Dimensions of social inequality in the health of women in England: occupational, material and behavioural pathways

This paper examines the role of behavioural and psychosocial risk and protective factors in explaining social inequalities in the general self-assessed health of women. Using path analysis, data from the Health Survey for England (1993) are used to demonstrate how different dimensions of social position (working conditions, general social advantage and material deprivation) have distinct pathways to ill-health. Smoking, diet, alcohol consumption, exercise, social support and job strain were all related to poorer health, but not always in the predicted direction. The effects of social position on health were not fully mediated through these risk and protective factors. Each dimension of social position had unique pathways to ill-health via other unidentified mechanisms. Furthermore, the salience of the three dimensions of social position differed according to the level of labour market attachment. Different path models are required to fit the data for women at home or in full-time or part-time work.

Social distribution of cardiovascular disease risk factors: change among men in England 1984-1993

OBJECTIVE

To investigate change in the social distribution of some of the main risk factors for cardiovascular disease in men in England during a period when inequality in cardiovascular disease mortality widened

DESIGN

Age standardised comparison of the social distribution of seven known risk factors for cardiovascular disease (body mass index, waist to hip ratio, systolic and diastolic blood pressure, consumption of fresh green vegetables, leisure time exercise, cigarette smoking and levels of social support) in two large cross sectional representative samples of the English population.

SUBJECTS

Men aged 20-64 years in the 1984 Health and Lifestyle Survey (excluding Scotland and Wales) first sweep and the 1993 Health Survey for England.

MAIN OUTCOME MEASURES

Mean values of continuous variables; age adjusted proportions of categorical variables; change in the relative index of inequality for each risk factor.

RESULTS

The overall prevalence of cardiovascular disease risk factors improved during the period in which cardiovascular disease mortality was falling. The social distribution of cardiovascular disease risk factors, in contrast, did not become more extreme. Increases in the relative index of inequality for angina from 1.75 to 1.86, for eating vegetables less than once a day from 1.76 in 1984 to 1.96 in 1993, and an apparently larger increase in inequality of social support, from 1.92 to 2.53 were not statistically significant. In most cases the degree of inequality in risk factors tended to narrow non-significantly: for example the relative index of inequality fell from 5.02 in 1984 to 3.07 in 1993 for systolic blood pressure, from 5.60 to 4.29 for current smoking and from 6.24 to 4.19 for eating other than wholemeal bread as the main form of bread in the diet. The two statistically significant changes in inequality were in the direction of narrowing inequality: from a relative index of inequality of 2.12 to 0.90 for diastolic blood pressure (p<0.01) and from 19.3 to 0.87 (p<0.01) for psychological distress as indicated by the General Health Questionnaire.

CONCLUSIONS

Healthier lifestyle options have not been adopted at a significantly faster rate by middle class than working class people over this time period. At the population level the change in risk factors is consistent with falling cardiovascular mortality. The change in the social distribution of risk factors within the population, however, shows little or no relation to the pattern of widening inequality in cardiovascular mortality. This may be because the effect is lagged, or because the adoption of healthier behaviour confers greater benefits on those in higher socioeconomic status groups.

Comparing health inequality in men and women: prospective study of mortality 1986-96

OBJECTIVES

To study prospectively the differences in health inequality in men and women from 1986-96 using the Office for National Statistics' longitudinal study and new socioeconomic classification. To assess the relative importance of social class (based on employment characteristics) and social position according to the general social advantage of the household to mortality risk in men and women.

DESIGN

Prospective study.

SETTING

England and Wales.

SUBJECTS

Men and women of working age at the time of the 1981 census, with a recorded occupation.

MAIN OUTCOME MEASURES

Mortality.

RESULTS

In men, social class based on employment relations, measured according to the Office for National Statistics' socioeconomic classification, was the most important influence on mortality. In women, social class based on individual employment relations and conditions showed only a weak gradient. Large differences in risk of mortality in women were found, however, when social position was measured according to the general social advantage in the household.

