The impact of the COVID-19 pandemic on presentations to health services following self-harm: systematic review

BACKGROUND

Evidence on the impact of the pandemic on healthcare presentations for self-harm has accumulated rapidly. However, existing reviews do not include studies published beyond 2020.

AIMS

To systematically review evidence on presentations to health services following self-harm during the COVID-19 pandemic.

METHOD

A comprehensive search of databases (WHO COVID-19 database; Medline; medRxiv; Scopus; PsyRxiv; SocArXiv; bioRxiv; COVID-19 Open Research Dataset, PubMed) was conducted. Studies published from 1 January 2020 to 7 September 2021 were included. Study quality was assessed with a critical appraisal tool.

RESULTS

Fifty-one studies were included: 57% (29/51) were rated as 'low' quality, 31% (16/51) as 'moderate' and 12% (6/51) as 'high-moderate'. Most evidence (84%, 43/51) was from high-income countries. A total of 47% (24/51) of studies reported reductions in presentation frequency, including all six rated as high-moderate quality, which reported reductions of 17-56%. Settings treating higher lethality self-harm were overrepresented among studies reporting increased demand. Two of the three higher-quality studies including study observation months from 2021 reported reductions in self-harm presentations. Evidence from 2021 suggests increased numbers of presentations among adolescents, particularly girls.

CONCLUSIONS

Sustained reductions in numbers of self-harm presentations were seen into the first half of 2021, although this evidence is based on a relatively small number of higher-quality studies. Evidence from low- and middle-income countries is lacking. Increased numbers of presentations among adolescents, particularly girls, into 2021 is concerning. Findings may reflect changes in thresholds for help-seeking, use of alternative sources of support and variable effects of the pandemic across groups.

Gatekeeper training for vendors to reduce pesticide self-poisoning in rural South Asia: a study protocol for a stepped-wedge cluster randomised controlled trial

INTRODUCTION

Pesticide self-poisoning kills an estimated 110 000-168 000 people worldwide annually. Data from South Asia indicate that in 15%-20% of attempted suicides and 30%-50% of completed suicides involving pesticides these are purchased shortly beforehand for this purpose. Individuals who are intoxicated with alcohol and/or non-farmers represent 72% of such customers. We have developed a 'gatekeeper' training programme for vendors to enable them to identify individuals at high risk of self-poisoning (gatekeeper function) and prevent such individuals from accessing pesticides (means restriction). The primary aim of the study is to evaluate the effectiveness of the gatekeeper intervention in preventing pesticide self-poisoning in Sri Lanka. Other aims are to identify method substitution and to assess the cost and cost-effectiveness of the intervention.

METHODS AND ANALYSIS

A stepped-wedge cluster randomised trial of a gatekeeper intervention is being conducted in rural Sri Lanka with a population of approximately 2.7 million. The gatekeeper intervention is being introduced into 70 administrative divisions in random order at each of 30 steps over a 40-month period. The primary outcome is the number of pesticide self-poisoning cases identified from surveillance of hospitals and police stations. Secondary outcomes include: number of self-poisoning cases using pesticides purchased within the previous 24 hours, total number of all forms of self-harm and suicides. Intervention effectiveness will be estimated by comparing outcome measures between the pretraining and post-training periods across the divisions in the study area. The original study protocol has been adapted as necessary in light of the impact of the COVID-19.

ETHICS AND DISSEMINATION

The Ethical Review Committee of the Faculty of Medicine and Allied Sciences, Rajarata University, Sri Lanka (ERC/2018/30), and the ACCORD Medical Research Ethics Committee, Edinburgh University (18-HV-053) approved the study. Results will be disseminated in scientific peer-reviewed journals.

TRIAL REGISTRATION NUMBER

SLCTR/2019/006, U1111-1220-8046.

Mental health before and during the COVID-19 pandemic in two longitudinal UK population cohorts

BACKGROUND

The COVID-19 pandemic and mitigation measures are likely to have a marked effect on mental health. It is important to use longitudinal data to improve inferences.

AIMS

To quantify the prevalence of depression, anxiety and mental well-being before and during the COVID-19 pandemic. Also, to identify groups at risk of depression and/or anxiety during the pandemic.

METHOD

Data were from the Avon Longitudinal Study of Parents and Children (ALSPAC) index generation (n = 2850, mean age 28 years) and parent generation (n = 3720, mean age 59 years), and Generation Scotland (n = 4233, mean age 59 years). Depression was measured with the Short Mood and Feelings Questionnaire in ALSPAC and the Patient Health Questionnaire-9 in Generation Scotland. Anxiety and mental well-being were measured with the Generalised Anxiety Disorder Assessment-7 and the Short Warwick Edinburgh Mental Wellbeing Scale.

RESULTS

Depression during the pandemic was similar to pre-pandemic levels in the ALSPAC index generation, but those experiencing anxiety had almost doubled, at 24% (95% CI 23-26%) compared with a pre-pandemic level of 13% (95% CI 12-14%). In both studies, anxiety and depression during the pandemic was greater in younger members, women, those with pre-existing mental/physical health conditions and individuals in socioeconomic adversity, even when controlling for pre-pandemic anxiety and depression.

CONCLUSIONS

These results provide evidence for increased anxiety in young people that is coincident with the pandemic. Specific groups are at elevated risk of depression and anxiety during the COVID-19 pandemic. This is important for planning current mental health provisions and for long-term impact beyond this pandemic.

Bans of WHO Class I Pesticides in Bangladesh-suicide prevention without hampering agricultural output

Background

Pesticide self-poisoning is a major problem in Bangladesh. Over the past 20-years, the Bangladesh government has introduced pesticide legislation and banned highly hazardous pesticides (HHPs) from agricultural use. We aimed to assess the impacts of pesticide bans on suicide and on agricultural production.

Methods

We obtained data on unnatural deaths from the Statistics Division of Bangladesh Police, and used negative binomial regression to quantify changes in pesticide suicides and unnatural deaths following removal of WHO Class I toxicity HHPs from agriculture in 2000. We assessed contemporaneous trends in other risk factors, pesticide usage and agricultural production in Bangladesh from 1996 to 2014.

