Examples of sex/gender sensitivity in epidemiological research: results of an evaluation of original articles published in JECH 2006-2014

Gender sensitivity of the COVID-19 mental health research in Europe: a scoping review

BACKGROUND

The integration of sex and gender aspects into the research process has been recognized as crucial to the generation of valid data. During the coronavirus pandemic, a great deal of research addressed the mental state of hospital staff, as they constituted a population at risk for infection and distress. However, it is still unknown how the gender dimension was included. We aimed to appraise and measure qualitatively the extent of gender sensitivity.

METHODS

In this scoping review, we searched MEDLINE, EMBASE, CINAHL PsycINFO and Social Sciences Citation Index (SSCI) from database inception to November 11, 2021. All quantitative studies with primary data published in English, German, or Spanish and based in the European Union were selected. Included studies had to have assessed the mental health of hospital staff using validated psychometric scales for depression, anxiety, PTSD symptoms, distress, suicidal behavior, insomnia, substance abuse or aggressive behavior. Two independent reviewers applied eligibility criteria to each title/abstract reviewed, to the full text of the article, and performed the data extraction. A gender sensitivity assessment tool was developed and validated, consisting of 18 items followed by a final qualitative assessment. Two independent reviewers assessed the gender dimension of each included article.

RESULTS

Three thousand one hundred twelve studies were identified, of which 72 were included in the analysis. The most common design was cross-sectional (75.0%) and most of them were conducted in Italy (31.9%). Among the results, only one study assessed suicidal behaviors and none substance abuse disorders or aggressive behaviors. Sex and gender were used erroneously in 83.3% of the studies, and only one study described how the gender of the participants was determined. Most articles (71.8%) did not include sex/gender in the literature review and did not discuss sex/gender-related findings with a gender theoretical background (86.1%). In the analysis, 37.5% provided sex/gender disaggregated data, but only 3 studies performed advanced modeling statistics, such as interaction analysis. In the overall assessment, 3 papers were rated as good in terms of gender sensitivity, and the rest as fair (16.7%) and poor (79.2%). Three papers were identified in which gender stereotypes were present in explaining the results. None of the papers analyzed the results of non-binary individuals.

CONCLUSIONS

Studies on the mental health of hospital staff during the pandemic did not adequately integrate the gender dimension, despite the institutional commitment of the European Union and the gendered effect of the pandemic. In the development of future mental health interventions for this population, the use and generalizability of current evidence should be done cautiously.

Recommendations for the Application of Sex and Gender Medicine in Preclinical, Epidemiological and Clinical Research

Gender medicine studies how health status and diseases differ between men and women in terms of prevention, therapeutic approach, prognosis, and psychological and social impact. Sex and gender analyses have been demonstrated to improve science, contributing to achieving real appropriateness and equity in the cure for each person. Therefore, it is fundamental to consider, both in preclinical and clinical research, the different clinical and biological features associated with sex and/or gender, where sex differences are mainly influenced by biological determinants and gender ones by socio-cultural and economic matters. This article was developed to provide knowledge and methodological tools for the development of studies/research protocols in which sex and gender should be taken into account.

Reporting of equity in observational epidemiology: A methodological review

Background

Observational studies can inform how we understand and address persisting health inequities through the collection, reporting and analysis of health equity factors. However, the extent to which the analysis and reporting of equity-relevant aspects in observational research are generally unknown. Thus, we aimed to systematically evaluate how equity-relevant observational studies reported equity considerations in the study design and analyses.

Methods

We searched MEDLINE for health equity-relevant observational studies from January 2020 to March 2022, resulting in 16 828 articles. We randomly selected 320 studies, ensuring a balance in focus on populations experiencing inequities, country income settings, and coronavirus disease 2019 (COVID-19) topic. We extracted information on study design and analysis methods.

Results

The bulk of the studies were conducted in North America (n = 95, 30%), followed by Europe and Central Asia (n = 55, 17%). Half of the studies (n = 171, 53%) addressed general health and well-being, while 49 (15%) focused on mental health conditions. Two-thirds of the studies (n = 220, 69%) were cross-sectional. Eight (3%) engaged with populations experiencing inequities, while 22 (29%) adapted recruitment methods to reach these populations. Further, 67 studies (21%) examined interaction effects primarily related to race or ethnicity (48%). Two-thirds of the studies (72%) adjusted for characteristics associated with inequities, and 18 studies (6%) used flow diagrams to depict how populations experiencing inequities progressed throughout the studies.