CONCLUSIONS

Comparisons of the extent of health inequality in men and women are affected by the measures of social inequality used. For women, even those in paid work, classifications based on characteristics of the employment situation may give a considerable underestimate. The Office for National Statistics' new measure of socioeconomic position is useful for assessing health inequality in men, but in women a more important predictor of mortality is inequality in general social advantage of the household.

Understanding social variation in cardiovascular risk factors in women and men: the advantage of theoretically based measures

Many studies have attempted to understand observed social variations in cardiovascular disease in terms of sets of intermediate or confounding risk factors. Tests of these models have tended to produce inconsistent evidence. This paper examines the relationships to cardiovascular risk factors or two theoretically based measures of social position. It shows that the strength of the relationships between social position and cardiovascular risk factors varies according to the definition of social position which is used: there is a closer relationship between most health behaviours and the Cambridge scale, an indicator of 'general social advantage and lifestyle', whereas the Erikson-Goldthorpe schema, which is based on employment relations and conditions, is more strongly related to work control and breathlessness. The implications of these findings for understanding the conflicting evidence in other studies of health inequalities are then discussed. The paper concludes that inconsistencies between studies may be in part due to unexamined differences between the conceptual bases of the measures of social position they use, combined with a failure to make explicit the hypothetical mechanisms of effect. If neither the conceptual basis of the measure of social position, nor the links between social position and health outcome tested in each study are clear, inconsistencies between studies will be difficult to interpret, making policy recommendations highly problematic.

Quality of life in children with Crohn's disease: a pilot study

BACKGROUND

Focus group meetings were held with two groups, each containing 12 children with Crohn's disease aged 8 to 12 and 12 to 17 years. The children were asked broad questions about how Crohn's disease and its treatment affected their lives. To explore these areas in more detail, an 88-item questionnaire was developed and read to an additional 16 of 20 children with Crohn's disease selected at random from outpatients. At first, many of the children denied that Crohn's disease affected their lives at all, but it soon became apparent that many were frustrated or angry about physical symptoms, lack of understanding about Crohn's disease, unpleasant investigations, treatment, and hospitalisation.

METHODS

The questionnaire covered six domains of health-related quality of life including symptoms and treatment, social, emotional, family, educational, and future aspects.

RESULTS

Elemental diet was the preferred treatment, although surgery was more effective in controlling symptoms. Children receiving steroids had more depressive symptoms. Absenteeism from school and inability to engage in school sports, swimming, and running were frequent problems. There were also difficulties with taking holidays and staying at friends' houses. Worry was reported in 14 of 16 children, anger and frustration and feeling fed up in 12 of 16.

CONCLUSIONS

In addition to being a symptomatically disabling condition, Crohn's disease has a great impact on the health-related quality of life of affected children. Future studies of treatment in children with inflammatory bowel disease should include an attempt to assess the impact on the child's health-related quality of life.

Quality of life of parents and siblings of children with inflammatory bowel disease

BACKGROUND

Few investigators have reported on the quality of life of family members of children with inflammatory bowel disease. Psychological symptoms have been reported in parents and siblings, but the problems that which give rise to these symptoms are seldom examined. In this pilot study, some of the issues that affect the quality of life of parents and siblings of children with inflammatory bowel disease were examined.

METHODS

Focus group meetings were held separately with 20 parents and 7 siblings of children with inflammatory bowel disease. The participants were encouraged to identify voluntarily problems related to the disease that affected their lives, and the discussions were tape recorded. Each participant subsequently wrote down the three most important concerns.

RESULTS

Thirteen (65%) parents were very concerned about the effect of the disease on the child's future jobs, marriage, independence) and 11 (55%) were worried about problems the ill child was encountering at school. Other issues of most concern to parents included side effects of medication (n = 7), limited job prospects (n = 3), persistent feelings of guilt (n = 3), and restricted family lifestyle (n = 1 ). Most siblings (57%) were concerned about their parents' keeping information about the illness from them, and three (43%) of them were also concerned about others bullying the ill child at school. Other issues of concern to siblings included fear about the disease and treatment (n = 3), parents overprotecting the ill child, and feelings of jealousy (n = 1).

