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Balachandran KP, Bhuvaneswari M. Expressed Emotion in Families of Children with Neurodevelopmental Disorders: A Mixed-Method Approach. Ann Neurosci 2024; 31:105-114. [PMID: 38694716 PMCID: PMC11060128 DOI: 10.1177/09727531231181014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/09/2023] [Indexed: 05/04/2024] Open
Abstract
Background Family interaction plays a pivotal role in the overall well-being of each member of a family unit. It is foreseeable that a family caring for an individual with a mental or physical health condition could experience negative family interactions for various reasons. Expressed emotion refers to the family environment based on the relatives' interaction with the individual diagnosed with a specific illness. Expressed emotion in the families of a person with any form of mental condition could pose potential psychological distress and burden to family members, notably the primary caregivers. Purpose The current study intends to explore the expressed emotion of the primary caregivers toward children with neurodevelopmental disorders (NDDs). The association between expressed emotion, stress experienced by the caregiver, and the self-sufficiency of the child diagnosed with neurodevelopmental disorders was examined. Methods The Five-Minute Speech Sample (FMSS), Kingston Caregivers' Stress Scale (KCSS), and Waisman Activities of Daily Living (WADL) were used to assess expressed emotion, stress, and a child's self-sufficiency, respectively. The snowball sampling technique was adopted, and data were collected from 35 primary caregivers through telephonic interviews. A mixed-method research design was adopted, and the data were analyzed qualitatively and quantitatively. Results The findings reveal that there is a significant association between expressed emotion and caregivers' stress, expressed emotion, and the child's self-sufficiency and a significant relationship between the caregivers' stress and the child's self-sufficiency. The qualitative analysis suggests the influence of factors such as future concerns, family factors, and relationship strains contribute to expressed emotion. Conclusion It can be concluded that those primary caregivers who reported extreme caregivers' stress and low self-sufficiency in their child exhibited high negative expressed emotion and diverse individual and systemic factors influenced the display of high expressed emotion within the family.
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Affiliation(s)
- Krishna Priya Balachandran
- Department of Social Sciences, School of Social Sciences and Languages, Vellore Institute of Technology, Vellore, Tamil Nadu, India
| | - Mohanraj Bhuvaneswari
- Department of Social Sciences, School of Social Sciences and Languages, Vellore Institute of Technology, Vellore, Tamil Nadu, India
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You W, Henneberg M. Large household reduces dementia mortality: A cross-sectional data analysis of 183 populations. PLoS One 2022; 17:e0263309. [PMID: 35239673 PMCID: PMC8893634 DOI: 10.1371/journal.pone.0263309] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 01/15/2022] [Indexed: 12/20/2022] Open
Abstract
Background Large households/families may create more happiness and offer more comprehensive healthcare among the members. We correlated household size to dementia mortality rate at population level for analysing its protecting role against dementia mortality. Methods This is a retrospective cross-sectional study. Dementia specific mortality rates of the 183 member states of World Health Organization were calculated and matched with the respective country data on household size, Gross Domestic Product (GDP), urban population and ageing. Scatter plots were produced to explore and visualize the correlations between household size and dementia mortality rates. Pearson’s and nonparametric correlations were used to evaluate the strength and direction of the associations between household size and all other variables. Partial correlation of Pearson’s approach was used to identify that household size protects against dementia regardless of the competing effects from ageing, GDP and urbanization. Multiple regression was used to identify significant predictors of dementia mortality. Results Household size was in a negative and moderately strong correlation (r = -0.6034, p < 0.001) with dementia mortality. This relationship was confirmed in both Pearson r (r = - 0.524, p<0.001) and nonparametric (rho = -0.579, p < 0.001) analyses. When we controlled for the contribution of ageing, socio-economic status and urban lifestyle in partial correlation analysis, large household was still in inverse and significant correlation to dementia mortality (r = −0.331, p <0.001). This suggested that, statistically, large household protect against dementia mortality regardless of the contributing effects of ageing, socio-economic status and urban lifestyle. Stepwise multiple regression analysis selected large household as the variable having the greatest contribution to dementia mortality with R2 = 0.263 while ageing was placed second increasing R2 to 0.259. GDP and urbanization were removed as having no statistically significant influence on dementia mortality. Conclusions While acknowledging ageing, urban lifestyle and greater GDP associated with dementia mortality, this study suggested that, at population level, household size was another risk factor for dementia mortality. As part of dementia prevention, healthcare practitioners should encourage people to increase their positive interactions with persons from their neighbourhood or other fields where large household/family size is hard to achieve.