Results

Mortality in hospital from pesticide poisoning fell after the 2000 ban: 15.1% vs 9.5%, relative reduction 37.1% [95% confidence interval (CI) 35.4 to 38.8%]. The pesticide poisoning suicide rate fell from 6.3/100 000 in 1996 to 2.2/100 000 in 2014, a 65.1% (52.0 to 76.7%) decline. There was a modest simultaneous increase in hanging suicides [20.0% (8.4 to 36.9%) increase] but the overall incidence of unnatural deaths fell from 14.0/100 000 to 10.5/100 000 [25.0% (18.1 to 33.0%) decline]. There were 35 071 (95% CI 25 959 to 45 666) fewer pesticide suicides in 2001 to 2014 compared with the number predicted based on trends between 1996 to 2000. This reduction in rate of pesticide suicides occurred despite increased pesticide use and no change in admissions for pesticide poisoning, with no apparent influence on agricultural output.

Conclusions

Strengthening pesticide regulation and banning WHO Class I toxicity HHPs in Bangladesh were associated with major reductions in deaths and hospital mortality, without any apparent effect on agricultural output. Our data indicate that removing HHPs from agriculture can rapidly reduce suicides without imposing substantial agricultural costs.

Changes in health in England, with analysis by English regions and areas of deprivation, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

BACKGROUND

In the Global Burden of Disease Study 2013 (GBD 2013), knowledge about health and its determinants has been integrated into a comparable framework to inform health policy. Outputs of this analysis are relevant to current policy questions in England and elsewhere, particularly on health inequalities. We use GBD 2013 data on mortality and causes of death, and disease and injury incidence and prevalence to analyse the burden of disease and injury in England as a whole, in English regions, and within each English region by deprivation quintile. We also assess disease and injury burden in England attributable to potentially preventable risk factors. England and the English regions are compared with the remaining constituent countries of the UK and with comparable countries in the European Union (EU) and beyond.

METHODS

We extracted data from the GBD 2013 to compare mortality, causes of death, years of life lost (YLLs), years lived with a disability (YLDs), and disability-adjusted life-years (DALYs) in England, the UK, and 18 other countries (the first 15 EU members [apart from the UK] and Australia, Canada, Norway, and the USA [EU15+]). We extended elements of the analysis to English regions, and subregional areas defined by deprivation quintile (deprivation areas). We used data split by the nine English regions (corresponding to the European boundaries of the Nomenclature for Territorial Statistics level 1 [NUTS 1] regions), and by quintile groups within each English region according to deprivation, thereby making 45 regional deprivation areas. Deprivation quintiles were defined by area of residence ranked at national level by Index of Multiple Deprivation score, 2010. Burden due to various risk factors is described for England using new GBD methodology to estimate independent and overlapping attributable risk for five tiers of behavioural, metabolic, and environmental risk factors. We present results for 306 causes and 2337 sequelae, and 79 risks or risk clusters.

FINDINGS

Between 1990 and 2013, life expectancy from birth in England increased by 5·4 years (95% uncertainty interval 5·0-5·8) from 75·9 years (75·9-76·0) to 81·3 years (80·9-81·7); gains were greater for men than for women. Rates of age-standardised YLLs reduced by 41·1% (38·3-43·6), whereas DALYs were reduced by 23·8% (20·9-27·1), and YLDs by 1·4% (0·1-2·8). For these measures, England ranked better than the UK and the EU15+ means. Between 1990 and 2013, the range in life expectancy among 45 regional deprivation areas remained 8·2 years for men and decreased from 7·2 years in 1990 to 6·9 years in 2013 for women. In 2013, the leading cause of YLLs was ischaemic heart disease, and the leading cause of DALYs was low back and neck pain. Known risk factors accounted for 39·6% (37·7-41·7) of DALYs; leading behavioural risk factors were suboptimal diet (10·8% [9·1-12·7]) and tobacco (10·7% [9·4-12·0]).

INTERPRETATION

Health in England is improving although substantial opportunities exist for further reductions in the burden of preventable disease. The gap in mortality rates between men and women has reduced, but marked health inequalities between the least deprived and most deprived areas remain. Declines in mortality have not been matched by similar declines in morbidity, resulting in people living longer with diseases. Health policies must therefore address the causes of ill health as well as those of premature mortality. Systematic action locally and nationally is needed to reduce risk exposures, support healthy behaviours, alleviate the severity of chronic disabling disorders, and mitigate the effects of socioeconomic deprivation.

FUNDING

Bill & Melinda Gates Foundation and Public Health England.

Self-poisoning in rural Sri Lanka: small-area variations in incidence

Background

Self-poisoning is one of the most common methods of suicide worldwide. The intentional ingestion of pesticides is the main contributor to such deaths and in many parts of rural Asia pesticide self-poisoning is a major public health problem. To inform the development of preventive measures in these settings, this study investigates small-area variation in self-poisoning incidence and its association with area-based socioeconomic and agricultural factors.

Methods

Ecological analysis of intentional self-poisoning in a rural area (population 267,613) of Sri Lanka in 2002. The geographic distribution of cases was mapped to place of residence. Using administrative division (GN), median population size 1416, as unit of analysis, associations with socioeconomic and agricultural indicators were explored using negative binomial regression models.

Results

The overall incidence of intentional self-poisoning in the study area was 315 per 100,000 (range: 0 – 2168 per 100,000 across GNs). Socioeconomic disadvantage, as indexed by poor housing quality (p = 0.003) and low levels of education (p < 0.001) but not unemployment (p = 0.147), was associated with a low self-poisoning incidence. Areas where a high proportion of the population worked in agriculture had low overall levels of self-poisoning (p = 0.002), but a greater proportion of episodes in these areas involved pesticides (p = 0.01). An association with extent of cultivated land was found only for non-pesticide poisoning (p = 0.01).

Conclusion

Considerable small-area variation in incidence rates of intentional self-poisoning was found. The noteworthy concentration of cases in certain areas and the inverse association with socioeconomic deprivation merit attention and should be investigated using individual-level exposure data.

