Sílvia Fraga

Socioeconomic status and the 25 × 25 risk factors as determinants of premature mortality: A multicohort study and meta-analysis of 1·7 million men and women

Summary Background In 2011, WHO member states signed up to the 25 × 25 initiative, a plan to cut mortality due to non-communicable diseases by 25% by 2025. However, socioeconomic factors influencing non-communicable diseases have not been included in the plan. In this study, we aimed to compare the contribution of socioeconomic status to mortality and years-of-life-lost with that of the 25 × 25 conventional risk factors. Methods We did a multicohort study and meta-analysis with individual-level data from 48 independent prospective cohort studies with information about socioeconomic status, indexed by occupational position, 25 × 25 risk factors (high alcohol intake, physical inactivity, current smoking, hypertension, diabetes, and obesity), and mortality, for a total population of 1 751 479 (54% women) from seven high-income WHO member countries. We estimated the association of socioeconomic status and the 25 × 25 risk factors with all-cause mortality and cause-specific mortality by calculating minimally adjusted and mutually adjusted hazard ratios [HR] and 95% CIs. We also estimated the population attributable fraction and the years of life lost due to suboptimal risk factors. Findings During 26·6 million person-years at risk (mean follow-up 13·3 years [SD 6·4 years]), 310 277 participants died. HR for the 25 × 25 risk factors and mortality varied between 1·04 (95% CI 0·98–1·11) for obesity in men and 2 ·17 (2·06–2·29) for current smoking in men. Participants with low socioeconomic status had greater mortality compared with those with high socioeconomic status (HR 1·42, 95% CI 1·38–1·45 for men; 1·34, 1·28–1·39 for women); this association remained significant in mutually adjusted models that included the 25 × 25 factors (HR 1·26, 1·21–1·32, men and women combined). The population attributable fraction was highest for smoking, followed by physical inactivity then socioeconomic status. Low socioeconomic status was associated with a 2·1-year reduction in life expectancy between ages 40 and 85 years, the corresponding years-of-life-lost were 0·5 years for high alcohol intake, 0·7 years for obesity, 3·9 years for diabetes, 1·6 years for hypertension, 2·4 years for physical inactivity, and 4·8 years for current smoking. Interpretation Socioeconomic circumstances, in addition to the 25 × 25 factors, should be targeted by local and global health strategies and health risk surveillance to reduce mortality. Funding European Commission, Swiss State Secretariat for Education, Swiss National Science Foundation, the Medical Research Council, NordForsk, Portuguese Foundation for Science and Technology.

Uso de tabaco por estudantes adolescentes portugueses e fatores associados

OBJETIVO: Descrever o uso de tabaco e identificar os seus determinantes em estudantes adolescentes. METODOS: Estudo transversal, tendo sido avaliadas 1.052 meninas e 984 meninos de 13 anos de idade matriculados em escolas publicas e privadas da cidade do Porto, Portugal. A proporcao individual de participacao foi de 77,5%. O adolescente e o seu responsavel preencheram um questionario sobre informacoes sociodemograficas e de comportamento em suas casas. Na escola, o adolescente completou outro questionario, com informacoes sobre o tabagismo. As variaveis continuas foram comparadas pelo teste Kruskal-Wallis e as proporcoes pelo teste de qui-quadrado. As estimativas de risco e respectivos intervalos de confianca de 95% foram calculados por regressao logistica nao condicional. RESULTADOS: Dos adolescentes avaliados, 19,9% (22,4% das meninas e 17,1% dos meninos) experimentaram fumar mas nao eram fumantes; 1,8% (2,0% das meninas e 1,5% dos meninos) fumavam ocasionalmente e 1,3% (2,0% das meninas e 0,4% dos meninos) fumavam pelo menos um cigarro por dia. A razao mais referida como a mais importante para experimentar fumar foi a curiosidade (46,3% das meninas e 45,6% dos meninos). Apos ajuste para os habitos tabagicos dos progenitores, dos irmaos e dos amigos, a associacao mais forte foi com o tabagismo dos amigos, nas meninas (OR=4,03; IC 95%: 2,69-6,04) e nos meninos (OR=5,39; IC 95%: 3,34-8,70). CONCLUSOES: Uma elevada proporcao tinha experimentado fumar e ter amigos fumantes foi o mais forte determinante para experimentar fumar.

