Thank you for your review of my recently published book "Social
Epidemiology - Strategies for Public Health Activism". You raise the
question of how social epidemiologists can find "strategies to put social
epidemiological findings into practice". In Chapter 9, pages 273-309,
readers of the book will find a comprehensive review entitled "Theories
for Social Epidemiological Interventions"...
Thank you for your review of my recently published book "Social
Epidemiology - Strategies for Public Health Activism". You raise the
question of how social epidemiologists can find "strategies to put social
epidemiological findings into practice". In Chapter 9, pages 273-309,
readers of the book will find a comprehensive review entitled "Theories
for Social Epidemiological Interventions" including: behavioral
modification, social learning theory, the Health Belief Model, the Model
of Behavioral Intentions, meta-analysis, the Transtheoretical Model,
interventions in stress and coping, social marketing, media advocacy,
participatory action research, empowerment interventions, and community
interventions and evaluation. It appears that you overlooked this section
of the book where the answers to your question can be found.
To the editors, the book review title states that I "EDITED" the book
when the book is a single author book by me alone.
It was with great interest that I read the recent article by
Henderson et al.,[1] as my main interests are closely related to the
potential effects of alcohol consumption (and that of other drugs) during
pregnancy. However, although I agree that some of the issues they raise
are relevant, there are several aspects of this article [1] that concern me,
about which I would like to offer some reflection...
It was with great interest that I read the recent article by
Henderson et al.,[1] as my main interests are closely related to the
potential effects of alcohol consumption (and that of other drugs) during
pregnancy. However, although I agree that some of the issues they raise
are relevant, there are several aspects of this article [1] that concern me,
about which I would like to offer some reflections.
First of all, I think that some caution should be exerted when
considering the conclusions made by evaluating observational studies with
different designs, and on different populations. Particularly, if they are
focused on such a complex issue as the potential effects of alcohol
consumption during pregnancy and more specifically, binge-drinking.
Indeed, some inconsistency in the results would be expected from such
studies a priori due to:
a) The heterogeneity of the different studies, either in terms of sample
size and methodological approaches, or in the life styles and genetic
background of the different populations studied.
b) The periods during pregnancy in which exposure occurred, and the
difficulties in determining the exact time. This is particularly important
for those mothers that recognized having had any binge-drinking.
c) The differing amount of alcohol intakes [2], and the difficulties to
define the exact amount, that may also be more marked in some populations
than in others.
d) The genetic constitutions of the populations studied. In this sense,
there are studies demonstrating that polymorphic mutations of a single
nucleotide diminish the individual metabolism of alcohol [3], and that the
frequencies of different polymorphisms vary between the human populations
[4-5]. Hence, this genomic variability and metabolic susceptibility either
in the women or in the embryo may result in different risks for congenital
defects. In addition, the huge amount of information provided by the
molecular analyses of the human genome has highlighted the impressive
complexity in the structural and functional aspects of DNA [6-11]. This
complexity also affects the relationship between functional polymorphic
variants of DNA, and the individual susceptibility to the effects of
different exposures, as well as the presence/absence of some particular
congenital defects.
Additionally, and considering all the above commented aspects, it is
not surprising that different epidemiological studies may produce
different results, even if they are well designed in epidemiological terms
and they have been “filtered for the high sensitivity filter”. Thus,
inconsistencies should not always be interpreted as only being due to
methodological aspects. Moreover, I consider that the results of
epidemiological analyses on the potential teratogenic effects of different
maternal exposures, should be evaluated not only through the statistical
significance of the results, but in the light of their current biological
bases, as well as evaluating the maternal benefit versus the embryonic-
fetal risk, before reaching any conclusion.