Patient outcomes and length of hospital stay after radical prostatectomy for prostate cancer: analysis of hospital episodes statistics for England

OBJECTIVE

To investigate the morbidity and mortality after radical prostatectomy (RP) in relation to the numbers of RPs carried out at individual hospitals, as recent studies of complex surgery report worse outcomes in low-volume hospitals, and there has been a large increase in RPs for localized prostate cancer.

METHODS

We analysed hospital episode statistics data for all 18 027 RPs in English National Health Service hospitals between 1997 and 2004.

RESULTS

In multivariate analysis, there was a U-shaped association of hospital volume with mortality (P for nonlinear trend, 0.004), but this finding was based on only 59 (0.3%) deaths. The mean length of stay was 6 days and decreased by 2.96% (95% confidence interval, CI, 1.98-3.92; P < 0.001) per quintile increase in hospital volume. In all, 16.1% of men had 30-day in-hospital complications; 20.3% were readmitted with complications within a year. The odds of 30-day in-hospital wound/bleeding complications decreased by 6% (95% CI 1-11; P = 0.02), and miscellaneous medical complications decreased by 10% (0-19; P = 0.04) per increase in hospital volume quintile. For re-admissions within a year, the hazard of vascular complications decreased by 15% (6-22; P = 0.001), wound/bleeding complications decreased by 8% (2-13; P = 0.01) and genitourinary complications decreased by 5% (2-8; P = 0.002), per increase in hospital volume quintile.

CONCLUSION

In men undergoing RP the length of hospital stay and rates of some short- and long-term postoperative complications afterward are lower in high-volume hospitals. The magnitudes of these effects on the outcomes studied may be too small and inconsistent to indicate a policy of selective referral to high-volume hospitals. Quality of life and oncological outcomes, however, could not be investigated in this dataset.

Reproducibility measures and their effect on diet-cancer associations in the Boyd Orr cohort

OBJECTIVES

To quantify measurement error in the estimation of family diet intakes using 7-day household food inventories and to investigate the effect of measurement-error adjustment on diet-disease associations.

DESIGN AND SETTING

Historical cohort study in 16 districts in England and Scotland, between 1937 and 1939.

SUBJECTS

4999 children from 1352 families in the Carnegie Survey of Diet and Health. 86.6% of these children were traced as adults and form the Boyd Orr cohort. The reproducibility analysis was based on 195 families with two assessments of family diet recorded 3-15 months apart.

METHODS

Intraclass correlation coefficients (ICCs) were calculated for a variety of nutrients and food groups. Diet-cancer associations reported previously in the Boyd Orr cohort were reassessed using two methods: (a) the ICC and (b) the regression calibration.

MAIN RESULTS

The ICCs for the dietary intakes ranged from 0.44 (beta carotene) to 0.85 (milk and milk products). The crude fully adjusted hazard ratio (HR) for cancer mortality per 1 MJ/day increase in energy intake was 1.15 (95% CI 1.06 to 1.24). After adjustment using the ICC for energy (0.80) the HR (95% CI) increased to 1.19 (1.08 to 1.31), and the estimate from regression calibration was 1.14 (0.98 to 1.32). The crude fully adjusted odds ratio (OR) for cancer incidence per 40 g/day increase in fruit intake was 0.84 (95% CI 0.73 to 0.97). After adjustment using the fruit ICC (0.78) it became 0.81 (0.67 to 0.96) and the OR derived from regression calibration was 0.81 (0.59 to 1.10).

CONCLUSIONS

The diet-disease relationships for the dietary intakes with low measurement error were robust to adjustment for measurement error.

Combining individual and ecological data to determine compositional and contextual socio-economic risk factors for suicide

The social and economic characteristics of geographic areas are associated with their suicide rates. The extent to which these ecological associations are due to the characteristics of the people living in the areas (compositional effects) or the influence of the areas themselves on risk (contextual effects) is uncertain. Denmark's Medical Register on Vital Statistics and its Integrated Database for Longitudinal Labour Market Research were used to identify suicides and 20 matched controls per case in 25-60-year-old men and women between 1982 and 1997. Individual and area (municipality) measures of income, marital and employment status were obtained. There were 9011 suicides and 180,220 controls. Individual-level associations with these risk factors were little changed when controlling for contextual effects. In contrast, ecological associations of increased suicide risk with declining area levels of employment and income and increasing proportions of people living alone were much attenuated after controlling for compositional effects. We found no consistent evidence that associations with individual-level risk factors differed depending on the areas' characteristics (cross-level interactions). This analysis suggests the ecological associations to be attributed to characteristics of the residents rather than area influences on risk.

Selecting a healthy diet score: lessons from a study of diet and health in early old age (the Boyd Orr cohort)

OBJECTIVES

To describe the selection and modification of an appropriate diet score to assess diet quality in early old age.

DESIGN AND SETTING

Cross-sectional analyses of the Boyd Orr cohort - a long-term follow-up of men and women whose families took part in a survey of diet and health in pre-war Britain. Dietary data were obtained from a 113-item food-frequency questionnaire. A nine-item Healthy Diet Indicator (HDI) developed by Huijbregts and colleagues was identified from the literature and modified because some dietary variables were unavailable and to accord more closely with recommendations of the UK Committee on Medical Aspects of Food Policy.

SUBJECTS

In total, 1475 traced, surviving cohort members aged 60 years and over.

RESULTS

Modification resulted in a 12-item Healthy Diet Score (HDS). We found that about half the variation in the HDS was explained by variation in the HDI (r=0.71). There was, however, little misclassification of subjects (<10%) into extreme thirds of the distribution by the HDS compared with the HDI. Items of the score most strongly correlated with overall score were saturated fat (r=-0.57), red meat (r=-0.46), dietary fibre (r=0.58), fruit and vegetables (r=0.54) and percentage energy from carbohydrates (r=0.51). Modifying existing items had greater impact on agreement between HDI and HDS than the addition of new items.

CONCLUSIONS

The selection and modification of diet scores is more complicated than often assumed. Furthermore, modest changes to an existing score can produce a score that is different from the original, and although it was not possible to test this issue, it may no longer predict subsequent health experience.