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Affiliation(s)
- Wenpeng You
- School of Biomedicine, The University of Adelaide, Adelaide, Australia
- * E-mail:
| | - Maciej Henneberg
- School of Biomedicine, The University of Adelaide, Adelaide, Australia
- Institute of Evolutionary Medicine, University of Zurich, Zürich, Switzerland
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Ohi T, Murakami T, Komiyama T, Miyoshi Y, Endo K, Hiratsuka T, Satoh M, Asayama K, Inoue R, Kikuya M, Metoki H, Hozawa A, Imai Y, Watanabe M, Ohkubo T, Hattori Y. Oral health-related quality of life is associated with the prevalence and development of depressive symptoms in older Japanese individuals: The Ohasama Study. Gerodontology 2021; 39:204-212. [PMID: 34009675 DOI: 10.1111/ger.12557] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 04/01/2021] [Accepted: 04/26/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVE This prospective study investigated the cross-sectional association between impaired oral health-related quality of life (OHRQoL) and the prevalence of depressive symptoms, and the longitudinal association between impaired OHRQoL and development of depressive symptoms among older adults. BACKGROUND Previous studies have shown a relationship between poor oral health and depression among older adults; however, findings are inconsistent. MATERIALS AND METHODS Participants were 669 community-dwelling older Japanese individuals aged≥55 years (mean: 67.8 ± 7.2 years). Data of 296 participants were used for longitudinal analyses. OHRQoL was evaluated using the Oral Impacts on Daily Performances scale. Impaired OHRQoL was defined as the presence of at least one impact on the scale. Depressive symptoms were assessed using the Japanese version of the Zung self-rating depression scale with a cut-off score of 40. RESULTS The cross-sectional logistic regression model demonstrated that impaired OHRQoL was significantly associated with depressive symptoms (odds ratio [OR], 5.17; 95% confidence interval [CI], 2.99-8.95) independent of age, sex, body mass index, hypertension, cerebrovascular/cardiovascular disease, smoking, drinking alcohol, education, cognitive function, objective oral health (dentition status) and oral health behaviour (dental visit within 1 year). Similarly, impaired OHRQoL predicted the development of depressive symptoms within 4 years in a fully adjusted longitudinal model (OR, 6.00; 95% CI, 1.38-26.09). CONCLUSION Impaired OHRQoL was identified as a potential comorbidity of depressive symptoms and a predictor for depressive disorder later in life. OHRQoL may be a useful clinical outcome for elder patients with regard to their mental and oral health.
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Affiliation(s)
- Takashi Ohi
- Division of Aging and Geriatric Dentistry, Department of Rehabilitation Dentistry, Tohoku University Graduate School of Dentistry, Sendai, Japan.,Japanese Red Cross Ishinomaki Hospital, Ishinomaki, Japan
| | - Takahisa Murakami
- Division of Aging and Geriatric Dentistry, Department of Rehabilitation Dentistry, Tohoku University Graduate School of Dentistry, Sendai, Japan.,Division of Public Health, Hygiene and Epidemiology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Takamasa Komiyama
- Division of Aging and Geriatric Dentistry, Department of Rehabilitation Dentistry, Tohoku University Graduate School of Dentistry, Sendai, Japan
| | - Yoshitada Miyoshi
- Division of Aging and Geriatric Dentistry, Department of Rehabilitation Dentistry, Tohoku University Graduate School of Dentistry, Sendai, Japan
| | - Kosei Endo
- Division of Aging and Geriatric Dentistry, Department of Rehabilitation Dentistry, Tohoku University Graduate School of Dentistry, Sendai, Japan
| | - Takako Hiratsuka
- Division of Aging and Geriatric Dentistry, Department of Rehabilitation Dentistry, Tohoku University Graduate School of Dentistry, Sendai, Japan
| | - Michihiro Satoh
- Division of Public Health, Hygiene and Epidemiology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Kei Asayama
- Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan.,Tohoku Institute for Management of Blood Pressure, Sendai, Japan
| | - Ryusuke Inoue
- Department of Medical Information Technology Center, Tohoku University Hospital, Sendai, Japan
| | - Masahiro Kikuya
- Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan
| | - Hirohito Metoki
- Division of Public Health, Hygiene and Epidemiology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan.,Tohoku Institute for Management of Blood Pressure, Sendai, Japan
| | - Atsushi Hozawa
- Department of Preventive Medicine and Epidemiology, Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
| | - Yutaka Imai
- Tohoku Institute for Management of Blood Pressure, Sendai, Japan
| | - Makoto Watanabe
- Research Institute of Living and Environmental Sciences, Miyagi Gakuin Women's University, Sendai, Japan
| | - Takayoshi Ohkubo
- Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan.,Tohoku Institute for Management of Blood Pressure, Sendai, Japan
| | - Yoshinori Hattori
- Division of Aging and Geriatric Dentistry, Department of Rehabilitation Dentistry, Tohoku University Graduate School of Dentistry, Sendai, Japan