Finally, and although Henderson et al.[1] make general comments on
some of these particular aspects, in their conclusion they state that “In
the absence of a strong research base on which to make any strong clinical
recommendations… despite the concurrent lack of evidence, from a public
health point of view we would suggest that it may be worthwhile
recommending pregnant women to avoid binge-drinking during pregnancy.” I
totally disagree with this recommendation, essentially on the basis of
three issues. First, making reference to avoid binge-drinking after the
first sentence may give rise to the idea that lower doses of alcohol might
be safe. Second, by recommending that the use of alcohol should be avoided
during pregnancy could be interpreted that alcohol consumption should
cease once women know that they are pregnant. However, when a mother
realizes that she is pregnant, nearly all the future organs and systems in
the fetus have been formed. I consider it more appropriate to recommend to
all woman who plan to becoming pregnant that they should avoid alcohol
before abandoning contraception. Third, in spite of that the results of
the observational studies are not consistent or are at times
contradictory, and given that the effects of alcohol in animals cannot be
fully extrapolated to humans, we must bear in mind that this exposure to
alcohol is totally unnecessary. Hence, even if the possibility of having
an adverse effect were remote, and even if the risks were only for women
having a particular genomic susceptibility, in the absence of a biological
test for susceptibility the embryo-foetal risk is valuable, Thus, the only
effective and correct recommendation from either the clinical or public
health point of view is that of total abstention in women who could become
pregnant and indeed, before they become pregnant. Other recommendations
for this unnecessary exposure may be tragic for some women and thus, for
individual and public health.
María Luisa Martínez-Frías
- ECEMC, Centro de Investigación sobre Anomalías Congénitas (CIAC),
Instituto de Salud Carlos III, Ministerio de Sanidad y Consumo, Madrid
(Spain).
- Centre for Biomedical Research on Rare Diseases (CIBERER), Madrid
(Spain).
- Departamento de Farmacología, Facultad de Medicina, Universidad
Complutense, Madrid (Spain).
Address Correspondence to: Dr. María Luisa Martínez-Frías, Centro de
Investigación sobre Anomalías Congénitas (CIAC), Instituto de Salud Carlos
III, Sinesio Delgado 4-6, 28029, Madrid, Spain.
References
1. Henderson J, Kesmodel U, Gray R. Systematic review of the fetal
effects of prenatal binge-drinking. J Epidemiol Community Health.
2007;61:1069-1073.
2. Martínez-Frias ML, Postmarketing analysis of medicines: methodology and
value of the spanish case-control study and surveillance system in
preventing birth defects. Drug Saf. 2007;30(4):307-16. Review.
3. Liu QR, Drgon T, Walther D, Johnson C, Poleskaya O, Hess J, Uhl GR.
Pooled association genome scanning: validation and use to identify
addiction vulnerability loci in two samples. Proc Natl Acad Sci U S A.
2005 Aug 16;102(33):11864-9. Rao VR, Bhaskar LV, Annapurna C, Reddy AG,
Thangaraj K, Rao AP, Singh L. Single nucleotide polymorphisms in alcohol
dehydrogenase genes among some Indian populations. Am J Hum Biol. 2007 May
-Jun;19(3):338-44.
4. Osier MV, Pakstis AJ, Soodyall H, Comas D, Goldman D, Odunsi A,
Okonofua F, Parnas J, Schulz LO, Bertranpetit J, Bonne-Tamir B, Lu RB,
Kidd JR, Kidd KK. A global perspective on genetic variation at the ADH
genes reveals unusual patterns of linkage disequilibrium and diversity. Am
J Hum Genet. 2002 Jul;71(1):84-99.
5. Sebat J, Lakshmi B, Troge J, Alexander J, Young J, Lundin P, Maner S,
Massa H, Walker M, Chi M, Navin N, Lucito R, Healy J, Hicks J, Ye K,
Reiner A, Gilliam TC, Trask B, Patterson N, Zetterberg A, Wigler M. Large-
scale copy number polymorphism in the human genome. Science. 2004;305:525-
528.
6. Iafrate AJ, Feuk L, Rivera MN, Listewnik ML, Donahoe PK, Qi Y, Scherer
SW, Lee C. Detection of large-scale variation in the human genome. Nat
Genet. 2004;36:949-951.
7. Freeman JL, Perry GH, Feuk L, Redon R, McCarroll SA, Altshuler DM,
Aburatani H, Jones KW, Tyler-Smith C, Hurles ME, Carter NP, Scherer SW,
Lee C. Copy number variation: new insights in genome diversity. Genome
Res. 2006;16:949-961.
8. Stranger BE, Forrest MS, Dunning M, Ingle CE, Beazley C, Thorne N,
Redon R, Bird CP, de Grassi A, Lee C, Tyler-Smith C, Carter N, Scherer SW,
Tavare S, Deloukas P, Hurles ME, Dermitzakis ET. Relative impact of
nucleotide and copy number variation on gene expression phenotypes.