Serum Insulin-Like Growth Factor-I Is Positively Associated with Serum Prostate-Specific Antigen in Middle-Aged Men without Evidence of Prostate Cancer

We have examined the relationship between serum insulin-like growth factor-I (IGF-I) and prostate-specific antigen in 367 healthy men without evidence of prostate cancer and found a positive association (P = 0.05). In men without prostate cancer, serum prostate-specific antigen is closely related to prostate size, and our findings, therefore, suggest that IGF-I may induce prostatic epithelial proliferation. Higher circulating levels of IGF-I have been associated with increased risk of both prostate cancer and possibly benign prostatic hyperplasia. Greater rates of cell proliferation induced by IGF-I may be a key biological pathway underlying these disorders.

Advice to eat fish and mood: a randomised controlled trial in men with angina

People with high intake of fish have lower reported rates of depression and a small trial in psychiatric patients suggested that fish oil supplements reduced episodes of depression and mania. As part of a factorial trial of interventions to reduce mortality in angina 452 men were randomised to advice to eat more fatty fish or no fish advice. Maxepa fish oil capsules were supplied to men who found the fish unpalatable. Fish intake and mood were assessed at baseline and six months. Most men (83%) had mood assessed using the Derogatis Stress Profile at baseline and follow-up. Self reported intake of fish was higher in the fish advice group at six months. There was, however, no difference in depression or anxiety in those allocated to receive fish advice. After controlling for baseline mood, the difference in depression score between those randomised to fish advice and those not was 1.29 (95% CI -0.29 to 2.88) and the difference in anxiety was 0.82 (95% CI -0.57 to 2.22) with positive differences indicating more depression or anxiety in those allocated to the fish arm. This trial provides no evidence that increased fatty fish intake in people without depressive symptoms has any substantial effect on mood.

Socioeconomic inequality and meningococcal disease

Incidence of meningococcal disease was associated with socioeconomic deprivation across a rural English region. In young children the incidence was twice as high in the most deprived compared with the least deprived electoral wards. By addressing social inequalities the incidence of this serious infection could be reduced.

Are we still dying for a tan?

We suggest that the risks and benefits to individual and population health of different patterns of sunlight exposure are poorly characterised. Furthermore, we believe that the risks of excess exposure to sunlight in North European countries have been overstated and that the potential benefits of exposure to sunlight (particularly in moderation) have been largely ignored. We contend that a re-appraisal of these risks and benefits is required to allow us to better formulate public health policy and to provide the public and individuals with appropriate advice.

Life course accumulation of disadvantage: childhood health and hazard exposure during adulthood

The present paper examines the association between physical and social disadvantage during childhood and lifetime exposure to health-damaging environments. Study members were participants of Boyd Orr's clinical, social and dietary survey conducted between 1937 and 1939 and were aged between 5 and 14 years at clinical examination. Study participants were traced and between 1997 and 1998 a random sample of 294 were interviewed. The lifegrid interview method was used to collect full occupational, residential and household histories, from which accumulated lifetime exposures to a range of environmental hazards were estimated. Age-adjusted height during childhood was found to be inversely related to subsequent exposure to all hazards combined (males p = 0.002; females p = 0.001). This relationship was found in males with manual fathers (p = 0.044) and females with non-manual fathers (p = 0.035). Chronic disease during childhood was also associated with greater subsequent hazard exposure in males with manual fathers (p = 0.008). Among females with non-manual fathers, in contrast, chronic disease during childhood was associated with reduced subsequent hazard exposure (p = 0.05). These findings suggest that exposure to health-damaging environments during adulthood may accumulate on top of health disadvantage during childhood and that this process of life course accumulation of disadvantage may vary by gender and childhood social class.

Inter-rater reliability of the Barthel ADL index: how does a researcher compare to a nurse?

OBJECTIVES

To investigate whether a nonclinical research assistant, using standardized scoring criteria, can reliably administer the Barthel Activities of Daily Living (ADL) Index in a sample of elderly inpatients.

DESIGN

Paired comparison of nurse and nonclinical research assistant Barthel Index assessments.

SETTING

Acute hospital wards from two hospitals in a UK Healthcare Trust, with a catchment population of approximately 224,000 people.

METHODS

A consecutive sample of 94 elderly patients with a variety of medical problems.

MAIN OUTCOME MEASURES

Barthel ADL Index, Folstein Mini-Mental Status Examination.

RESULTS

Whilst the inter-rater reliability of the Barthel Index was within acceptable boundaries, two items out of ten had only fair agreement and low crude agreement (transfer and dressing) on Cohen's kappa scores.

CONCLUSIONS

Depending on the differences observed in any particular context, the Barthel Index can be applied with reasonable reliability by nonclinical staff applying the standardized scoring criteria. It should be noted, however, that the kappa coefficients between clinical and nonclinical assessors tend to be lower than those found when comparing two clinically trained assessors in previous research.

Growth hormone, IGF-I and cancer. Less intervention to avoid cancer? More intervention to prevent cancer?

The GH/IGF-I axis has a clearly established role in somatic growth regulation and there is much evidence suggesting that it can play a contributing role in neoplastic tissue growth; a number of recent epidemiological reports indicate that it may also be an important determinant of cancer incidence. Whilst there have been previous reports of changes to the axis in patients with established cancers, these new studies are distinct in being prospective and the inferences that can be made from this are outlined in this review. The recent studies are considered within the context of other indirect epidemiological evidence, and together indicate that the GH/IGF-I axis may establish the level of predisposition to a number of common cancers and indeed that such risk may be programmed from early life. There is considerable evidence for a number of possible mechanisms, both direct and indirect, which could account for the associations between GH/IGF-I levels and cancer incidence; these mechanisms are briefly summarised. The implications of the new findings are then discussed in relation to the increasing clinical usage of chronic GH administration and the need for further studies to establish any consequent increase in cancer risk. Finally the opportunities for further work to optimise cancer risk assessment and risk reduction strategies are highlighted.

Crisis telephone consultation for deliberate self-harm patients: effects on repetition

BACKGROUND

No interventions have been shown to be effective in reducing deliberate self-harm (DSH) repetition in this group of patients as a whole.

