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Raninen J, Ramstedt M, Thor S, Törrönen J. Mind the gap! Gender differences in alcohol consumption among Swedish ninth graders 1989-2021. Drug Alcohol Rev 2024; 43:596-603. [PMID: 37434384 DOI: 10.1111/dar.13718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 06/21/2023] [Accepted: 06/21/2023] [Indexed: 07/13/2023]
Abstract
INTRODUCTION To examine gender differences in drinking habits among Swedish ninth graders over the period 1989-2021. METHODS Annual school surveys with nationally representative samples of ninth-grade students in Sweden covering the period 1989-2021, total sample of 180,538 students. Drinking habits were measured with self-reports of frequency and quantity of use and frequency of heavy episodic drinking. Differences between genders were compared annually and differences were tested using logistic and ordinary least square regression models with cluster robust standard errors. RESULTS Small gender differences in the prevalence of alcohol use during the first part of the study period were followed by an increasing gap over the past decade with girls being more likely to drink alcohol than boys. Boys consumed larger amounts of alcohol than girls during the first three decades of the studied period but no gender differences were found in later years. Binge drinking was more prevalent among boys during 1989 to 2000 but no systematic gender difference was found during the past 15 years. DISCUSSION AND CONCLUSIONS There used to be clear gender differences in drinking habits among ninth graders in Sweden with boys drinking more than girls. This gap has narrowed over the past three decades and among contemporary adolescents, no gender differences are found neither in binge drinking nor volume of drinking and the prevalence of drinking is even higher among girls.
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Affiliation(s)
- Jonas Raninen
- Swedish Council for Information on Alcohol and Other Drugs, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Centre for Alcohol Policy Research, La Trobe University, Melbourne, Australia
| | - Mats Ramstedt
- Swedish Council for Information on Alcohol and Other Drugs, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Public Health Sciences, Stockholm University, Stockholm, Sweden
| | - Siri Thor
- Swedish Council for Information on Alcohol and Other Drugs, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Jukka Törrönen
- Department of Public Health Sciences, Stockholm University, Stockholm, Sweden
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Patrão AL, Almeida MDC, Matos SMA, Chor D, Aquino EML. Gender and psychosocial factors associated with healthy lifestyle in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) cohort: a cross-sectional study. BMJ Open 2017; 7:e015705. [PMID: 28851775 PMCID: PMC5724152 DOI: 10.1136/bmjopen-2016-015705] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES It has been estimated that over 50% of the premature deaths occurring in Western countries can be attributed to causes rooted in lifestyle. In turn, leading a healthy lifestyle has also been associated with a wide range of psychosocial factors. Today, it is known that these differ among men and women. The present article aimed to identify, from a gender-based perspective, the psychosocial factors associated with healthy lifestyles in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) cohort, the largest study concerning adult health conducted in Latin America to date. DESIGN This cross-sectional study was conducted using ELSA-Brasil baseline data, collected between 2008 and 2010. SETTING Six Brazilian public higher education and research institutions. PARTICIPANTS The ELSA-Brasil cohort consists of approximately 15 000 employees (8218 women and 6887 men), both currently working and retired. MAIN OUTCOME MEASURES The lifestyle indicator was constructed by summing the scores attributed to four different behaviours. RESULTS The women of the ELSA-Brasil cohort have healthier lifestyles than men. In women, strong associations were found between a healthy lifestyle and age 60 years or older, Asian race and university level of education or higher. In men, being 60 years or older, of Asian or Caucasian race, having a high-school equivalent level of education or higher, being retired, having a housekeeper, having a good or very good self-perception of health and being satisfied with body image were the psychosocial factors associated with leading a healthy lifestyle. CONCLUSIONS The factors that influenced healthy lifestyles were found to differ among men and women, a fact that must be addressed when developing programmes designed to promote health.