Science. 2007;315:848-853.
9. Kapranov P, Cheng J, Dike S, Nix DA, Duttagupta R, Willingham AT,
Stadler PF, Hertel J, Hackermuller J, Hofacker IL, Bell I, Cheung E,
Drenkow J, Dumais E, Patel S, Helt G, Ganesh M, Ghosh S, Piccolboni A,
Sementchenko V, Tammana H, Gingeras TR. Genome-wide RNA maps reveal new
RNA classes and a possible function for pervasive transcription. Science.
2007;316:1484-1488.
10. The ENCODE Project Consorcium. Identification and analysis of
functional elements in 1% of the human genome by the ENCODE pilot project.
Nature 2007;447:799-816.
11. Martínez-Frías ML, The human genome. An extremely complex system.Bol
ECEMC Rev Dismorf Epidemiol 2007;82-
91.(http://bvs.isciii.es/mono/pdf/CIAC_06.pdf)
The interesting paper of Dr Bellis and colleagues [1] reports
strikingly increased mortality in rock and pop stars.
A widespread opinion is that fame is the reason for the manifold
psychological problems of the stars. These problems are seen as a
consequence of the pressure of the fans, the media, the music industry, or
obtrusive paparazzi. Also, the availability of drugs and alcohol and the
problem of...
The interesting paper of Dr Bellis and colleagues [1] reports
strikingly increased mortality in rock and pop stars.
A widespread opinion is that fame is the reason for the manifold
psychological problems of the stars. These problems are seen as a
consequence of the pressure of the fans, the media, the music industry, or
obtrusive paparazzi. Also, the availability of drugs and alcohol and the
problem of coping with obscurity after a period of fame are commonly
stressed as etiological factors.
The crucial question is, however, whether fame leads to psychiatric
problems or – the other way around – certain psychiatric problems may be a
prerequisite for getting famous.
An analysis of the biographies of pop stars who died young showed that
features of personality disorders were present before these stars got
famous.[2]
The main reasons for premature death identified in the study were drug or
alcohol overdose and/or chronic substance abuse. But also some other
reasons for increased mortality, such as suicide, accidents and violence,
point into the direction of a certain psychiatric illness: The features of
borderline personality disorder include substance abuse, impulsive
behaviour, high-risk behaviour (e.g. speeding), depression, suicidality,
self-mutilation (mostly in women), unsteady interpersonal relationships,
problems with sexuality, feelings of emptiness, and eating disorders.
Etiological factors include traumatic childhood experiences and genetic
contributions.
In most studies with borderline patients, the mean age is around 27 years,
which may be a possible explanation for the magic age of 27 at which
Joplin, Hendrix, Morrison and Cobain died.
Since Aristotle, who saw the association between melancholia and poetry,
many scientific authors have investigated the relationship of “genius and
madness”. A number of studies found significantly increased rates of
psychiatric disorders in artists, in particular in performance artists
(e.g. singers and actors).[3-5]
The striking relationship between death, drugs, and Rock ‘n’ Roll may be
explained by the dopamine reward system and the associated endogenous
opioid system of the human brain. Borderline patients seem to have a
dysfunction of these systems, which they try to compensate by using heroin
and cocaine, drugs that stimulate these systems directly. Also, frequent
sexual contacts, risky behaviours, aggression, self-mutilation or
overeating increase endorphin levels, but one of the best techniques is to
get attention by a large audience. Narcissism is one of the main features
of borderline personality disorder, and this explains why the affected
persons try harder to get famous and develop more creativity and fantasy
as musicians, actors or writers. Due to their high emotionality, their
performance is perceived as more touching and authentic by the public.
Should we warn persons at risk to get famous? The answer is no. Performing
on stage may be a more successful therapy than any psychiatric treatment,
and without these exceptional artists, our culture would suffer great
losses.