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Falkingham J, Evandrou M, Qin M, Vlachantoni A. Chinese women's health and wellbeing in middle life: Unpacking the influence of menopause, lifestyle activities and social participation. Maturitas 2020; 143:145-150. [PMID: 33308620 DOI: 10.1016/j.maturitas.2020.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 08/12/2020] [Accepted: 10/14/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To examine Chinese middle-aged women's health and wellbeing and the associated biosocial correlates. STUDY DESIGN This study used a cross-sectional design, including selected retrospectively collected information on the final menstrual period, drawn from the 2013 wave of the China Health and Retirement Longitudinal Study (CHARLS). Women aged 45 to 59 were selected. MAIN OUTCOME MEASURES Factor analysis of 16 menopausal symptom ratings yielded four different and independent measures of pre-/peri-menopausal and early postmenopausal women's health. These were: negative mood (feel frustrated, sad, lonely, worried, bored, angry, tired and stressed), positive emotions (feel enthusiastic, content and happy), musculoskeletal pain (shoulder/neck pain, knee and other joint pain, and back pain), and sleep and memory problems (trouble sleeping and poor memory). RESULTS Menopausal status was positively associated with sleep and memory problems, whilst the number of years since the final menstrual period was positively associated with musculoskeletal pain. In contrast, lifestyle activities and social participation were linked to positive emotions. The association between selected biosocial factors and negative mood was not significant after controlling for other demographic and social background factors. CONCLUSIONS Musculoskeletal health as well as sleep and memory problems are positively associated with menopausal biological factors amongst Chinese mid-life women. Maintaining active social engagement contributes to positive wellbeing among middle-aged women.
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Affiliation(s)
- Jane Falkingham
- ESRC Centre for Population Change, University of Southampton, Southampton, SO17 1BJ, UK.
| | - Maria Evandrou
- ESRC Centre for Population Change, University of Southampton, Southampton, SO17 1BJ, UK; Centre for Research on Ageing, University of Southampton, Southampton, SO17 1BJ, UK
| | - Min Qin
- ESRC Centre for Population Change, University of Southampton, Southampton, SO17 1BJ, UK; Centre for Research on Ageing, University of Southampton, Southampton, SO17 1BJ, UK
| | - Athina Vlachantoni
- ESRC Centre for Population Change, University of Southampton, Southampton, SO17 1BJ, UK; Centre for Research on Ageing, University of Southampton, Southampton, SO17 1BJ, UK
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Abstract
Family relationships are enduring and consequential for well-being across the life course. We discuss several types of family relationships—marital, intergenerational, and sibling ties—that have an important influence on well-being. We highlight the quality of family relationships as well as diversity of family relationships in explaining their impact on well-being across the adult life course. We discuss directions for future research, such as better understanding the complexities of these relationships with greater attention to diverse family structures, unexpected benefits of relationship strain, and unique intersections of social statuses.
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Affiliation(s)
- Patricia A Thomas
- Department of Sociology and Center on Aging and the Life Course, Purdue University, West Lafayette, Indiana
| | - Hui Liu
- Department of Sociology, Michigan State University, East Lansing
| | - Debra Umberson
- Department of Sociology and Population Research Center, University of Texas at Austin
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Thomas PA. The Impact of Relationship-Specific Support and Strain on Depressive Symptoms Across the Life Course. J Aging Health 2015; 28:363-82. [PMID: 26092652 DOI: 10.1177/0898264315591004] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE This study integrates stress process theory into a life course framework to examine how support and strain from particular relationship types (spouse/partner, children, mother, and friends/relatives) influence trajectories of depressive symptoms among different age groups, net of support and strain from other relationship types. METHOD Latent growth curve models were used on nationally representative panel data (N = 3,617) from the Americans' Changing Lives survey (1986, 1989, 1994, and 2001/2002). RESULTS Net of support and strain from other relationships, support from a spouse was related to fewer depressive symptoms among each age group. Friendships were important for depressive symptoms among younger and older adults, whereas only support/strain from family relationships influenced depressive symptoms among adults in midlife. DISCUSSION Findings demonstrate the importance of support and strain in multiple types of network members for the mental health of adults across the life course.