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Affiliation(s)
- Ana Luísa Patrão
- Institute of Collective Health, Universidade Federal da Bahia, Salvador, Brazil
| | | | | | - Dora Chor
- FIOCRUZ, Oswaldo Cruz Foundation, National School of Public Health, Rio de Janeiro, Brazil
| | - Estela M L Aquino
- Institute of Collective Health, Universidade Federal da Bahia, Salvador, Brazil
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Short NA, Cronkite R, Moos R, Timko C. Men and women who attend Al-Anon: gender differences in reasons for attendance, health status and personal functioning, and drinker characteristics. Subst Use Misuse 2015; 50:53-61. [PMID: 25245105 DOI: 10.3109/10826084.2014.957772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Although Al-Anon Family Groups (Al-Anon) is the most common source of help for people concerned about someone else's drinking, only 16% of members are men. To identify gender differences, we compared demographics, reasons for attendance, health status, and personal functioning, and drinker characteristics of 174 men and women attending Al-Anon. Men and women were similar in most areas; however, some key differences emerged. Men reported better overall mental health than women, and described some differing concerns and drinker characteristics. With this information, healthcare providers may facilitate men's participation in Al-Anon by addressing their unique concerns and possible barriers to attendance.
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Affiliation(s)
- Nicole A Short
- 1Department of Psychology, Florida State University , Tallahassee, Florida , USA
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Barbosa-Leiker C, McPherson S, Cameron JM, Jathar R, Roll J, Dyck DG. Depression as a mediator in the longitudinal relationship between psychological stress and alcohol use. JOURNAL OF SUBSTANCE USE 2013. [DOI: 10.3109/14659891.2013.808711] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Vijayasiri G, Richman JA, Rospenda KM. The Great Recession, somatic symptomatology and alcohol use and abuse. Addict Behav 2012; 37:1019-24. [PMID: 22632797 PMCID: PMC3383405 DOI: 10.1016/j.addbeh.2012.04.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Revised: 03/29/2012] [Accepted: 04/20/2012] [Indexed: 11/18/2022]
Abstract
While most research has examined the long-term effects of alcohol consumption on health, the current study examines how health status impacts on drinking behavior. Using data from a national study conducted between 2010 and 2011 to assess the impact of the recession on drinking behavior, this study examines how economic hardships linked to the recent economic recession affect physical health, and how physical health may in turn affect alcohol use. Structural equation models were used to test the predicted associations. The data demonstrate that many of the economic stressors linked to the recession are associated with increased somatic symptoms. Somatic symptoms are also associated with increased drinking for men, but not for women. These findings suggest that men may use alcohol to self medicate somatic symptomatology. The current findings are consistent with gender role-based explanations that account for gender disparities in the utilization of medical care.
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Affiliation(s)
- Ganga Vijayasiri
- Institute for Health Research and Policy, University of Illinois at Chicago, 1747 West Roosevelt Street (MC 275), Chicago, Illinois 60612, United States
| | - Judith A. Richman
- Department of Psychiatry, University of Illinois at Chicago, 1601 West Taylor Street (MC 912), Chicago, Illinois 60612, United States
| | - Kathleen M. Rospenda
- Department of Psychiatry, University of Illinois at Chicago, 1601 West Taylor Street (MC 912), Chicago, Illinois 60612, United States
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Smith GW, Shevlin M, Murphy J, Houston JE. An Assessment of the Demographic and Clinical Correlates of the Dimensions of Alcohol Use Behaviour. Alcohol Alcohol 2010; 45:563-72. [DOI: 10.1093/alcalc/agq052] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Abstract
Little attention has been paid to the relationship between caregiver burden and alcohol use. It is important to examine the particular aspects of caregiver burden that most influence alcohol use. A mail survey was conducted using a representative sample of 998 employed Chicago residents who provided informal care for at least one person. Ordinary least squares regression models were computed to examine the relationship between caregiver burden and drinking outcomes. Findings suggest that caregivers who experience social and emotional burdens related to caregiving are at risk for problematic alcohol use and warrant attention from health care and mental health service professionals.