Prof. Dr. B. Bandelow
Department of Psychiatry and Psychotherapy
University of Göttingen
von-Siebold-Str. 5
D-37085 Göttingen, Germany
Tel. +49-551-396607
Fax +49-551-398952
E-mail: Sekretariat.Bandelow@medizin.uni-goettingen.de
References
1. Bellis M, Hennell T, Lushey C, Hughes K, Tocque K, Ashton J. Elvis
to Eminem: quantifying the price of fame though early mortality of
European and North American rock and pop stars. J Epidemiol Community
Health 2007;2007(61):896-901.
2. Bandelow B. Celebrities - vom schwierigen Glück, berühmt zu sein
[Celebrities - About the difficult luck to be famous]. 2nd edition.
Reinbek, Germany: Rowohlt; 2006.
3. Andreasen NC. Creativity and mental illness: prevalence rates in
writers and their first-degree relatives. American Journal of Psychiatry.
1987;144(10):1288-92.
4. Ludwig AM. Creative achievement and psychopathology: comparison among
professions. American Journal of Psychotherapy. 1992;46(3):330-56.
5. Post F. Creativity and psychopathology. A study of 291 world-famous
men. Br J Psychiatry. 1994;165(2):22-34.
The Journal has previously explored interesting taxation and health
issues [1,2] and the recent paper by Mytton et al [3] on food taxes is no
exception. This new work nicely demonstrates the complexities,
uncertainties and potential benefit of taxing certain foods as an
instrument to reduce the high burden of chronic diseases. The key issues
raised are which foods get substituted as a result of decrea...
The Journal has previously explored interesting taxation and health
issues [1,2] and the recent paper by Mytton et al [3] on food taxes is no
exception. This new work nicely demonstrates the complexities,
uncertainties and potential benefit of taxing certain foods as an
instrument to reduce the high burden of chronic diseases. The key issues
raised are which foods get substituted as a result of decreased
consumption of the more expensive foods, and the regressive nature of the
taxes. However, a simple policy option that can easily address both issues
is the provision of subsidised “healthy foods” (eg, fruits, vegetables,
whole grains, nuts and legumes) to low-income groups. The subsidies could
be financed from taxes on the “unhealthy foods” so that the net effect is
fiscally neutral to the tax-payer. Electronic cards provided to low-income
groups could allow for discounts on these foods in a manner that maximises
anonymity for the users and minimises risks of any embarrassment.
Specific taxes on such components as salt and sugar might also assist
in maximising a health-promoting food pricing strategy. Actual regulatory
limits on salt, sugar and saturated fat in processed foods may be a backup
option, if taxes on these were not as effective as anticipated.
“Healthy food” producers may support some of these moves and prove to
be allies with health agencies and government in introducing these
changes. However, some industry losers will be likely to object strongly
and potentially use the ruthless survival tactics of the tobacco industry,
the asbestos industry, and the leaded petrol industry etc.
A particularly promising alliance for health workers is however, the
environmental movement with its concern over greenhouse gas emissions.
That is a methane tax on livestock may act as a proxy tax on saturated fat
by raising the price of ruminant meat and dairy products. Methane charges
on the agricultural sector are currently being explored in at least one
country (New Zealand) as part of a comprehensive approach to greenhouse
gas control. Such taxes promise to deliver both environmental and public
health nutrition benefits and as such should also be a priority for future
policy development.
Nick Wilson
Senior Lecturer, University of Otago, Wellington, New Zealand
Osman Mansoor
Public health physician, Wellington, New Zealand
Competing interests: None.
References
1 Selmer RM, Kristiansen IS, Haglerod A, et al. Cost and health
consequences of reducing the population intake of salt. J Epidemiol
Community Health 2000;54:697-702.
2 Wilson N, Thomson G, Tobias M, Blakely T. How much downside?
Quantifying the relative harm from tobacco taxation. J Epidemiol Community
Health 2004;58:451-4.
3 Oliver Mytton, Alastair Gray, Mike Rayner and Harry Rutter. Could
targeted food taxes improve health? J Epidemiol Community Health
2007;61;689-694.
This fine study (full version not accessible to me), like so many
studies claiming similar virtues for fruits and vegetables, in fact
reflects the displacement of dense, non-evolutionary, carbohydrates (rice,
pasta, potatoes, bread) by other macronutrients or by less dense carbs.
All confirm the VLDL-generating (atherogenesis) and pancreas-straining (type2 diabetes) results of dietary carbohydra...