AIMS

To investigate the effect on repetition of offering emergency telephone support in a group of hospital-admitted DSH patients.

METHOD

A total of 827 DSH patients admitted to medical wards were randomly allocated to either control or intervention (green card) groups. In addition to treatment as usual, the intervention group was offered telephone support should any further crises occur. The main outcome measure was DSH repetition within six months of the index event.

RESULTS

The intervention had no significant effect on the overall DSH repetition rate (odds ratio 1.20, 95% CI 0.82-1.75). Sub-group analysis suggested that response to the intervention differed according to the past history of DSH--subjects with a previous history repeating more often and first-timers appearing to benefit.

CONCLUSIONS

No overall effect of the intervention was shown. Conclusions concerning sub-groups must be regarded as speculative, but they suggest that further assessment of the value of telephone support in first-timer DSH patients is indicated.

Reconstructing the life course: health during early old age in a follow-up study based on the Boyd Orr cohort

A method is described for investigating life course influences on health in early old age. The lives of some 300 individuals at present aged 65-75 y have been reconstructed from the archived records of a pre-WWII survey, in which they took part as children, and from lifegrid interviews with the same individuals 60 y later. Despite loss to study at several points those interviewed are shown to be representative of the British population socio-demographically, in comparison with the 1931 and 1991 decennial censuses, and physically, in comparison with the Health Survey for England. Bias is conservative because the most disadvantaged were disproportionately affected by loss to follow-up through death and because non-responders to interview were more disadvantaged as children than the interviewees. Representativeness and conservative bias, it is argued, justify the use of these data for investigating life course influences on health in early old age.

Socio-economic and dietary influences on leg length and trunk length in childhood: a reanalysis of the Carnegie (Boyd Orr) survey of diet and health in prewar Britain (1937-39)

Social class differences in height have been recognised for many centuries. However, few studies have examined the extent to which these differences are made up of differences in leg length or trunk length. This paper reanalyses cross-sectional information on children examined in Britain in the 1930s. We assess associations between socio-economic status and diet and the components of childhood stature. The analyses were based on the records of 2990 children aged 2 years to 14 years 9 months who were examined in the Carnegie (Boyd Orr) survey of diet and health (1937-39). z-Scores for the measures of childhood stature were calculated using polynomial regression techniques with the study population as the standard. Univariable and multivariable statistical techniques were used to assess the relationships between childhood height, leg length and trunk length, and dietary and socio-economic factors measured at the level of the household. Leg length was the component of stature most strongly associated with measures of childhood diet and socio-economic status. A greater part of the difference in stature between socio-economic groups was caused by differences in leg length rather than trunk length. In multiple regression analyses, district of residence and family food expenditure were generally the two factors most strongly related to stature. In a subsample of the surveyed children, for whom birthweight information was available, trunk length and leg length were equally strongly related to birthweight. Leg length appears to be a particularly sensitive indicator of childhood socio-economic circumstances. Although contemporary studies highlight the importance of biological factors in determining childhood height, the data analysed in this study suggest that socio-economic circumstances were also important in explaining height differentials in prewar Britain.

Randomised controlled trial comparing effectiveness and acceptability of an early discharge, hospital at home scheme with acute hospital care

OBJECTIVE

To compare effectiveness and acceptability of early discharge to a hospital at home scheme with that of routine discharge from acute hospital.

DESIGN

Pragmatic randomised controlled trial.

SETTING

Acute hospital wards and community in north of Bristol, with a catchment population of about 224 000 people.

SUBJECTS

241 hospitalised but medically stable elderly patients who fulfilled criteria for early discharge to hospital at home scheme and who consented to participate.

INTERVENTIONS

Patients' received hospital at home care or routine hospital care.

MAIN OUTCOME MEASURES

Patients' quality of life, satisfaction, and physical functioning assessed at 4 weeks and 3 months after randomisation to treatment; length of stay in hospital and in hospital at home scheme after randomisation; mortality at 3 months.

RESULTS

There were no significant differences in patient mortality, quality of life, and physical functioning between the two arms of the trial at 4 weeks or 3 months. Only one of 11 measures of patient satisfaction was significantly different: hospital at home patients perceived higher levels of involvement in decisions. Length of stay for those receiving routine hospital care was 62% (95% confidence interval 51% to 75%) of length of stay in hospital at home scheme.

CONCLUSIONS

The early discharge hospital at home scheme was similar to routine hospital discharge in terms of effectiveness and acceptability. Increased length of stay associated with the scheme must be interpreted with caution because of different organisational characteristics of the services.

Hospital at home or acute hospital care? A cost minimisation analysis

OBJECTIVE

To compare, from the viewpoints of the NHS and social services and of patients, the costs associated with early discharge to a hospital at home scheme and those associated with continued care in an acute hospital.

DESIGN

Cost minimisation analysis.

SETTING

Acute hospital wards and the community in the north of Bristol (population about 224 000).

SUBJECTS

241 hospitalised but medically stable elderly patients who fulfilled the criteria for early discharge to a hospital at home scheme and who consented to participate.

MAIN OUTCOME MEASURES

Costs to the NHS, social services, and patients over the 3 months after randomisation.

RESULTS

The mean cost for hospital at home patients over the 3 months was 2516 pounds, whereas that for hospital patients was 3292 pounds. Under all the assumptions used in the sensitivity analysis, the cost of hospital at home care was less than that of hospital care. Only when hospital costs were assumed to be less than 50% of those used in the initial analysis was the difference equivocal.

CONCLUSIONS

The hospital at home scheme is less costly than care in the acute hospital. These results may be generalisable to schemes of similar size and scope, operating in a similar context of rising acute admissions.