Conclusions

Despite over 80% of the equity-focused observational studies providing a rationale for a focus on health equity, reporting of study design features relevant to health equity ranged from 0-95%, with over half of the items reported by less than one-quarter of studies. This methodological study is a baseline assessment to inform the development of an equity-focussed reporting guideline for observational studies as an extension of the well-known Strengthening Reporting of Observational Studies in Epidemiology (STROBE) guideline.

"What's Sex and Gender Got to Do With It?" A Scoping Review of Sex- and Gender-Based Analysis in Pharmacoepidemiologic Studies of Medication Adherence

OBJECTIVES

Medication taking is a complex multidimensional behavior that may be impeded by a range of biological and psychosocial factors, including sex and gender. We aimed to synthesize how sex and gender have been reported and analyzed in pharmacoepidemiologic studies of medication.

METHODS

We searched for English-language peer-reviewed articles of observational studies (eg, cross-sectional, cohort, and case-control) that examined medication adherence among adults and included sex or gender in their reporting.

RESULTS

We included 937 studies among 530 537 287 participants published between the year 1979 and 2021. Most studies were cross-sectional (47%), lasted ≤ 1 year (35%), examined self-reported adherence (53%), did not assess specific adherence problem(s) (40%), and included medications for cardiovascular conditions (24%) or systemic infections (24%). A quarter of studies (25%) used sex and gender interchangeably, more than one third of studies (36%) that reported gender data likely collected data on sex, and < 1% of studies described sex and gender as distinct variables. Studies of cisgender participants more often reported that females/women experienced greater adherence problems often than males/men (31% vs 20%), particularly discontinuation and cost-related nonadherence. Only 21 studies (2%) reported on transgender individuals, and these predominantly examined antiretroviral medications for HIV.

CONCLUSIONS

Our review revealed substantial conflation of sex and gender in studies of medication adherence and a paucity of research among transgender individuals. Moreover, our synthesis showed sex/gender disparities in medication taking with studies reporting greater medication adherence problems among cisgender women and transgender participants than cisgender men.

A scoping review establishes need for consensus guidance on reporting health equity in observational studies

OBJECTIVES

To evaluate the support from the available guidance on reporting of health equity in research for our candidate items and to identify additional items for the Strengthening Reporting of Observational studies in Epidemiology-Equity extension.

STUDY DESIGN AND SETTING

We conducted a scoping review by searching Embase, MEDLINE, CINAHL, Cochrane Methodology Register, LILACS, and Caribbean Center on Health Sciences Information up to January 2022. We also searched reference lists and gray literature for additional resources. We included guidance and assessments (hereafter termed "resources") related to conduct and/or reporting for any type of health research with or about people experiencing health inequity.

RESULTS

We included 34 resources, which supported one or more candidate items or contributed to new items about health equity reporting in observational research. Each candidate item was supported by a median of six (range: 1-15) resources. In addition, 12 resources suggested 13 new items, such as "report the background of investigators".

CONCLUSION

Existing resources for reporting health equity in observational studies aligned with our interim checklist of candidate items. We also identified additional items that will be considered in the development of a consensus-based and evidence-based guideline for reporting health equity in observational studies.

The quality of gender and sex integration in scientific articles resulting from health research funded by the Brazilian Ministry of Health 2004-2016

Aim

Integrating sex and gender into health research is critical to contributing to an ethical and more responsible science to address significant knowledge gaps, resulting in higher-quality evidence for all.

Subject and methods

Using the Essential Metrics for Assessing Sex and Gender Integration in Health Research Proposals Involving Human Participants, we evaluate the quality of the integration of sex and gender in the 350 scientific articles produced by 144 health studies funded by the Department of Science and Technology of the Brazilian Ministry of Health between 2004 and 2016.

Results

The results show that clinical research articles are the type of studies that most frequently report on sex differences, while population and public health research articles most frequently report on gender differences. Analysis of the quality of sex and gender integration reveals low levels of qualification in the items of the literature review and research objectives (section 1) and participant recruitment and retention (section 2). However, the data collection tools, data analysis, and knowledge translation (section 3) items were rated as excellent and good.