Parents’ views on factors that help or hinder breast milk supply in neonatal care units: systematic review

Objective To synthesise what is known about the parents’ views on factors that help or hinder breast milk supply during their infants’ hospitalisation in neonatal intensive care units (NICU). Methods A systematic search of PubMed, ISI WoK, PsycINFO and SciELO, targeting studies presenting original empirical data that examined parents’ perspectives regarding breast milk supply experiences in NICU, was performed. Based on content analysis, three independent researchers synthesised the findings of seven studies. Categories of facilitators and barriers were identified using quotations stated in the studies: parents’ breast milk supply experience; parents–professionals relationships; characteristics of the NICU; and parents’ social background and expectations. Results The studies, five qualitative and two mixed methods, were published between 1994 and 2011. With heterogeneous study designs, fathers’ perspectives were analysed in one article. Only one study defined breastfeeding. According to parents’ perspectives, successful breast milk supply in NICU depends on coherent and accurate knowledge about its techniques and benefits, reinforcement of mothers’ motivation and alignment between NICUs routines and parents’ needs. Parents perceived issues related to their own current breast milk supply experience, simultaneously, as main facilitators and barriers. Parents–professionals relationship constituted the second group of facilitators, but the fourth of barriers. The characteristics of the NICU were more relevant as a barrier than as a facilitator. Conclusions Although parents’ perspectives are grounded on individual child-focused experiences, their emphasis on learning and motivation guided by short-term goals opens room to the collective intervention of experts. This may facilitate the engagement of mothers, fathers and health professionals on family-centred care.

Qualidade do ar interior e sintomas respiratórios em escolas do Porto

Aim: To evaluate the association between the indoor air quality in Porto schools and the prevalence of allergic and respiratory symptoms in adolescents. Material and methods: Temperature, relative humidity, carbon dioxide (CO2) and volatile organic compound (VOC) concentrations were evaluated in nine Porto schools. Questionnaires were distributed to 9 classes of 7th, 8th and 9th year students in each school, total 1607 adolescents, with a mean age of 14.0 years (standard deviation = 0.3). Information was collected on participants’ socio-demo-graphic and social characteristics, behaviour, and housing conditions. The International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire was used to evaluate respiratory symptoms. Results: 5.8% of participants stated they had had asthma, 9.2% wheezing, 22.0% sneezing and 6.6% itchy rash In the 12 months preceding the evaluation. After adjustment for parental educational attainment level, CO2 > 2100 ppm values were associated with exercise-induced wheeze [OR = 1.86 (95%CI:1.20-2.89)] and night cough [OR = 1.40 (4.20-2.89)]. We observed an increasing odds ratio in wheezing symptoms over the last 12 months, in asthma ‘at some point’ and asthma over the last 12 months, and night cough at schools with higher VOC values. The association was not statistically significant, however. Conclusion: Lower indicators of indoor air quality, particularly CO2, were associated with a greater respiratory symptomatology. Rev Port Pneumol 2008; XIV (4): 487-507

Association of socioeconomic status with inflammatory markers: a two cohort comparison

OBJECTIVE To assess the association between socioeconomic status (SES) and inflammatory markers using two different European population samples. METHODS We used data from the CoLaus (N=6412, Lausanne, Switzerland) and EPIPorto (N=1205, Porto, Portugal) studies. Education and occupational position were used as indicators of socioeconomic status (SES). High-sensitivity C-reactive protein (hs-CRP) was available for both cohorts. Interleukin-6 (IL-6) and tumour necrosis factor-α (TNF-α) were available in CoLaus; leukocyte count and fibrinogen in EPIPorto. RESULTS We showed that low SES was significantly associated with high inflammation in both studies. We also showed that behavioural factors contributed the most to SES differences in inflammation. In both studies the larger difference between the lowest and the highest SES was observed for hs-CRP. In the Swiss sample, a linear association between education and hs-CRP persisted after adjustment for all mediating factors and confounders considered (p for linear trend <0.001). CONCLUSION Large social differences exist in inflammatory activity, in part independently from demographic and behavioural factors, chronic conditions and medication use. SES differences in inflammation are also similar in countries with different underlying socioeconomic conditions.

Elder abuse and socioeconomic inequalities: a multilevel study in 7 European countries.

OBJECTIVES To compare the prevalence of elder abuse using a multilevel approach that takes into account the characteristics of participants as well as socioeconomic indicators at city and country level. METHODS In 2009, the project on abuse of elderly in Europe (ABUEL) was conducted in seven cities (Stuttgart, Germany; Ancona, Italy; Kaunas, Lithuania, Stockholm, Sweden; Porto, Portugal; Granada, Spain; Athens, Greece) comprising 4467 individuals aged 60-84 years. We used a 3-level hierarchical structure of data: 1) characteristics of participants; 2) mean of tertiary education of each city; and 3) country inequality indicator (Gini coefficient). Multilevel logistic regression was used and proportional changes in Intraclass Correlation Coefficient (ICC) were inspected to assert explained variance between models. RESULTS The prevalence of elder abuse showed large variations across sites. Adding tertiary education to the regression model reduced the country level variance for psychological abuse (ICC=3.4%), with no significant decrease in the explained variance for the other types of abuse. When the Gini coefficient was considered, the highest drop in ICC was observed for financial abuse (from 9.5% to 4.3%). CONCLUSION There is a societal and community level dimension that adds information to individual variability in explaining country differences in elder abuse, highlighting underlying socioeconomic inequalities leading to such behavior.

Alcohol use among 13-year-old adolescents: associated factors and perceptions.