Childhood obesity and adult cardiovascular mortality: a 57-y follow-up study based on the Boyd Orr cohort

Few studies have examined associations between childhood overweight and adult disease. We examined the relation between BMI measured in childhood and adult all-cause and cardiovascular mortality in a 57-y follow-up of a cohort study based on the Carnegie (Boyd Orr) Survey of Family Diet and Health in prewar Britain (1937-1939). Complete baseline and follow-up data were available for 1165 males and 1234 females who were aged between 2 y and 14 y 9 mo when they were examined. All-cause and cardiovascular mortality were associated with higher childhood BMIs. Compared with those with BMIs between the 25th and 49th centiles, the hazard ratio (95% CI) for all-cause mortality in those above the 75th BMI centile for their age and sex was 1.5 (1.1, 2.2) and for ischemic heart disease it was 2.0 (1.0, 3.9). There was also a suggestion of a nonlinear association with overall mortality; those in the 25-49th centile of the BMI distribution had the lowest mortality rates. The linear associations may be due in part to the tracking of BMI between childhood and adulthood. High BMI in adults is known to be associated with raised blood pressure and abnormal lipid profiles. The relative contributions of adult and childhood overweight to the observed mortality patterns are uncertain. From the public health perspective, strategies aimed at reducing weight in childhood are important but may only affect adult health if such weight reduction persists into adulthood.

Childhood leg length and adult mortality: follow up of the Carnegie (Boyd Orr) Survey of Diet and Health in Pre-war Britain

OBJECTIVE

To investigate the relation between childhood height, its components--leg length and trunk length--and mortality in adulthood.

DESIGN

Cohort study based on the Carnegie (Boyd Orr) Survey of diet and health in pre-war Britain, 1937-9.

SETTING

The 14 centres in England and Scotland that participated in the Carnegie Survey and where children were examined. Scottish centres: Aberdeen, Dundee, West Wemyss, Coaltown of Wemyss, Hopeman, Methlick, Tarves, Barthol Chapel. English Centres: Liverpool, York-shire, Barrow in Furness, Wisbech, Fulham, and Bethnal Green.

SUBJECTS

2990 boys and girls aged between 2 years and 14 years 9 months when they were examined in 1937-9. These children were drawn from 1134 families who underwent a one week assessment of family diet and home circumstances. Of these, 2547 (85%) have been traced and flagged using the NHS Central Register.

MAIN OUTCOME MEASURES

Age adjusted overall, coronary heart disease, and cancer mortality in men and women in relation to age and sex specific z scores for height, leg length, and trunk length. All analyses were adjusted for the possible confounding effects of childhood and adult socioeconomic circumstances and childhood diet.

RESULTS

Leg length was the component of childhood height most strongly associated with socioeconomic and dietary exposures. There was no significant relation between childhood height and overall mortality. Height-mortality relations were observed in relation to both coronary heart disease (CHD) and cancer. Leg length was the component of height most strongly related to cause specific mortality. In men and women CHD mortality increased with decreasing childhood leg length. Men in the lowest leg length quintile had a relative risk (RR) of 2.5 (95% CI 1.0 to 6.2) compared to those with the longest legs (linear trend p = 0.14). Similarly, women in the lowest leg length quintile had a RR of 3.9 (95% CI 0.8 to 19.0; linear trend p < 0.01). Adjustment for childhood and adult socioeconomic circumstances had little effect on these trends. In men, but not women, those who as children had long legs experienced increased cancer mortality. The significant relations between anthropometry and both CHD and cancer mortality were restricted to those aged < 8 years when measured.

CONCLUSIONS

These findings suggest that adverse diet and living conditions in childhood, for which leg length seems to be a particularly sensitive indicator, are associated with increased risk of CHD in adulthood and possibly reduced cancer risk. It is likely that these influences operate after birth, during the first few years of life.

Use of the EuroQoL among elderly acute care patients

The assessment of the validity and reliability of generic quality of life (QoL) instruments among elderly patient groups has tended to lag behind such assessments in general populations, yet it is an important methodological issue. This paper presents the findings from a study of the use of the EuroQoL among an elderly acute care patient group, focusing particularly on the ability to self-complete, construct validity and sensitivity to change. Two hundred and fourteen UK patients aged 65 years and over, participating in a randomized controlled trial comparing hospital at home and routine hospital care were asked to complete the EuroQoL and a number of other instruments at randomization and at 4 week and 3 month follow-ups. The inability to self-complete the EuroQol was found to be strongly related to both increased age and reduced cognitive function (p < 0.0001). From logistic regression, the expected probability of an acute care patient requiring interview administration at age 65 years is 11%, at age 75 years is 37% and at age 85 years is 73%. The relationships with age and limiting long-standing illness/disability were weaker than expected, but the results obtained from the EuroQoL were highly correlated with those from both the Barthel Index and the COOP-WONCA charts where this was anticipated. Preliminary evidence of sensitivity to change was found from descriptive statistics of the changes in scores for four specific subgroups of patients, but the small numbers and high variability in each sub-sample means that this should be interpreted with caution. The most important issue arising from the research concerns the impact of age on the ability to self-complete the EuroQoL questionnaire. It is argued that this research points to the need for rigorous studies (such as randomized controlled trials) to assess the impact of the format of administration of the EuroQoL on the scores obtained.

Effect of varying the time frame for COOP-WONCA functional health status charts: a nested randomised controlled trial in Bristol, UK

STUDY OBJECTIVES

To investigate whether changing the stated time frame for COOP-WONCA charts has any effect on responses. Specifically, to assess the effect of attempting to avoid the situation where the time frame crosses the onset of an acute episode.

DESIGN

A randomised controlled trial of two time frames, nested within a main trial comparing early discharge with a hospital at home scheme against routine discharge policy. The time frames compared were the standard two weeks (four for the pain chart) and a shorter period of 48 hours for all seven charts.

SETTING

Acute hospital wards in Frenchay Healthcare Trust and the Avon Orthopaedic Centre in Bristol.

PARTICIPANTS

Patients entered into the main trial, who were medically stable, in need of continued rehabilitative care but suitable for discharge to hospital at home.

MAIN RESULTS

A total of 200 patients were randomised, 106 to the shorter time frame, 94 to the standard charts. No clear differences were observed between the two groups for the proportion failing to self complete the charts. For the (seven) chart scores, only pain was statistically significantly different between the time frames (Mann-Whitney p = 0.0085; proportion reporting moderate or severe pain 19% higher in the standard group, 95% confidence intervals 5% to 33%). For both this chart and that for change in health, however, there was evidence of greater differences between the versions of the chart among those admitted more recently (p values for relevant interactions 0.004 and < or = 0.001 respectively).