This fine study (full version not accessible to me), like so many
studies claiming similar virtues for fruits and vegetables, in fact
reflects the displacement of dense, non-evolutionary, carbohydrates (rice,
pasta, potatoes, bread) by other macronutrients or by less dense carbs.
All confirm the VLDL-generating (atherogenesis) and pancreas-straining (type2 diabetes) results of dietary carbohydrate in excess of
human glycogen storage capacity and/or provoking excessive insulin
responses.
This paper has brought about many topical issues regarding the ways
to tackle social inequalities. However, one area that has not been
mentioned is the impact of technology in contributing to inequality in
healthcare.
Currently the climate is shifting towards an electronic media, with a
growing case for health to follow the same trend. In theory this seems to
bridge the healthcare inequal...
This paper has brought about many topical issues regarding the ways
to tackle social inequalities. However, one area that has not been
mentioned is the impact of technology in contributing to inequality in
healthcare.
Currently the climate is shifting towards an electronic media, with a
growing case for health to follow the same trend. In theory this seems to
bridge the healthcare inequalities, but in practice this is not true.
With the increase in dependence of electronic media to disseminate
information, we have inadvertently increased the digital divide. In most
cases the many of the people who are at most risk from serious health
conditions come from underserved populations, populations that are
generally made up of individuals who are of low socioeconomic status,
possess low level of health literacy and are members of marginalised
ethnic and minority groups. These underserved and vulnerable populations
often have limited access to relevant health information especially
information that is otherwise easily available over the Internet. This is
one of the symptoms of the Digital Divide, however within the health
sector the Digital Divide as a more specialised problem. Many of the
characteristics that identify those on the “have not” side of the Digital
Divide also apply to those who suffer from the negative effects of health
disparities. While information and knowledge are not guarantors of good
health care decisions and adherence to recommended health behaviour, their
ease of availability has shown to contribute to them.
Thus another typology that needs to be considered is the importance
of finding the most effective and efficient manner to disseminate health
promotion information to various populations groups. Communication
technologies can be utilised to develop a typology, but the actual
dissemination will involve the use of both convention methodologies and
technological technologies.
Mustard and Etches examined the differences between male and female
socioeconomic gradients in mortality, finding that, in absolute terms, the
gradient is consistently larger for men, but that in relative terms, the
gradients are equal or at least less consistently larger for men.[1] But
efforts to evaluate differences in socioeconomic inequality in some
outcome for groups with different overall rat...
Mustard and Etches examined the differences between male and female
socioeconomic gradients in mortality, finding that, in absolute terms, the
gradient is consistently larger for men, but that in relative terms, the
gradients are equal or at least less consistently larger for men.[1] But
efforts to evaluate differences in socioeconomic inequality in some
outcome for groups with different overall rates of experiencing the
outcome need to be undertaken with an appreciation of the way various
measures of inequality are affected by the prevalence of an outcome.
First, consider relative differences in mortality. Ordinarily, the
rarer an outcome, the greater tends to be the relative difference between
rates of experiencing it and the smaller tends to be the relative
difference between rates of avoiding it.[2-7]. Thus, one typically finds
greater relative socioeconomic (or racial) difference in mortality among
groups with lower overall mortality, as, for example, among the young
(compared with the old),[6] in relatively healthy countries like Norway
and Sweden,[2,6] among British civil servants (compared with the UK
population at large),[6] among infants born to better educated mothers
(compared with those born to less educated mothers).[4] When such
patterns are observed, it is a mistake, without more, to regard greater
relative differences in mortality within the group with lower mortality to
reflect greater inequality in a meaningful way (particularly when the
relative difference in the opposite outcome is smaller in that group).
The notable thing about a comparison of the size of relative
socioeconomic differences in mortality among women and those among men is
that the observed pattern does not conform to the expectation of a greater
relative socioeconomic difference among the group with lower overall
mortality (women). Thus, that relative socioeconomic differences in
mortality are as large for men as women (and sometimes larger) suggests
the existence of a meaningful difference between socioeconomic effects
upon men and upon women. That is, the departure from the usual pattern
suggests that the risk distributions of higher and lower SES men differ
more than the risk distributions of higher and lower SES women –
presumably due to the various factors discussed by Mustard and Etches,
notwithstanding the inconsistent results of studies exploring the roles of
such factors. And the greater socioeconomic difference in the risk
distributions of men is sufficient to overcome the tendency for the
greater relative difference to be observed among the group with lower
mortality. On the other hand, the relative socioeconomic difference in
survival rates will likely be lower among women, as would typically be the
case simply because mortality is lower among women, and will be so to an
enhanced degree because of the greater SES difference in the male than the
female risk distribution.