Conclusion

Funding agencies and public institutions should recognize the importance of the integration of sex and gender at all stages of the research process, for instance, through awareness and training for researchers and reviewers, clear requirements, and the possibility to use metrics in the evaluations process.

Women experiencing homelessness and mental illness in a Housing First multi-site trial: Looking beyond housing to social outcomes and well-being

OBJECTIVE

There is scant research on the effectiveness of permanent supportive housing for homeless women with mental illness. This study examines the effectiveness of Housing First with an unprecedentedly large sample of homeless women from five Canadian cities, and explore baseline risk factors that predict social, health and well-being outcomes over a 24 month-period.

METHODS

The At Home/Chez Soi multi-site randomized controlled Housing First trial recruited over 600 women between October 2009 and July 2011. This is a post-hoc subgroup exploratory analysis of self-identified women with at least one follow-up interview who were randomized to Housing First (HF) (n = 374) or treatment-as-usual (TAU) (n = 279) and had at least one follow-up interview. Linear mixed models and generalized estimating equations were used after multiple imputation was applied to address missing data.

RESULTS

At the end of follow-up, the mean percentage of days spent stably housed was higher for women in the intervention 74.8% (95%CI = 71.7%-77.8%) compared with women in the treatment-as-usual group, 37.9% (95%CI = 34.4%-41.3%), p<0.001. With few exceptions, social and mental health outcomes were similar for both groups at 6-, 12-, 18- and 24-months post-enrollment. Suicidality was a consistent predictor of increased mental health symptoms (beta = 2.85, 95% CI 1.59-4.11, p<0.001), decreased quality of life (beta = -3.99, 95% CI -6.49 to -1.49, p<0.001), decreased community functioning (beta = -1.16, 95% CI -2.10 to -0.22, p = 0.015) and more emergency department visits (rate ratio = 1.44, 95% CI 1.10-1.87, p<0.001) over the study period. Lower education was a predictor of lower community functioning (beta = -1.32, 95% CI -2.27 to -0.37, p = 0.006) and higher substance use problems (rate ratio = 1.27, 95% CI 1.06-1.52, p = 0.009) during the study.

CONCLUSIONS

Housing First interventions ensured that women experiencing homelessness are quickly and consistently stably housed. However, they did not differentially impact health and social measures compared to treatment as usual. Ensuring positive health and social outcomes may require greater supports at enrolment for subgroups such as those with low educational attainment, and additional attention to severity of baseline mental health challenges, such as suicidality.

TRIAL REGISTRATION

International Standard Randomized Control Trial Number Register Identifier: ISRCTN42520374.

Women and thyroid cancer incidence: overdiagnosis versus biological risk

PURPOSE OF THE REVIEW

Our aim is to discuss the concepts of sex and gender in the context of thyroid cancer epidemiology.

RECENT FINDINGS

It has been long-established in global epidemiologic data that thyroid cancer incidence rates are higher in women than men. However, what has been less well understood is whether this reflects sex disparities in cancer susceptibility, gender disparities in detection, or a combination. A recent meta-analysis of autopsy data from individuals who were not known to have thyroid cancer in their lifetime demonstrated no difference in the prevalence of thyroid cancer in women and men, suggesting that gender differences may be the reason for gender-based differences in thyroid cancer detection. This finding, and sex differences in auto immunity and other factors that may affect cancer susceptibility are explored.

SUMMARY

Additional research to explore gender- and sex-specific data on thyroid cancer would inform our understanding of the differences and similarities between men and women in susceptibility and detection of thyroid cancer and help to optimize disease management for all genders and both sexes.