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Lee CT, Yeh CJ, Lee MC, Lin HS, Chen VCH, Hsieh MH, Yen CH, Lai TJ. Social support and mobility limitation as modifiable predictors of improvement in depressive symptoms in the elderly: Results of a national longitudinal study. Arch Gerontol Geriatr 2012; 55:530-8. [DOI: 10.1016/j.archger.2012.03.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Revised: 03/02/2012] [Accepted: 03/03/2012] [Indexed: 10/28/2022]
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Gao Y, MacDonald D, Collins KD, Alaghehbandan R, Chen Y. Role of social support in the relationship between sexually transmitted infection and depression among young women in Canada. J Epidemiol 2010; 20:313-8. [PMID: 20551580 PMCID: PMC3900792 DOI: 10.2188/jea.je20090133] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Individuals with a self-reported history of sexually transmitted infection (STI) are at high risk for depression. However, little is known about how social support affects the association between STI and depression among young women in Canada. Methods Data were drawn from the Canadian Community Health Survey (CCHS), conducted in 2005. A total of 2636 women aged 15–24 years who provided information on STI history were included in the analysis. Depression was measured by a depression scale based on the Composite International Diagnostic Interview Short-Form (CIDI-SF). The 19-item Medical Outcomes Study (MOS) Social Support Survey assessed functional social support. A log-binomial model was used to estimate the prevalence ratio (PR) for self-reported STI history associated with depression and to assess the impact of social support on the association. Results The adjusted PR for self-reported STI history associated with depression was 1.61 (95% CI, 1.03 to 2.37), before social support was included in the model. The association between STI history and depression was no longer significant when social support was included in the model (adjusted PR, 1.28; 95% CI, 0.83 to 1.84). The adjusted PRs for depression among those with low and intermediate levels of social support versus those with a high level of social support were 5.62 (95% CI, 3.50 to 9.56) and 2.19 (1.38 to 3.68), respectively. Conclusions Social support is an important determinant of depression and reduces the impact of self-reported STI on depression among young women in Canada.
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Affiliation(s)
- Yanhui Gao
- Department of Epidemiology and Community Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada K1H 8M5
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9
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Komatsu Y, Kai Y, Nagamatsu T, Shiwa T, Suyama Y, Sugimoto M. [Buffering effect of social support in the workplace on job strain and depressive symptoms]. ACTA ACUST UNITED AC 2010; 52:140-8. [PMID: 20424382 DOI: 10.1539/sangyoeisei.b9012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The present study examined the buffering effect of social support in the workplace on job strain and depressive symptoms by conducting a cross-sectional survey using a self-report. METHODS The subjects were 712 employees (male, over 40 yr old) who worked at a precision machine factory. The questionnaire determined the subjects, ages, types of occupation, scores of depressive symptoms, job strain (job demand and job control), and social support (supervisor support and coworker support). Job strain and social support were evaluated by the Job Content Questionnaire (JCQ). The Center for Epidemiologic Studies Depression Scale (CES-D) score was measured and depressive symptoms were defined as a CES-D score > or = 16 point. Job strain and social support were calculated and divided into low-score groups (LG) and high-score groups (HG), respectively, by the median value. The mean values of CES-D in the LG and HG of job strain or social support were compared by the t-test. The hierarchical multiple regression was analyzed with the CES-D score as the dependent variable and by the characteristics of the participants, job strain and social support, and the cross-product interaction term of job strain and social support as independent variables. The effect of the degree of social support in the LG and HG of job strain on the CES-D score was evaluated by analysis of covariance adjusted for age. RESULTS The results showed that 23.2% of the workers had depressive symptoms, and that, the CES-D scores in the job demand group were significantly higher in HG than in LG. The CES-D scores in the job control, supervisor support, and coworker support groups were significantly higher in LG than in HG. The hierarchical multiple regression analysis showed that job demand, job control, supervisor support, and coworker support had significant main effects on the CES-D score. Furthermore, it was shown that there was a significant interaction in the CES-D score between job control and supervisor support, and that, the CES-D score in the supervisor support group was significantly higher in LG than that in HG only when job control was low. CONCLUSIONS These results suggest that supervisor support may have the effect of buffering depressive symptoms related to low job control.