While it is a point more pertinent in the usual circumstances where a
factor such a SES causes a greater relative difference among the group
with lower base rate rather than in the instant situation where that
pattern does not exist, it nevertheless warrants note that there is no
reason ever to expect any factor to have the same relative effect within
two different populations that have different baseline rates. In fact, it
would be illogical to expect such a pattern. In the case of the young
compared with the old, for a simple example, there is obviously no more
reason to expect a factor like lower SES to cause equivalent relative
increases in mortality among the young and the old than there is to expect
lower SES to cause equivalent relative decreases in survival rates. And
in situations where baseline rates are different, it is mathematically
impossible for a factor to cause equivalent relative increases in one
outcome and equivalent relative decreases in the other outcome. More
concretely, if mortality is 5% percent among high SES young people and 10%
among high SES old people and being of low SES increased mortality to the
same relative degree among the young and old (say, doubling it in each
population, that is, from 5% to 10% among the young and from 10% to 20%
among the old), it necessarily would cause different proportionate
decreases in survival rates among the two populations (from 95% to 90%
among the young, a 5.3% reduction, and from 90% to 80% among the old, a
11.1% reduction. Thus, it makes no sense to have any expectation of
similar proportionate effects of some factor or to attribute significance
to the fact that proportionate effects differ.
All to say, in the usual case where a factor causes a greater
relative difference within a population with a lower base rate, it is a
mistake to attach meaning to that greater difference. One may, however,
derive meaning from a situation where, as in the context examined by
Mustard and Etches, the factor fails to do so or even does the opposite.
Now consider the absolute socioeconomic differences, which the study
found to be consistently greater among men than among women. Like
relative differences, absolute differences also tend to vary depending on
the prevalence of an outcome. Instead of the linear relationship with the
prevalence of an outcome exhibited with the relative differences in
experiencing or avoiding an outcome, however, the absolute difference
exhibits an inverted U-shaped relationship with the prevalence of an
outcome. Without exploring the nuances of that relationship, which are
explored elsewhere,[2,6,7] with respect to socioeconomic differences in
mortality, we should expect the absolute difference to be greater in the
population with the higher baseline rate, even when that population shows
greater relative socioeconomic in mortality, as for example, where we
observe larger socioeconomic absolute differences in mortality among the
old than the young notwithstanding the larger relative difference among
the young than the old (which, of course, is typically attended by a
smaller relative difference in the opposite outcome among the young than
the old). In any case, the larger absolute difference in mortality among
men than women is what we should expect because of the higher mortality
among men regardless of whether there is any meaningful difference in the
way socioeconomic status affects men and women.
In sum, one ought not to attach meaning to the consistently greater
absolute socioeconomic difference in mortality among men than among women
inasmuch as it is exactly what would be expected given the greater
mortality of men. One might, however, attach some meaning to the fact
that one does not observe a greater relative socioeconomic difference
among women than men and more so to the fact that one sometimes observes a
larger relative difference among men than women.
References
1. Mustard CA, Etches J. Gender differences in socioeconomic
inequality in mortality. J Epidemiol Community Health. 2003;57:974-980.