CONCLUSIONS

While the present findings give some support for the wide applicability of the standard version, there is sufficient evidence here to indicate that the time frame may influence the results, particularly for patients with a recent acute episode. In the absence of further data, then, it would seem prudent to consider a shorter time frame for such patients, especially if the aim is to assess current health status or to measure changes over a comparatively short period of time, or both.

Lifecourse exposure and later disease: a follow-up study based on a survey of family diet and health in pre-war Britain (1937-1939)

There is an increasing interest in the origins of adult disease in early life. The elucidation of such explanations of current morbidity and mortality must depend upon the follow-up of previously established cohorts. This paper describes the design of and background to such a follow-up of one of the richest data sources for this type of research: Sir John Boyd Orr's survey of diet and health in pre-war Britain. 1,352 families from 16 centres in England and Scotland were surveyed; 3,762 children aged up to 19 years from these families were examined. Socio-economic information and detailed one week dietary diary records are available for all families. Detailed medical examinations (including anthropometry) were undertaken on children in 14 of the centres. Most of the information is cross-sectional although 1,322 children were examined on two or more occasions one year apart to assess the effects of dietary supplementation. Dietary records were retrieved for 1,343 (99.3%) of the families. Medical examination records were found for 3,560 (94.6%) of the children who were examined in the survey and attempts have been made to trace 4,973 children who were either examined or whose family participated in the dietary survey. The data demonstrate relationships between family food expenditure and height in childhood and housing conditions. Eighty-five per cent (4211/4973) of the children have been traced and flagged on the National Health Service Central Register, Southport. The characteristics of those traced do not differ significantly from those we have been unable to trace although untraced females were slightly heavier. To date 696 (16.5%) of the cohort have died. The cohort will be used to investigate the relationship between diet, nutritional status (height, weight, cristal height), health and social circumstances in childhood, and mortality and morbidity in adulthood.

Epidemiology and patterns of hospital use after parasuicide in the south west of England

OBJECTIVE

To describe the epidemiology, management, and outcome of parasuicide in the south west of England.

DESIGN

Descriptive analysis using routine information systems.

SETTING

The former South Western Regional Health Authority, population aged 10 and over: 2.9 million.

SUBJECTS

These comprised 5080 residents of the South Western Health Region, admitted on 5770 occasions for parasuicide between April 1992 and March 1993 to hospitals in the south west.

MAIN OUTCOME MEASURES

Person based age and sex standardised admission ratios for parasuicide; readmission for parasuicide in the subsequent 12 months; admission to psychiatric hospital after parasuicide; in-hospital mortality for those admitted after attempted suicide.

RESULTS

The overall rate of parasuicide admission was 174 per 100,000 per year. Rates were highest in males aged 20-24 (381 per 100,000) and in females aged 15-19 (625 per 100,000). Parasuicide is the third most frequent cause of acute medical admission in the south west. A total of 10.0% of admissions received psychiatric inpatient care as a direct result of their parasuicide admission and 10.1% were readmitted in the following 12 months with a repeat episode of parasuicide. Significant variations in standardised admission ratios for parasuicide were observed between the districts. Some of this variation is related to socioeconomic differences between districts, the rest is probably due to differences in practice between districts. There is no clear evidence that these variations result in differences in readmission rates. Districts where psychiatric inpatient facilities were located on the same site as the general hospital tended to admit a greater percentage of parasuicide patients for psychiatric inpatient care. A quarter of all suicide deaths from overdose occurred in hospital. It is estimated that there are 87,000 parasuicide admissions in England and Wales annually.

CONCLUSIONS

Parasuicide is a common cause of acute hospital admission and there is evidence that hospital admission practices for parasuicide vary across the south west. Randomised controlled trials are needed to evaluate the most appropriate form of management for those patients who do not require admission on medical grounds.

Variation in purchasing for the invasive management of coronary heart disease

This paper reports the results of a postal questionnaire survey of Directors of Public Health in all health authorities in the United Kingdom (as at March 1994). Our aim was to examine variations in the purchasing of coronary artery bypass grafting, percutaneous transluminal coronary angioplasty and coronary angiography. Information on planned service developments in cardiology was also sought. The response rate was 62%. The mean rate of CABG was 374 per million total population (range 162-710); PTCA 183 (range: 18-648); and coronary angiography 1,010 (range 581-2,334). The mean ratio of invasive treatment to angiography was 1:2 Variations in provision were not related to mortality from coronary heart disease or the availability of a local provider. Those districts purchasing higher levels of CABG tended to purchase higher levels of PTCA (Spearman's r = 0.52). Observed variations in purchasing of invasive treatments and investigation for coronary heart disease do not relate to population "need' as defined by mortality rates from CHD. The greatest variations are seen in the purchasing of PTCA, an intervention whose place in the management of CHD is as yet not fully defined. Consensus guidelines on the appropriate use of these interventions and on population needs are required.

Antibiotic prophylaxis for bacterial meningitis: overuse and uncertain efficacy

BACKGROUND

There is little evidence supporting the efficacy of prophylactic antibiotics in preventing secondary cases of bacterial meningitis, and recent guidance extended the use of prophylactic antibiotics amongst children who attend pre-school groups.

METHODS

We examined the volume of rifampicin prescribed, and that recommended to contacts of cases of meningococcal and Hib meningitis in Somerset over a three-year period using case note records of the Consultant for Communicable Disease Control (CCDC) and PACT data.

RESULTS

There was evidence of excessive prescribing over and above that recommended by the CCDC.

CONCLUSIONS

Excessive prescribing increases the chance of serious drug side effects and the development of antibiotic resistance. It is suggested that both meningitis contacts and information about early symptoms of meningitis, as well as an explanation of the rationale behind the prescribing of antibiotic prophylaxis to contacts. This may reduce the likelihood of unnecessary prescribing and subsequent complications.

Relation between parasuicide, suicide, psychiatric admissions, and socioeconomic deprivation

OBJECTIVE

To examine the relations between parasuicide, suicide, psychiatric inpatient admissions, and socioeconomic deprivation.

DESIGN

Ecological analysis with data from routine information systems and the 1991 census.

