded high-risk group (n=210) had longer index hospital stays (total 1314 vs. 501 days, p=0.001), more readmissions (168 vs. 136 stays,p=0.032) and trend towards more in-hospital readmission days (672 vs. 361 days p=0.22) compared to all low-risk randomized patients. Conclusion: Early three days discharge after PPCI in low-risk stratified patients is feasible, reduces the initial hospital stay and does not lead to increased use of health resources due to readmissions compared to usual care.

P480 Importance of diet in inflammatory bowel disease – data from the patients’ view

complications occurred in 11.4% and minor in 12.3% after IRA including closure of a defunctioning loop-ileostomy when present. Corresponding figures for IPAA were 16.2% and 23.6% (ns and p = 0.02 respectively). Any complication after IRA and IPAA including stoma closure occurred in 23.8% and 39.8% respectively (p < 0.01). Morbidity during follow-up time calculated as patients with any late complication requiring laparotomy was for primary catchment area patients with IRA (n = 73) and with IPAA (n = 68) 11% and 18% respectively (ns).

Contextual and Individual Influences on Diabetes and Heart Disease in Havana Primary Care Catchment Areas

A population health profile is a cumulative product of socioenvironmental and political factors that create the contexts in which health problems arise, as well as opportunities and barriers to addressing them. Research on context has focused on demonstrating its effects, direct or indirect, on health indicators, but has made few incursions into assessing its role as a mediator of other factors. While individual risk factors for chronic diseases are well known, the same cannot be said for the complex of contextual factors operating at various levels and over the lifespan. Estimate relative influences by contextual versus individual factors as determinants of diabetes type 2 and heart disease. A cross-sectional study was carried out in populations served by 12 family doctor-and-nurse practices in Havana, in 840 families selected by simple random sampling, 70 per practice. Principal components analysis was used, as well as contextual logistic regression models with a nested model strategy, whose fit was meant to estimate the relative contributions of contextual compared to individual risk factors for diabetes and heart disease. Context was described and analyzed at two levels: that of the family or household and that of the catchment area served by a family doctor-and-nurse practice (geographically defined as a neighborhood). For diabetes, the contextual effect of neighborhood was modified when household effect was removed; that is, the effect of neighborhood was indirect and mediated by household. Individual coefficients were practically invariant; the principal effect of household changed noticeably on removal of individual effects, while age maintained its effect without variation. For heart disease, the effect of neighborhood was slightly modified when household effect was controlled for. Individual coefficients showed little change. There was an important direct effect of household on risk of heart disease. Age and high blood pressure coefficients hardly varied. We confirmed interactions between individual and contextual (neighborhood and household) factors, whose effects on individual health are not entirely mediated by individual factors. Research needs to pay more attention to context beyond its direct effect on individual risk factors.

Successful public health action to reduce the incidence of symptomatic vitamin D deficiency

BackgroundIn response to a resurgence of symptomatic cases of vitamin D deficiency in a high-risk predominantly ethnic minority population, a programme of universal rather than targeted vitamin D supplementation was...