2. Scanlan JP. Can we actually measure health disparities? Chance
2006:19(2):47-51:
http://www.jpscanlan.com/images/Can_We_Actually_Measure_Health_Disparities.pdf
3. Scanlan JP. Measuring health disparities. J Public Health Manag
Pract 2006;12(3):294 [Lttr]:
http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=641470
4. Scanlan JP. Race and Mortality. Society. 2000;37(2):19-35:
http://www.jpscanlan.com/images/Race_and_Mortality.pdf
6. Scanlan JP. The misinterpretation of health inequalities in the
United Kingdom. Paper presented at: British Society for Population Studies
Annual Conference 2006, Southampton, England, Sept. 18-20, 2006:
http://www.jpscanlan.com/images/BSPS_2006_Complete_Paper.pdf
7. Scanlan JP. Effects of choice of measure on determination of
whether healthcare disparities are increasing or decreasing. Journal
Review May 1, 2007:
http://journalreview.org/view_pubmed_article.php?pmid=16107620&webenv=0h47ZzSPm53V3vavWSTKfeZJC3TTIQeEg5zvfZbY_tw4NXLD0IqOknuqAO%402B6009F6637C3170_0043SID&qkey=1&rescnt=2&retstart=0&q=vaccarino+rathore
Martikainen et al.[1] note that relative, and in some cases absolute,
socioeconomic differences in mortality have increased in the past 15-25
years in some European countries and the US, and find that over the period
1971 to 2000 such increases also occurred in Finland. The authors,
however, overlook the statistical tendency whereby the rarer an outcome,
the greater the relative difference between ra...
Martikainen et al.[1] note that relative, and in some cases absolute,
socioeconomic differences in mortality have increased in the past 15-25
years in some European countries and the US, and find that over the period
1971 to 2000 such increases also occurred in Finland. The authors,
however, overlook the statistical tendency whereby the rarer an outcome,
the greater the relative difference between rates of experiencing it and
the smaller the relative differences between rates of avoiding it.[2-6.]
Thus, with respect to the observed increasing relative socioeconomic
differences in mortality rates in many countries in recent decades
(presumably including Finland), a key factor is that mortality has been
declining. In such circumstances, one should expect increasing relative
differences in mortality (though declining relative differences in
survival rates). But without more, neither the increasing relative
difference in mortality rates nor the declining relative difference in
survival rates should be regarded as indicating meaningful changes in
health inequality.
In situations where absolute differences in mortality are increasing
during times of a general decline in mortality, there may be more reason
to regard such increase as indicating a meaningful worsening of health
inequality.[2,3] But one would have to explore the specifics of the
situations to draw such conclusion with any confidence.
The tendency for relative differences in mortality to be larger where
an outcome is rarer is also a reason why one would expect relative
educational and occupational social class difference to be larger in
younger than older age groups,[3] a pattern that the authors note and
support with data in Table 3.. But one would generally expect relative
differences in survival to be larger among the older age groups, though
the article does not provide the data to determine whether that is the
case. So one ought not to regard the larger relative mortality
differences in mortality among the young to suggest anything meaningful
It is hard to know whether these purely statistical factors affect
the measuring of the roles of education and occupation in the observed
mortality differences. But for reasons noted in the preceding paragraphs
it is usually difficult to draw meaningful inferences about any changes
relating to health inequalities without considering the implications of
those factors. And, given the influence of the prevalence of an outcome
in the size of differences in experiencing or avoiding it, it is important
that a study of patterns of change in any aspects of inequalities in
mortality show the various mortality rates at the
points in time used in the analyses.
References
1. Martikainen P, Blomgren J, Valkonen T. Change in the total and
independent effects of education and occupational social class on
mortality: analyses of all Finnish men and women the period 1971-2000. J
Epidemiol Community Health 2007;61:499-505.
2. Scanlan JP. Can we actually measure health disparities? Chance
2006:19(2):47-51:
http://www.jpscanlan.com/images/Can_We_Actually_Measure_Health_Disparities.pdf.
3. Scanlan JP. The misinterpretation of health inequalities in the
United Kingdom. Paper presented at: British Society for Population Studies
Annual Conference 2006, Southampton, England, Sept. 18-20, 2006:
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It is with great interest we read the response with well researched
references to this article on bias. We were particularly curious to know
how to tackle consent bias as consent is an ethical issue and many
high risk persons do not get included in an epidemiological study both
observational or interventional because of cultural values due to exclusion
of non consenters.There should be a method to t...
It is with great interest we read the response with well researched
references to this article on bias. We were particularly curious to know
how to tackle consent bias as consent is an ethical issue and many
high risk persons do not get included in an epidemiological study both
observational or interventional because of cultural values due to exclusion
of non consenters.There should be a method to tackle on the lines of
intention to treat analysis study design which we are attempting in a
study to determine behavioral barriers to adequate glycaemic control in
patients with type-2 Diabetes which is just concluded.The study subjects
were from a tertiary care hospital in Delhi, and a community based Health
Centre for a population covered by organised health insurance. We are in
the process of analyzing the data and we feel that consent bias will
exclude patients in behavioral studies in diseases due to
apprehensions,fear.