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Affiliation(s)
- Kathleen M. Rospenda
- The University of Illinois at Chicago, Department of Psychiatry (MC 912), Psychiatric Institute, 1601 W Taylor Street, Chicago, IL 60612
| | - Lisa M. Minich
- The University of Illinois at Chicago, Department of Psychiatry (MC 912), Psychiatric Institute, 1601 W Taylor Street, Chicago, IL 60612
| | - Lauren A. Milner
- The University of Illinois at Chicago, Department of Psychiatry (MC 912), Psychiatric Institute, 1601 W Taylor Street, Chicago, IL 60612
| | - Judith A Richman
- The University of Illinois at Chicago, Department of Psychiatry (MC 912), Psychiatric Institute, 1601 W Taylor Street, Chicago, IL 60612
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Polen MR, Green CA, Perrin NA, Anderson BM, Weisner CM. Drinking Patterns, Gender and Health I: Attitudes and Health Practices. ADDICTION RESEARCH & THEORY 2010; 18:122-142. [PMID: 23946720 PMCID: PMC3740444 DOI: 10.3109/16066350903398486] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Despite considerable research, relationships among gender, alcohol consumption, and health remain controversial, due to potential confounding by health-related attitudes and practices associated with drinking, measurement challenges, and marked gender differences in drinking. We examined gender/alcohol consumption differences in health-related attitudes and practices, and evaluated how these factors affected relationships among gender, alcohol consumption, and health status. METHODS A stratified random sample of adult health-plan members completed a mail survey, yielding 7884 respondents (2995 male/4889 female). Using MANCOVAs and adjusting for health-related attitudes, values, and practices, we examined gender differences in relationships between alcohol consumption and health. RESULTS More frequent heavy drinking was associated with worse health-related attitudes and values, worse feelings about visiting the doctor, and worse health-related practices. Relationships between health-related practices and alcohol use differed by gender, and daily or almost daily heavy drinking was associated with significantly lower physical and mental health for women compared to men. Drinking status (lifelong abstainers, former drinkers, and level of regular alcohol consumption) was related to health status and vitality, even after adjusting for health-related attitudes, values, and practices. Relationships did not differ by gender. Former drinkers reported lower physical and mental health status than either lifelong abstainers or current drinkers. CONCLUSIONS Drinking status is independently related to physical health, mental health, and vitality, even after controlling for the health-related attitudes, values, and practices expected to confound these relationships. Among current drinkers, women who engage in very frequent heavy drinking have worse physical and mental health than their male counterparts.
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Affiliation(s)
- Michael R. Polen
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, OR 97227-1110, USA
| | - Carla A. Green
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, OR 97227-1110, USA
| | - Nancy A. Perrin
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, OR 97227-1110, USA
| | - Bradley M. Anderson
- Addiction Medicine Department, Interstate Medical Office East, Kaiser Permanente Northwest, 3550 N. Interstate Avenue, Portland, OR 97227, USA
| | - Constance M. Weisner
- University of California, San Francisco, 401 Parnassus Ave, Box F-0984, San Francisco, CA 94143 and Kaiser Permanente Division of Research, 2000 Broadway, 3rd floor, Oakland, CA, USA
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Strandheim A, Holmen TL, Coombes L, Bentzen N. Alcohol use and physical health in adolescence: a general population survey of 8,983 young people in North-Trøndelag, Norway (the Young-HUNT study). Subst Use Misuse 2010; 45:253-65. [PMID: 20025452 DOI: 10.3109/10826080903080680] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
AIMS To investigate the relationship between adolescents' alcohol use and physical health. DESIGN A total population, cross-sectional survey of adolescents, aged 13-19 years, attending secondary or high school in Nord-Trøndelag County, Norway. 8,983 youths (91%) answered the Young-Hunt questionnaire in the 1995-1997 HUNT-survey. METHOD Self-reported data mainly analyzed by logistic regression models. Findings 80% of the respondents had tried alcohol, and 29% reported more than 10 intoxications. Ill health perception was associated with frequent alcohol intoxications. Tension symptoms had the closest relationship to frequency of intoxications in both genders. Girls that frequently used health services had frequent alcohol intoxications. FUNDING Central Norway Regional Health and the County Council of Nord-Trøndelag. CONCLUSIONS There is a close association of physical health complaints and alcohol intoxication frequency in Norwegian teenagers. The study's limitations were noted.