CONCLUSION

Families of children with inflammatory bowel disease experience many problems that may affect their quality of life. Resources should be made available to help families with these concerns.

Estimating intraclass correlation for binary data

This paper reviews many different estimators of intraclass correlation that have been proposed for binary data and compares them in an extensive simulation study. Some of the estimators are very specific, while others result from general methods such as pseudo-likelihood and extended quasi-likelihood estimation. The simulation study identifies several useful estimators, one of which does not seem to have been considered previously for binary data. Estimators based on extended quasi-likelihood are found to have a substantial bias in some circumstances.

Social mobility and personal satisfaction: evidence from ten countries

This paper examines survey data relating class mobility to satisfaction and dissatisfaction with seven different domains of everyday life among nationally representative samples of men and women living in ten industrialized nations. The evidence is set against competing pessimistic and optimistic accounts of the mobility experience found in earlier literature. Results show that individuals who move from working-class origins to middle-class destinations are no more likely to be systematically satisfied or dissatisfied with life than are the socially immobile or even those downwardly mobile from advantaged backgrounds into the working class. Indeed, in all nations, the overall association between class experience and satisfaction with life is both weak and uneven across the different life-domains. The study also serves to illustrate an important principle of research methodology more generally.

Social position, social roles and women's health in England: changing relationships 1984-1993

The aim of this study is to investigate the relationships between social roles, social position and health in English women using theoretically derived measures of social position. Data are taken from the Health and Lifestyle Survey, carried out between 1984-1985, and the Health Survey for England of 1993. First the paper asks whether health inequality in women is still evident when theoretically derived measures (the Erikson-Goldthorpe schema and the Cambridge scale) are used. It goes on to explore the extent to which different combinations of family roles and employment circumstances might affect social variations in health. Finally, the paper shows that health differences between women in different combinations of social roles were not the same in 1993 as in 1984 and examines some reasons why this change may have occurred.

Ketoacidosis occurring in newly diagnosed and established diabetic children

A 6-y retrospective case note review was performed to determine the causes of ketoacidosis. 135 patients and 463 diabetic years were involved. Fifty-two ketoacidosis episodes occurred: 19 episodes in new patients and 33 episodes in 19 patients with established diabetes. 27% of newly diagnosed patients presented in ketoacidosis. They were similar in terms of age, sex and proportion living in single parent families to those presenting without ketoacidosis. The 33 ketoacidosis episodes occurring in established patients included 12 episodes in 3 children who were transferred to our care because of uncontrolled diabetes. Insulin omission was the cause of ketoacidosis in 9/19 (47%) patients, and was suspected in a further 5/19 (26%). Family and school problems were common and 14/19 patients came from single parent families. Established patients aged > or = 11 y were predominantly female (10F, 2M), whereas patients aged < or = 10 y were predominantly male (6M, 1F). 7 patients with multiple ketoacidosis episodes were all > or = 11 y and 6 were female. Families with > or = 2 diabetic children appeared vulnerable, 4 cases coming from 3/7 such families.

Quality of life in children with Crohn's disease

In a 10-week randomised cross-sectional study we used an 88-item questionnaire to assess the quality of life in 16 children (ages 8-17 years) with Crohn's disease and their families. The questionnaire covered six domains of health-related quality of life, including disease and its treatment, social, emotional, family, education, and future aspects. Crohn's disease affected education, with absenteeism in 12 and distraction during school work in six. Three children had had a home tutor, and five stated their need for one. Engaging in sports was a problem for eight children, mainly because of a lack of energy in five and the presence of a stoma in three children. Three children had missed every PE lesson in 1 year. Five children cited the social problem of being unable to stay over at friends' houses. Bullying concerned parents more than the children. Holiday difficulties included long distance traveling or lack of toilet facilities during school trips. Elemental diet was the preferred treatment, although the majority complained about the taste. Surgery was the most effective method of symptom control, though the resulting stoma was upsetting and restricted sports activities. Children on steroids had more depressive symptoms. Using the Rutter A Questionnaire, five children were designated "neurotic." Parents' views of the severity of symptoms significantly correlated with their children's views regarding rectal bleeding, poor growth, lack of energy, and poor appetite (p < 0.01). The main parental concerns were the side effects of medications and issues concerning their children's future, including schooling, job prospects, and marriage. The parents of 11 children cited problems with children's behaviour. The parents of seven cited disruption of work, and those of six named taking holidays. Crohn's disease in children, in addition to being a symptomatically disabling condition, has a great impact on the health-related quality of life of both sufferers and their parents. The questionnaire was a useful instrument, and with some adjustment it can be used again in large group studies.