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Affiliation(s)
- Yuki Komatsu
- School of Nursing, Faculty of Medicine, Toho University, Tokyo, Japan.
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Coventry WL, Medland SE, Wray NR, Thorsteinsson EB, Heath AC, Byrne B. Phenotypic and discordant-monozygotic analyses of stress and perceived social support as antecedents to or sequelae of risk for depression. Twin Res Hum Genet 2010; 12:469-88. [PMID: 19803775 DOI: 10.1375/twin.12.5.469] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The associations between social support and depression, and between stress and depression have been the subject of considerable research, and although this has included longitudinal designs, these have rarely controlled for genetic effects that mediate these associations. The sample comprised 7,356 female and 4,882 male participants aged 18-95 from the Australian NHMRC Twin Registry (ATR). Of these, between 100 and 324 female pairs and between 41 and 169 male pairs, depending on the measure, were monozygotic (MZ) pairs discordant for depression. We use the co-twin control design in combination with prospective analyses to explore the association between a composite of predictors (perceived social support, stress, and support x stress) and depression. With familial effects included, both perceived support and stress were antecedents to, and sequelae of, depression, but no stress-buffering occurred. With familial effects controlled, stress was a sequela of a prior depressive episode, and neither lack of support nor stress were antecedents to depression, though their interaction approached significance for males. The male twin who later became depressed had previously reported lower perceived support in the face of multiple stressors compared to his co-twin who did not become depressed. We show that associations commonly observed with prospective designs are partly due to familial factors.
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Affiliation(s)
- William L Coventry
- School of Behavioural, Cognitive and Social Sciences, University of New England, Armidale, Australia.
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Parr CL, Veierød MB, Laake P, Lund E, Hjartåker A. Test-retest reproducibility of a food frequency questionnaire (FFQ) and estimated effects on disease risk in the Norwegian Women and Cancer Study (NOWAC). Nutr J 2006; 5:4. [PMID: 16448553 PMCID: PMC1434764 DOI: 10.1186/1475-2891-5-4] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2005] [Accepted: 01/31/2006] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The Norwegian Women and Cancer Study (NOWAC) is a national population-based cohort study with 102 443 women enrolled at age 30-70 y from 1991 to 1997. The present study was a methodological sub-study to assess the test-retest reproducibility of the NOWAC food frequency questionnaire (FFQ), and to study how measurement errors in the data can affect estimates of disease risk. METHODS A random sample of 2000 women aged 46-75 y was drawn from the cohort in 2002. A self-instructive health and lifestyle questionnaire with a FFQ section was mailed to the same subjects twice (test-retest), about three months apart, with a response rate of 75%. The FFQ was designed to assess habitual diet over the past year. We assess the reproducibility of single questions, food groups, energy, and nutrients with several statistical measures. We also demonstrate the method of regression calibration to correct disease risk estimates for measurement error. Alcohol intake (g/day) and high blood pressure (yes/no) is used in the example. RESULTS For single foods there were some indications of seasonal reporting bias. For food groups and nutrients the reliability coefficients ranged from 0.5-0.8, and Pearson's r, Spearman's rs, and two intraclass correlation coefficients gave similar results. Although alcohol intake had relatively high reproducibility (r = 0.72), odds ratio estimates for the association with blood pressure were attenuated towards the null value compared to estimates corrected by regression calibration. CONCLUSION The level of reproducibility observed for the FFQ used in the NOWAC study is within the range reported for similar instruments, but may attenuate estimates of disease risk.
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Affiliation(s)
- Christine L Parr
- Institute of Basic Medical Sciences, Department of Biostatistics, University of Oslo, P.O. Box 1122 Blindern, N-0317 Oslo, Norway
| | - Marit B Veierød
- Institute of Basic Medical Sciences, Department of Biostatistics, University of Oslo, P.O. Box 1122 Blindern, N-0317 Oslo, Norway
| | - Petter Laake
- Institute of Basic Medical Sciences, Department of Biostatistics, University of Oslo, P.O. Box 1122 Blindern, N-0317 Oslo, Norway
| | - Eiliv Lund
- Institute of Community Medicine, University of Tromsø, N-9037 Tromsø, Norway
| | - Anette Hjartåker
- Institute of Basic Medical Sciences, Department of Biostatistics, University of Oslo, P.O. Box 1122 Blindern, N-0317 Oslo, Norway
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