Reporting of health equity considerations in equity-relevant observational studies: Protocol for a systematic assessment

Background: The mitigation of unfair and avoidable differences in health is an increasing global priority. Observational studies including cohort, cross-sectional and case-control studies tend to report social determinants of health which could inform evidence syntheses on health equity and social justice. However, the extent of reporting and analysis of equity in equity-relevant observational studies is unknown. Methods: We define studies which report outcomes for populations at risk of experiencing inequities as “equity-relevant”. Using a random sampling technique we will identify 320 equity-relevant observational studies published between 1 January 2020 to 27 April 2022 by searching the MEDLINE database. We will stratify sampling by 1) studies in high-income countries (HIC) and low- and middle-income countries (LMIC) according to the World Bank classification, 2) studies focused on COVID and those which are not, 3) studies focused on populations at risk of experiencing inequities and those on general populations that stratify their analyses. We will use the PROGRESS framework which stands for place of residence, race or ethnicity, occupation, gender or sex, religion, education, socioeconomic status, social capital, to identify dimensions where inequities may exist. Using a previously developed data extraction form we will pilot-test on eligible studies and revise as applicable. Conclusions: The proposed methodological assessment of reporting will allow us to systematically understand the current reporting and analysis practices for health equity in observational studies. The findings of this study will help inform the development of the equity extension for the STROBE (Strengthening the Reporting of Observational studies in Epidemiology) reporting guidelines.

Guidance relevant to the reporting of health equity in observational research: a scoping review protocol

INTRODUCTION

Health inequities are defined as unfair and avoidable differences in health between groups within a population. Most health research is conducted through observational studies, which are able to offer real-world insights about etiology, healthcare policy/programme effectiveness and the impacts of socioeconomic factors. However, most published reports of observational studies do not address how their findings relate to health equity. Our team seeks to develop equity-relevant reporting guidance as an extension of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. This scoping review will inform the development of candidate items for the STROBE-Equity extension. We will operationalise equity-seeking populations using the PROGRESS-Plus framework of sociodemographic factors. As part of a parallel stream of the STROBE-Equity project, the relevance of candidate guideline items to Indigenous research will be led by Indigenous coinvestigators on the team.

METHODS AND ANALYSIS

We will follow the Joanna Briggs Institute method for conducting scoping reviews. We will evaluate the extent to which the identified guidance supports or refutes our preliminary candidate items for reporting equity in observational studies. These candidate items were developed based on items from equity-reporting guidelines for randomised trials and systematic reviews, developed by members of this team. We will consult with our knowledge users, patients/public partners and Indigenous research steering committee to invite suggestions for relevant guidance documents and interpretation of findings. If the identified guidance suggests the need for additional candidate items, they will be developed through inductive thematic analysis.

ETHICS AND DISSEMINATION

We will follow a principled approach that promotes ethical codevelopment with our community partners, based on principles of cultural safety, authentic partnerships, addressing colonial structures in knowledge production and the shared ownership, interpretation, and dissemination of research. All products of this research will be published as open access.

Measurement of gender as a social determinant of health in epidemiology-A scoping review

BACKGROUND

The relevance of gender as a social determinant of health and its role in the production of health inequalities is now broadly acknowledged. However, the plethora of existing approaches to capture gender, which often stem from disciplines outside of epidemiology, makes it difficult to assess their practicality and relevance for a given research purpose. We conducted a scoping review to 1) map the evidence of how gender can be operationalised in quantitative epidemiology and 2) design a tool to critically evaluate the measures identified.

METHODS

We identified peer-reviewed articles in electronic databases (PubMed, Embase and PsycINFO). Eligible sources described the quantitative operationalisation of the social dimension of gender. With the help of a newly developed checklist, we assessed their relevance from an analytical perspective (e.g. intersectionality) and their potential for implementation in epidemiology.

RESULTS

Gender measures principally assessed gender roles and norms, gender-based discrimination and violence, and structural gender (in)equality. Of the 344 measures included in this review, the majority lacked theoretical foundation, and tended to reinforce the binary understanding of gender through stereotypes of femininity and masculinity. Only few measures allowed for an intersectional approach and a multilevel understanding of gender mechanisms. From a practical point of view, gender measures demonstrated potential for use in varied populations and contexts.

CONCLUSIONS

A range of gender measures are readily available for epidemiological research, addressing different levels and dimensions of gender as a social construct. With our theory-informed, practice-driven scoping review, we highlighted strengths and limitations of such measures and provided analytical tools for researchers interested in conducting intersectional, gender-sensitive analyses.

Do Intervention Studies to Promote Physical Activity and Reduce Sedentary Behavior in Children and Adolescents Take Sex/Gender Into Account? A Systematic Review

BACKGROUND

Physical inactivity is often reported in youth and differs among boys and girls. The aim of this study is to assess sex/gender considerations in intervention studies promoting physical activity and reducing sedentary behavior in youth using a sex/gender checklist.