Somatization and illness behaviour in a neurology ward

One hundred and thirty-three female patients admitted to a neurological ward were fully investigated for the presence of organic neurological disease, and assessed for psychiatric disorder and illness behaviour, using the Clinical Interview Schedule (CIS) and the Illness Behaviour Questionnaire (IBQ). The likelihood of the presenting symptoms being due to organic disease was expressed by the neurologists on a visual analogue scale and the psychiatrists used a similar technique to describe whether the symptoms could be the result of psychiatric disorder. Many patients either had clear organic disease or somatic presentation of psychiatric disorder 'somatization', but one-third fell between these two extremes and either had a complex mixture of the two types of illness or could not be accurately diagnosed. The IBQ scores were raised in those with psychiatric disorder but did not help to explain why some patients present to the neurologists with symptoms that are unexplained by either organic disease or psychiatric disorder. Close liaison between neurologists and psychiatrists increases the detection of psychiatric disorder but some patients would require long-term follow-up to understand the true nature of the underlying disorder.

Psychiatric morbidity and illness behaviour in female neurological in-patients

Ninety three female neurological in-patients were assessed in a collaborative neurological and psychiatric study. An overall prevalence of definite psychiatric disorder of 34% was found, depression being the most common diagnosis. Psychiatric morbidity was most common when the neurologist felt that the presentation could not be explained by a neurological disorder. The majority of such patients had symptoms which could be explained by the psychiatric disorder but a substantial number could not be given a definite diagnosis. The General Health Questionnaire was not found to be a useful screening instrument in this setting.

Electrodermal response to sexual materials

Four groups of college students selected on the basis of high or low Eysenck Personality Inventory scores were asked to talk or simply think about a series of slides differing in overt sexual content. Data showed that for both conditions those high on Neuroticism (n = 8) showed more electrodermal activity than did those scoring low (n = 8), and over all subjects there was a significant correlation between Neuroticism scores and the physiological measure. High and low scorers on Extraversion scale (ns = 10) showed no analogous differences in electrodermal activity.

The components of the standard and reverse Müller-Lyer illusions

The absolute contribution of each type of oblique figure in the standard and reverse Müller-Lyer illusions is determined by placing one oblique figure at different distances from the end of a test line (either horizontal or vertical) and measuring shift in the line's apparent midpoint as a function of proximity of the oblique figure. The absolute effect of both types of figure, apex-in > < or apex-out < > is one of contraction, and superimposed on this, again for both types of figure, is a smaller expansion effect which is phasic and varies with proximity of the figure to the line. The major factor in the reverse illusion appears to be the apex-in > < and not the apex-out < > figure as previously supposed. For both standard and reverse illusions, and again for both types of figures, there is a visual field effect, since contraction is greater when the obliques lie in the right or in the lower hemifield. The fundamental similarities in mode of action of each type of oblique are further demonstrated by showing that geometrical figures in general, regardless of shape or orientation, give rise to similar patterns of absolute contraction with a phasic expansion component superimposed. The Müller-Lyer oblique figures therefore operate as two of many possible examples of a single underlying mechanism, and recent arguments that the Müller-Lyer is really two separate constituent illusions are not supported.

A Case of Patent Ductus Arteriosus

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Cases of Bronchiectasis

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Congenital Absence of Sternal Portion of the Pectoralis Major

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