OBJECTIVE To describe the frequency and determinants of alcohol use in a representative sample of 13 years old adolescents, and to analyse qualitatively how adolescents perceive this issue. STUDY DESIGN Cross-sectional study with quantitative and qualitative components. METHODS Two thousand and thirty-six adolescents attending schools in a city in Portugal were surveyed using a self-reported, structured questionnaire. The qualitative component of the study included 30 semi-structured interviews that intended to assess the reasons for and consequences of drinking as perceived by adolescents, and also the preventive strategies they suggested. RESULTS Overall, 50.0% of girls and 44.9% of boys reported that they had experimented with alcohol, and 4.7% of girls and 6.6% of boys drink alcohol at least once per month. Most adolescents recognised that drinking alcohol is harmful and an addiction which is difficult to treat, but this perception was not associated with their own behaviour. Adolescents only identified minor and temporary consequences of drinking alcohol, usually related to very high and acute consumption. In order to prevent alcohol abuse and its consequences, adolescents proposed measures based on strict control, legal restrictions and economic measures, some of which are already in place in Portugal. CONCLUSION A high proportion of adolescents had experimented with alcohol by 13 years of age, showing the importance of starting prevention at an early life stage. The results also reflect the importance of reviewing prevention programmes in schools, highlighting the importance of families.

Physical fighting among school-going Portuguese adolescents: Social and behavioural correlates

OBJECTIVE The purpose of this study was to estimate the frequency and to assess the determinants of physical fighting among Portuguese school-going adolescents. METHODS A cross-sectional evaluation of urban adolescents born in 1990 and enrolled in public and private schools of Porto was performed in 2007. We identified 3161 17-year-old eligible adolescents and 73.3% accepted to participate. Information was collected using a self-administered questionnaire assessing socio-demographic, behavioural, family and health-related characteristics. The magnitude of the associations between those characteristics and physical fighting was estimated using logistic regression. RESULTS Overall, 33.8% of adolescents (48.6% of boys and 20.1% of girls; p < 0.001) engaged in a physical fight during the previous 12 months. The school premises were the most frequently reported setting where fights occurred (girls--41.2% and boys--46.7%, p = 0.179). After adjustment, and in both genders, we found statistically significant associations between physical fighting and grade retention, smoking, drinking and age at first sexual intercourse. CONCLUSION Physical fighting among school-going adolescents is frequent, tends to occur at school premises and to cluster with other well recognized adverse health behaviours.

Early Initiation of Smoking and Alcohol Drinking as a Predictor of Lower Forearm Bone Mineral Density in Late Adolescence: A Cohort Study in Girls

Background Adolescence is a critical stage for bone accrual. It is also decisive for the establishment of behaviors such as smoking and alcohol drinking. Objective To quantify the short- and long-term associations between smoking and drinking initiation and bone mineral density in adolescent girls. Methods We used prospective data from 731 girls identified in public and private schools in Porto, Portugal. Evaluations were conducted when participants were 13 and 17 years old. Bone mineral density (BMD) was measured at the forearm by dual-energy X-ray absorptiometry and weight, height and fat-free mass were measured. Pubertal development status was estimated using menarche age. Self-administered questionnaires were used to collect data on smoking and alcohol drinking, physical exercise and calcium and vitamin D intakes. BMD in early and late adolescence was analyzed as a continuous or dichotomous (Z-score cutoff: −1.0) variable. Associations were calculated using linear or logistic regression. Results Over one quarter of these girls had tried smoking by 13, while 59% had drunk alcoholic beverages and 20% had experienced both behaviors by that age. Lower mean BMD at 17 years of age was observed in girls who had ever smoked by 13, as well as in those who reported drinking at that age. There were no significant cross-sectional associations between experience and frequency of smoking or drinking and BMD at 13 years of age. However, we observed significant associations between BMD z-score<−1 in late adolescence and having ever smoked by 13, after adjustment for menarche age and sports practice, (OR = 1.92; 95% CI: 1.21, 3.05) and with ever smoking and drinking in the same period (OR = 2.33; 95% CI: 1.36, 4.00). Conclusion Our study adds prospective evidence to the role of early initiation of smoking and alcohol drinking as relevant markers of lower bone mineral density in late adolescence.

A scoping review on studies of cyberbullying prevalence among adolescents

This descriptive scoping aims to understand how the prevalence of cyberbullying has been estimated across studies. A systematic scoping review of cyberbullying empirical studies was conducted by using three bibliographic databases to search for papers published between January 2004 and August 2014. A protocol was defined to identify the relevant papers. Papers selected were included in a data sheet developed by the authors to record specific findings. In total, 159 studies were included in the scoping review. Most of the prevalence studies were conducted in the last 4 years, mainly in North America (n = 77) and in Europe (n = 65). High methodological heterogeneity was found among the studies, which may contribute to explain variability in prevalence estimates. Cyberbullying experiences were assessed through several different perspectives: focused only on victims, focused only on perpetrators, or focused on both victims and perpetrators (without differentiating between if they are victims or perpetrators). Most of the studies tend to assess cybervictimization experiences. However, even considering the same perspective, the same country, and the same recall period, a high variability in the estimates was observed. As a main conclusion, the way in which the prevalence of cyberbullying is estimated is influenced by methodological research options.