METHODS

A systematic search was conducted in August 2018 to identify all relevant controlled trials. Studies screened must have reported a quantified measure of physical activity and/or sedentary behavior, and identified participants by sex/gender at baseline. For evaluation of the sex/gender consideration, the authors used a sex/gender checklist developed by expert consensus.

RESULTS

The authors reviewed sex/gender considerations in all aspects of intervention development, implementation, and evaluation in 217 studies. Sex/gender aspects were only rudimentarily taken into account, most frequently during statistical analyses, such as stratification or interaction analysis.

CONCLUSIONS

Sex/gender effects are not sufficiently reported. To develop guidelines that are more inclusive of all girls and boys, future interventions need to document sex/gender differences and similarities, and explore whether sex/gender influences different phases of intervention programs. The newly developed sex/gender checklist can hereby be used as a tool and guidance to adequately consider sex/gender in the several steps of intervention planning, implementation, and evaluation.

Sex differences in incidence of respiratory symptoms and management by general practitioners

BACKGROUND

Differences between women and men play an important role in lung physiology and epidemiology of respiratory diseases, but also in the health care processes.

OBJECTIVE

To analyse sex differences in patients encountering their general practitioner (GP) with respiratory symptoms with regard to incidence, GP's management and final diagnoses.

METHODS

Retrospective cohort study, using data of the Dutch Practice Based Research Network. All patients who encountered their GP from 01-07-2013 until 30-06-2018 with a new episode of care starting with a reason for encounter in the respiratory category (R) of the ICPC-2 classification were included (n = 16 773). Multi-level logistic regression was used to analyse influence of patients' sex on management of GPs with adjustment for possible confounders.

RESULTS

We found a significant higher incidence of respiratory symptoms in women than in men: 230/1000 patient years [95% confidence interval (CI) 227-232] and 186/1000 patient years (95% CI 183-189), respectively. When presenting with cough, GPs are more likely to perform physical examination [odds ratio (OR) 1.22; 95% CI 1.11-1.35] and diagnostic radiology (OR 1.25; 95% CI 1.08-1.44), but less likely to prescribe medication (OR 0.88; 95% CI 0.82-0.95) in men. When visiting the GP with dyspnoea, men more often undergo diagnostic imaging (OR 1.32; 95% CI 1.05-1.66) and are more often referred to a specialist (OR 1.35; 95% CI 1.13-1.62).

CONCLUSIONS

Women encounter their GP more frequently with respiratory symptoms than men and GPs perform more diagnostic investigations in men. We suggest more research in general practice focussing on sex differences and possible confounders.

Representation of gender in migrant health studies - a systematic review of the social epidemiological literature

Background

Gender as a social construct contributes to determine who migrates and which migration-related risks and opportunities emerge in all phases of the migration trajectory. Simultaneously, migration influences the individual as well as societal definition and perception of gender roles. An explicit gender perspective in migration-related epidemiological research can contribute to adequately analyse and interpret the health of migrants. This systematic review gives a comprehensive overview on how gender has been conceptualised, operationalised and measured in social epidemiologic studies aiming to assess the influence of gender on health among migrants.

Methods

We searched PubMed, Embase, CINAHL, the Cochrane Library, EconLit and PsycINFO and conducted backward reference searching. Reviewers independently selected studies, extracted data and conducted the quality assessment. Eligible studies actively aimed to understand, identify or explain the influence of gender on migrants’ health, whereby the role of gender can encompass a variety of mechanisms, processes or states of differentiation, discrimination and/or inequality.

Results

Almost all of the 43 studies were cross-sectional and focussed on health outcomes in the post-migration phase. The most common theme of research was the health of male migrants in the US, and in particular of men who have sex with men (MSM). All studies treated gender as a binary variable (men vs. women), without discussing additional types of gender identities. A minority of studies differentiated clearly between sex and gender. Gender was mostly operationalised through attitudes toward gender roles and gender-based discrimination, experienced at the individual level. Community and societal level gender measures capturing structural gender determinants were underrepresented.

Conclusions

The intersections of migration and gender suggested synergistic effects on health that only become visible when considering those two social determinants together. Future research needs to embrace a multilevel and non-binary understanding of gender and reflect on the influence of gender in the different phases of the migration journey.