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Affiliation(s)
- Arve Strandheim
- Department of Public Health and General Practice, The Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
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Green CA, Polen MR, Leo MC, Janoff SL, Anderson BM, Weisner CM, Perrin NA. Drinking Patterns, Gender and Health III: Avoiding vs. Seeking Healthcare. ADDICTION RESEARCH & THEORY 2010; 18:160-180. [PMID: 23795149 PMCID: PMC3686530 DOI: 10.3109/16066350903398502] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Inability to predict most health services use and costs using demographics and health status suggests that other factors affect use, including attitudes and practices that influence health and willingness to seek care. Alcohol consumption has generated interest because heavy, chronic consumption causes adverse health consequences, acute consumption increases injury, and moderate drinking is linked to better health while hazardous drinking and alcohol-related problems are stigmatized and may affect willingness to seek care. METHODS A stratified random sample of health-plan members completed a mail survey, yielding 7884 respondents (2995 male/4889 female). We linked survey data to 24 months of health-plan records to examine relationships between alcohol use, gender, health-related attitudes, practices, health, and service use. In-depth interviews with a stratified 150-respondent subsample explored individuals' reasons for seeking or avoiding care. RESULTS Quantitative results suggest health-related practices and attitudes predict subsequent service use. Consistent predictors of care were having quit drinking, current at-risk consumption, cigarette smoking, higher BMI, disliking visiting doctors, and strong religious/spiritual beliefs. Qualitative analyses suggest embarrassment and shame are strong motivators for avoiding care. CONCLUSIONS Although models included numerous health, functional status, attitudinal and behavioral predictors, variance explained was similar to previous reports, suggesting more complex relationships than expected. Qualitative analyses suggest several potential predictive factors not typically measured in service-use studies: embarrassment and shame, fear, faith that the body will heal, expectations about likelihood of becoming seriously ill, disliking the care process, the need to understand health problems, and the effects of self-assessments of health-related functional limitations.
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Affiliation(s)
- Carla A. Green
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, OR 97227-1110, USA
| | - Michael R. Polen
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, OR 97227-1110, USA
| | - Michael C. Leo
- Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239-3098, USA
| | - Shannon L. Janoff
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, OR 97227-1110, USA
| | - Bradley M. Anderson
- Addiction Medicine Department, Interstate Medical Office East, Kaiser Permanente Northwest, 3550 N. Interstate Avenue, Portland, OR 97227, USA
| | - Constance M. Weisner
- University of California, San Francisco, 401 Parnassus Ave, Box F-0984, San Francisco, CA 94143 and Kaiser Permanente Division of Research, 2000 Broadway, 3rd floor, Oakland, CA 94612, USA
| | - Nancy A. Perrin
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, OR 97227-1110, USA
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Christie-Mizell CA, Peralta RL. The gender gap in alcohol consumption during late adolescence and young adulthood: gendered attitudes and adult roles. JOURNAL OF HEALTH AND SOCIAL BEHAVIOR 2009; 50:410-426. [PMID: 20099448 DOI: 10.1177/002214650905000403] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
We utilize data from the National Longitudinal Survey of Youth young adult sample (N = 1,488) to investigate whether gender role attitudes and the occupation of and transition to three adult roles (i.e., employment, marriage, and parenthood) contribute to the maintenance of the gender gap in the frequency and quantity of alcohol use. Our results indicate that traditional gender role attitudes are related to less frequent drinking for both men and women, but role attitudes are not associated with the number of drinks consumed. We also find that employment and transitions to employment increase the frequency and quantity of drinking, but less so for women compared to men. Furthermore, marriage, parenthood, and transitions to parenthood are related to less frequent drinking for women only. In terms of the number of drinks consumed, only employment and transitions to employment distinguish men and women. Employment is related to increased quantity of drinking for men, but decreased drinking for women, while transitions to employment have no effect on men, but do decrease the amount of drinking for women. Marriage decreases the number of drinks consumed equally for both men and women.