SETTING

24 localities in the area covered by the Bristol and District Health Authority (population 817,000), consisting of aggregations of neighbouring wards, with an average population of 34,000.

SUBJECTS

6089 subjects aged over 10 years admitted to hospital after parasuicide between April 1990 and March 1994; 997 suicides occurring 1982-91; 4763 subjects aged 10-64 years admitted with acute psychiatric illness between April 1990 and March 1994.

RESULTS

Localities varied significantly in standardised admission ratios for parasuicide and standardised mortality ratios for suicide (P < 0.001). Spearman's rank correlation coefficient between the standardised mortality ratio for suicide and standardised admission ratio for parasuicide was 0.73 (95% confidence interval 0.46 to 0.88). Correlation between parasuicide and Townsend score was 0.86 (0.70 to 0.94) and between suicide and Townsend score 0.73 (0.46 to 0.88). The partial correlation coefficient between suicide and parasuicide after the Townsend score was adjusted for was 0.29 (-0.13 to 0.62). The correlation between standardised admission ratio for parasuicide and standardised admission ratio for psychiatric illness was 0.76 (0.51 to 0.89) and between standardised mortality ratio for suicide and standardised admission ratio for psychiatric illness was 0.72 (0.45 to 0.87).

CONCLUSION

A strong ecological association exists between suicide and parasuicide, with socioeconomic deprivation accounting for much of this relation. This strong association provides supporting evidence for the importance of social policy measures in attaining Health of the Nation targets on mental health.

Epidemiology of meningococcal disease and a community outbreak in Somerset

We describe the epidemiology of meningococcal disease in Somerset and a community outbreak in one district. Fifty-seven cases of meningococcal disease occurred in residents of Somerset between 1 May 1990 and 30 April 1993 (incidence 4.7/100,000/year), of whom six died. Thirteen of the cases occurred in one local authority area in a six month period from 1 November 1992 to 30 April 1993; an incidence of 26.6/100,000/year. Twenty-seven patients were given benzyl-penicillin before admission to hospital. General practitioners were significantly more likely to give benzylpenicillin to patients with rashes. The proportion that received prophylaxis tended to increase after a press release was issued and general practitioners were advised. The number of cases was too small to demonstrate the protective effect of early administration of benzylpenicillin. In five cases the consultant in communicable disease control was not informed for over 12 hours. Thirty-seven of the 48 index cases for whom information was available received rifampicin prophylaxis before discharge from hospital.

Risk factors for giardiasis: a case-control study in Avon and Somerset

Giardia lamblia is a common and increasing cause of gastrointestinal illness in the UK. We report a case-control study that examined risk factors for giardiasis. Patients with giardiasis were identified from reports to the Consultants in Communicable Disease in Avon and Somerset, and age-sex matched controls were obtained from their general practitioners' lists. Details of travel history, water consumption and recreational water use were collected by postal questionnaire. Over the period July 1992 to May 1993, 74 cases and 108 matched controls were obtained. The data were analysed using conditional logistic regression. Swimming appeared to be an independent risk factor for giardiasis (odds ratio 2.4, 95% CI 1.0 to 6.1, P = 0.050). Travel (P = 0.001), particularly to developing countries, and type of travel (P = 0.004)--that is, camping, caravanning or staying in holiday chalets--were also observed to be significant risk factors. Other recreational water use and drinking potentially contaminated water were found to be not statistically significant after adjustment for other factors.

Infertility prevalence, needs assessment and purchasing

A postal questionnaire was used to assess the prevalence of primary and secondary infertility in Somerset. Three age groups of women were surveyed: those aged 36-40 (n = 965), 41-45 (n = 1115) and 46-50 years (n = 1061). Using these three age groups, most of whom had completed their reproductive lifespan, time trends both in the prevalence of infertility and service use were obtained. A 75.7 per cent response rate was achieved. No trends towards increasing prevalence of infertility were seen, but greater use was made of services in the younger age group. The overall prevalence of primary infertility was 16.1 per cent (95 per cent confidence interval (Cl) 14.6-17.6) if failure to conceive after one year is used as the definition of infertility. Similarly, the prevalence of secondary infertility was 15.8 per cent. It was found that 26.4 per cent (95 per cent Cl 24.6-28.2) of women were likely to suffer from infertility at some time and only 3.0 per cent of women were involuntarily childless. Twenty-five women (1.1 per cent) suffered recurrent miscarriages. There was no change in the likelihood of conception in the three age groups of women suffering infertility. Those in lower socio-economic groups were less likely to consult their general practitioners (GPs) when difficulties in conceiving were experienced. Examinations of a sample of responders' and non-responders' medical records suggested that the use of postal questionnaires in assessing the prevalence of infertility may, to some extent, be prone to bias.(ABSTRACT TRUNCATED AT 250 WORDS)

The public health physician's role in chemical incidents

Chemical incidents such as the methylisocyanate release at Bhopal and the aluminium sulphate incident in Lowermoor, Cornwall, are uncommon. However, five chemical incidents occurred in Somerset in 12 months between 1990 and 1991, and District Health Authorities are required to have plans to deal with such events. A survey of the plans held by the Consultants in Communicable Disease Control in South Western and Wessex Regional Health Authorities is discussed and the roles of public health physicians and emergency organizations are outlined.

Mysterious slapped face rash at holiday centre

OBJECTIVE

To discover the cause of an outbreak of facial rash in a holiday centre.

DESIGN

Questionnaire survey of those with rash; analysis of samples of linen.

SETTING

Holiday centre in south west England.

PATIENTS

98 holiday-makers presenting to the first aid post with a facial rash.

INTERVENTION

Replacement of bed linen with new linen in selected parts of the site.

RESULTS

The attack rate was 7.0-14.2/1000 for most accommodation areas in the centre, but in one accommodation area the rate was zero. The pH of rinse water from sheets varied from 7.4 to 9.0. Those parts of the accommodation provided with new linen had zero attack rates.

CONCLUSION

The facial rash resulted from irritation from washing powder retained owing to insufficient rinsing during laundering. Modifications to the rinsing process led to a gradual disappearance of the rash.