Sorry that I am late in submitting my responses to the
issue on grading of health care. My Institution is engaged in providing
community based health services in marginalised population in the
metroplis of Delhi with 10 million population with a record migration rate
of 4% per year.The Ministry Of Health has taken a bold step in introducing
Indian Public Health Standards in attempt to revamp and introd...
Sorry that I am late in submitting my responses to the
issue on grading of health care. My Institution is engaged in providing
community based health services in marginalised population in the
metroplis of Delhi with 10 million population with a record migration rate
of 4% per year.The Ministry Of Health has taken a bold step in introducing
Indian Public Health Standards in attempt to revamp and introduce quality
care concept in primary health care which is first step for grading which
should be available and known to people as a matter of better Governance.
Dear Dr. van Lenthe,
Thank you for your review of my recently published book "Social Epidemiology - Strategies for Public Health Activism". You raise the question of how social epidemiologists can find "strategies to put social epidemiological findings into practice". In Chapter 9, pages 273-309, readers of the book will find a comprehensive review entitled "Theories for Social Epidemiological Interventions"...
Dear Editor,
It was with great interest that I read the recent article by Henderson et al.,[1] as my main interests are closely related to the potential effects of alcohol consumption (and that of other drugs) during pregnancy. However, although I agree that some of the issues they raise are relevant, there are several aspects of this article [1] that concern me, about which I would like to offer some reflection...
Dear Editor
The interesting paper of Dr Bellis and colleagues [1] reports strikingly increased mortality in rock and pop stars. A widespread opinion is that fame is the reason for the manifold psychological problems of the stars. These problems are seen as a consequence of the pressure of the fans, the media, the music industry, or obtrusive paparazzi. Also, the availability of drugs and alcohol and the problem of...
Dear Editor
The Journal has previously explored interesting taxation and health issues [1,2] and the recent paper by Mytton et al [3] on food taxes is no exception. This new work nicely demonstrates the complexities, uncertainties and potential benefit of taxing certain foods as an instrument to reduce the high burden of chronic diseases. The key issues raised are which foods get substituted as a result of decrea...
Dear Editor
This fine study (full version not accessible to me), like so many studies claiming similar virtues for fruits and vegetables, in fact reflects the displacement of dense, non-evolutionary, carbohydrates (rice, pasta, potatoes, bread) by other macronutrients or by less dense carbs.
All confirm the VLDL-generating (atherogenesis) and pancreas-straining (type2 diabetes) results of dietary carbohydra...
Dear Editor
This paper has brought about many topical issues regarding the ways to tackle social inequalities. However, one area that has not been mentioned is the impact of technology in contributing to inequality in healthcare.
Currently the climate is shifting towards an electronic media, with a growing case for health to follow the same trend. In theory this seems to bridge the healthcare inequal...
Dear Editor
Mustard and Etches examined the differences between male and female socioeconomic gradients in mortality, finding that, in absolute terms, the gradient is consistently larger for men, but that in relative terms, the gradients are equal or at least less consistently larger for men.[1] But efforts to evaluate differences in socioeconomic inequality in some outcome for groups with different overall rat...
Dear Editor
Martikainen et al.[1] note that relative, and in some cases absolute, socioeconomic differences in mortality have increased in the past 15-25 years in some European countries and the US, and find that over the period 1971 to 2000 such increases also occurred in Finland. The authors, however, overlook the statistical tendency whereby the rarer an outcome, the greater the relative difference between ra...
Dear Editor,
It is with great interest we read the response with well researched references to this article on bias. We were particularly curious to know how to tackle consent bias as consent is an ethical issue and many high risk persons do not get included in an epidemiological study both observational or interventional because of cultural values due to exclusion of non consenters.There should be a method to t...
Dear Editor
Sorry that I am late in submitting my responses to the issue on grading of health care. My Institution is engaged in providing community based health services in marginalised population in the metroplis of Delhi with 10 million population with a record migration rate of 4% per year.The Ministry Of Health has taken a bold step in introducing Indian Public Health Standards in attempt to revamp and introd...
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