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JEERANUN K, DUANGPORN K. Dietary patterns for reducing cardiovascular disease risk among Thai alcohol drinkers. Nutr Diet 2008. [DOI: 10.1111/j.1747-0080.2008.00313.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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O'Neil C, Maranda M. The development and initial validation of the identification of alcohol dependence in women scale. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2007; 33:333-40. [PMID: 17497557 DOI: 10.1080/00952990601175128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
The purpose of this research was to develop the Identification of Alcohol Dependence in Women (IADW) Scale, which is a 51-question instrument, designed to discriminate between alcohol and non-alcohol dependent women. Questions focus on physical, psychological, family and home life, and use of alcohol. Initial testing of the IADW Scale provides preliminary evidence that it is reliable, has content validity, and is capable of correctly classifying group membership with accuracy. Eighty-six percent of the cases in the alcohol dependent group and 98% of the non-alcohol dependent group were correctly classified using direct and stepwise methods of discriminant analysis.
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Affiliation(s)
- Carol O'Neil
- University of Maryland School of Nursing, Baltimore, MD 21201, USA.
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Green CA, Perrin NA, Polen MR. Gender Differences in the Relationships Between Multiple Measures of Alcohol Consumption and Physical and Mental Health. Alcohol Clin Exp Res 2006; 28:754-64. [PMID: 15166650 DOI: 10.1097/01.alc.0000125342.28367.a1] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Epidemiological research examining health consequences of alcohol consumption generally relies on average volume consumed, yet examinations of drinking patterns show different dimensions of use associated with different health outcomes. Gender differences in metabolism and body composition may lead to gender-specific consequences of drinking frequency, quantity consumed per occasion, average amount consumed, and drinking pattern. Inconsistent results suggest gender differences are not well understood. METHODS Participants were 3069 male and 2600 female health maintenance organization survey respondents. Gender differences in relationships between alcohol consumption and health were examined using analyses of covariance adjusting for age alone and for age, ethnicity, marital status, body water index, and smoking. Past-year alcohol consumption (frequency, quantity per occasion, average drinks per month, and drinking pattern) and health measures (Short Form-36 general health, physical functioning, mental health subscales) were examined. RESULTS Gender x drinking frequency and drinking quantity interactions were significant in age-adjusted and fully adjusted models of general health and physical functioning. Gender interactions for drinking pattern were significant in the age-adjusted model and marginally significant in the fully adjusted model. No gender x drinking measure interactions were found for mental health. Fully adjusted models attenuated but did not eliminate gender differences for health and magnified relationships for functioning, the latter after adjusting for body water. For both genders, light to moderate consumption and more frequent drinking were associated with better health and functioning; relationships were stronger among women than men. CONCLUSIONS Gender x drinking measure interactions in health outcomes suggest analyses should include such interactions except, possibly, for mental health. Adjusting for potential confounders can attenuate (general health) or magnify (physical functioning) gender differences. Functional status appears a sensitive measure for evaluating gender differences in alcohol's health effects, adjusting for body water. Women's health may benefit proportionally more from moderate drinking than men's.
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Affiliation(s)
- Carla A Green
- Oregon Health & Science University and Kaiser Permanente Center for Health Research, Portland, Oregon.
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Newton JT, Bower EJ. The social determinants of oral health: new approaches to conceptualizing and researching complex causal networks. Community Dent Oral Epidemiol 2005; 33:25-34. [PMID: 15642044 DOI: 10.1111/j.1600-0528.2004.00190.x] [Citation(s) in RCA: 152] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Oral epidemiological research into the social determinants of oral health has been limited by the absence of a theoretical framework which reflects the complexity of real life social processes and the network of causal pathways between social structure and oral health and disease. In the absence of such a framework, social determinants are treated as isolated risk factors, attributable to the individual, having a direct impact on oral health. There is little sense of how such factors interrelate over time and place and the pathways between the factors and oral health. Features of social life which impact on individuals' oral health but are not reducible to the individual remain under-researched. A conceptual framework informing mainstream epidemiological research into the social determinants of health is applied to oral epidemiology. The framework suggests complex causal pathways between social structure and health via interlinking material, psychosocial and behavioural pathways. Methodological implications for oral epidemiological research informed by the framework, such as the use of multilevel modelling, path analysis and structural equation modelling, combining qualitative and quantitative research methods, and collaborative research, are discussed.
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Affiliation(s)
- J Timothy Newton
- Department of Oral Health Services Research and Dental Public Health, GKT Dental Institute, Caldecot Road, London SE5 9RW, UK.
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