Systematic review registration

PROSPERO CRD42019124698.

The effect of early-life and adult socioeconomic position on development of lifestyle-related diseases

BACKGROUND

Early-life socioeconomic position (SEP) is associated with lifestyle-related diseases in adulthood. However, evidence is lacking on the extent to which adult SEP mediates this association.

METHODS

Time to either chronic obstructive pulmonary disease (COPD), cardiovascular disease or diabetes were assessed in the Danish population born between 1961 and 1971 (n = 793 674) from age 30 until 2015. Early-life position was assessed in 1981 (by parental) and again at age 30 (own) by four markers; income, occupation, education-divided into high, middle, low-and a combined score for all markers. Using a counterfactual approach, we estimated the total effect of early-life position on disease onset and the degree to which adult position mediated this effect.

RESULTS

Results of the time-to-event analysis showed a gradient of all early-life markers on the risk of developing all lifestyle-related diseases. Notably, comparing those in the lowest to the highest educational position, the hazard of COPD was 130% higher for women [hazard ratio = 2.30(95% confidence interval = 2.20-2.41)] and 114% higher for men [2.14 (2.05-2.25)]. About 67%(63-70%) of the effect of educational position was mediated through adult position for COPD, 55% for cardiovascular disease and 50% for diabetes. For the combined score 44, 29 and 33%, respectively, was mediated.

CONCLUSION

About one-tenth to two-thirds of the effect of early-life position is mediated by the position attained in adulthood. The degree mediated depend on the outcome investigated, gender and the social position marker used indicating that alternative pathways may play a key role in developing effective policies targeting early-life behaviours.

Bridging research integrity and global health epidemiology (BRIDGE) guidelines: explanation and elaboration

Over the past decade, two movements have profoundly changed the environment in which global health epidemiologists work: research integrity and research fairness. Both ought to be equally nurtured by global health epidemiologists who aim to produce high quality impactful research. Yet bridging between these two aspirations can lead to practical and ethical dilemmas. In the light of these reflections we have proposed the BRIDGE guidelines for the conduct of fair global health epidemiology, targeted at stakeholders involved in the commissioning, conduct, appraisal and publication of global health research. The guidelines follow the conduct of a study chronologically from the early stages of study preparation until the dissemination and communication of findings. They can be used as a checklist by research teams, funders and other stakeholders to ensure that a study is conducted in line with both research integrity and research fairness principles. In this paper we offer a detailed explanation for each item of the BRIDGE guidelines. We have focused on practical implementation issues, making this document most of interest to those who are actually conducting the epidemiological work.

Health-Risk Behaviors and Protective Factors Among Adolescents in Rural British Columbia

PURPOSE

This study explores the relationship between rural residency, selected protective factors (family and school connectedness along with prosocial peer attitudes), and health-compromising behaviors (alcohol and tobacco use and nonuse of seatbelt) among adolescents.

METHODS

A subsample of adolescents residing in remote areas was extracted from a province-wide, school-based survey in British Columbia (BC), Canada (weighted N = 2,999). We employed χ² statistic to test rural-urban differences separately by gender. Logistic regression analysis was used to examine the relationship between protective factors and behaviors compromising health.

FINDINGS

In boys, rural residency was associated with multiple problem behaviors (binge drinking, smokeless tobacco use, and nonuse of seatbelt), whereas for girls it was linked to riding without a seatbelt. The final logistic regression models confirmed that rural environment was a significant risk factor for not wearing a seatbelt among both boys and girls, and smokeless tobacco among boys (adjusted odds ratio between 1.44 and 3.05). Rurality, on the other hand, did not predict binge drinking. Logistic regression analyses also revealed that both school connectedness and prosocial peer attitude protected boys against binge drinking and smokeless tobacco, but the results were not as robust for girls.

CONCLUSIONS

These findings could provide information for location-based intervention efforts promoting adolescent health, highlighting the protective role of the school atmosphere and prosocial peer relationships, especially among boys.

Sex difference: an important issue to consider in epidemiological and clinical studies dealing with serum paraoxonase-1

The aim of this study was to evaluate the influence of sex on serum paraoxonase-1 (PON1) activities and on its relationship with cardiovascular disease risk factors such as overall and central obesity. Arylesterase and lactonase activities of PON1 were assessed in 374 women and 92 men. Both arylesterase and lactonase activities were significantly higher in women compared to men (p<0.001), irrespectively of confounders such as high density lipoprotein-cholesterol, age, smoking and body mass index or waist circumference. Sex also strongly influenced the interplay between PON1 and both fat measures, with only the arylesterase showing a significant and independent inverse correlation with the former parameter (r = -0.248, p<0.001) and the risk of overall obesity (odds ratio: 0.559, 95% confidence interval: 0.340-0.919) in women, but not in men; conversely, neither of the two activities remained associated with waist circumference in men or women after full adjustment. Noteworthy, the association between arylesterase and BMI in the female subsample was significant among women younger than forty-five years (r = -0.453, p<0.001, R ² = 0.207). In conclusion, our study suggests that sex might chiefly influence PON1 activity and its contribution to cardiovascular disease risk. Further studies are needed to confirm and clarify our preliminary findings.

Interventions on children's and adolescents' physical activity and sedentary behaviour: protocol for a systematic review from a sex/gender perspective

BACKGROUND

Low levels of physical activity (PA) and high levels of sedentary behaviour (SB) have been observed in young people. Both behaviours are detrimental for health with patterns tending to continue into adulthood. There is sustained value in establishing health habits in early years. Even though levels of SB and participation in PA differ among boys and girls, and the effectiveness of interventions to promote PA and/or prevent sedentary behaviours varies by sex/gender to date, sex/gender in systematic reviews is not yet widely considered. Additionally, while tools have been proposed, there is no consensus on the criteria to assess sex/gender in systematic reviews in the context of health promotion. The main objectives of this systematic review are to evaluate the effects of interventions on girls' and boys' PA and SB and to appraise the extent to which the studies have taken sex/gender into account.

METHODS

Eleven electronic databases will be searched to identify all relevant (randomized) controlled trials. Two independent reviewers will screen studies, extract data and appraise the quality of studies. The main outcome of the studies will be a quantified measure of PA and/or SB. Risk of bias of individual studies will be assessed using the Cochrane Risk of Bias Tool for RCTs. Meta-analyses will be conducted when possible among studies with sufficient homogeneity. To evaluate sex/gender considerations in primary studies, we will use a sex/gender checklist that builds on existing tools and was developed during a 2-day, iterative process among a multidisciplinary panel of 16 experts. The GRADE framework will be used to evaluate evidence across studies for each main efficacy outcome.

DISCUSSION

To our knowledge, our systematic review will be the first to analyse how sex/gender is considered in interventions promoting PA and/or reducing SB in children and adolescents in detail. The review will provide information on how sex/gender aspects have been considered in recent research and the extent to which sex/gender might impact study outcomes. Our findings will be of interest to stakeholders, health promoters, researchers and policy makers who wish to support more equal outcomes from interventions promoting PA and/or reducing SB.

TRIAL REGISTRATION

PROSPERO CRD42018109528 .

Sex difference: an important issue to consider in epidemiological and clinical studies dealing with serum paraoxonase-1

The aim of this study was to evaluate the influence of sex on serum paraoxonase-1 (PON1) activities and on its relationship with cardiovascular disease risk factors such as overall and central obesity. Arylesterase and lactonase activities of PON1 were assessed in 374 women and 92 men. Both arylesterase and lactonase activities were significantly higher in women compared to men (p<0.001), irrespectively of confounders such as high density lipoprotein-cholesterol, age, smoking and body mass index or waist circumference. Sex also strongly influenced the interplay between PON1 and both fat measures, with only the arylesterase showing a significant and independent inverse correlation with the former parameter (r = −0.248, p<0.001) and the risk of overall obesity (odds ratio: 0.559, 95% confidence interval: 0.340–0.919) in women, but not in men; conversely, neither of the two activities remained associated with waist circumference in men or women after full adjustment. Noteworthy, the association between arylesterase and BMI in the female subsample was significant among women younger than forty-five years (r = −0.453, p<0.001, R² = 0.207). In conclusion, our study suggests that sex might chiefly influence PON1 activity and its contribution to cardiovascular disease risk. Further studies are needed to confirm and clarify our preliminary findings.