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2001Annual Report - 2001 Annual Report - 20012001
University of Glasgow • 4 Lilybank Gardens • Glasgow G12 8RZ T: +44 (0) 141 357 3949 • F: +44 (0) 141 337 2389 • W: www.msoc-mrc.gla.ac.uk
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The MRC Social & Public Health Sciences Unit
The Social and Public Health Sciences Unit (SPHSU) is jointly funded by the UK Medical Research Council, and the Chief Scientist Office at the Department of Health at the Scottish Executive. The Unit's aim is to:
Promote human health by the study of social and environmental influences on health.
Specific objectives include: • Studying how people's social positions, and their social and physical environments, influence their physical and mental health and capacity to lead healthy lives;
• Designing and evaluating interventions aiming to improve public health and reduce social inequalities in health, and;
• Influencing policy and practice by communicating the results and implications of research.
During 2001 we continued to work towards all three objectives, in particular by expanding our portfolio of evaluation research, engaging directly with policy makers, and grappling with issues around 'what counts as evidence' in public health policy making. We have aimed to contribute especially to the evidence base of Scottish policy-making, and to maintain our wider UK links while developing and sustaining international collaborations. We were pleased to welcome as visiting workers Mehrangiz Ebrahimi-Mameghani from Iran, Kristina Manderbacka and Ilmo Keskimäki from Finland, Matthew Shaw from MRC Gambia, and Deborah Osbourne from Australia, as well as Joy Adamson from the MRC HSRC and Ian Deary from the University of Edinburgh.
In this report we describe recent work and list publications and presentations in 2001 and early 2002. Our web site (www.msoc-mrc.gla.ac.uk) contains copies of this and previous annual reports, and other information about SPHSU, including full reports of projects and feedback leaflets we send to study participants. Any inquiries about our research or other activities should be directed to the named researcher(s) or to our librarian, Mary Robins.
Sally Macintyre OBE PhD FRSE FMedSci 25629_Txt 9/8/02 9:20 AM Page 2
Staff List 3
The West of Scotland Twenty-07 Study: Health in the Community 4
Social and Spatial Patterning of Health 6
Gender and Health 11
Sexual and Reproductive Health 16
Measuring Health, Variations in Health and the Determinants of Health in Scotland 22
Evaluating the Health Effects of Social Interventions 26
Ethnicity, Religion & Health 31
Young People’s Health & Health Behaviour 36
Other Research 44
Other Unit News 46
Professional Activities by Unit Members, 2001-2002 47
Publications and Presentations, 2001-2002 48 25629_Txt 9/8/02 9:20 AM Page 3
4 The MRC Social and Public Health Sciences Unit
Staff, Students and Co-workers, 2001 to mid-2002
DIRECTOR: ASSOCIATE DIRECTORS: Sally Macintyre OBE PhD FRSE FMedSci Graham Hart PhD Mark Petticrew PhD
RESEARCH STAFF: Joanne Abbotts BSc Lisa Arai MSc (left 28.09.01) Caroline Allen PhD Ursula Berger Dr. Oec. Publ. Katie Buston PhD Allan Clark BSc (left 20.08.01) Judith Connell MA Steven Cummins PhD Geoffrey Der MSc Matt Egan PhD Anne Ellaway MSc Rani Elwy MSc (left 30.06.01) Carol Emslie PhD Graeme Ford MA Islay Gemmell PhD (left 26.10.01) Jacki Gordon MPH Mary-Kate Hannah MSc Seeromanie Harding MSc Marion Henderson BA Cassandra Higgins MPhil Kate Hunt MSc Katy Levin MSc Alastair Leyland PhD Maria Maynard PhD Laura McKay MA Alice McLeod MSc (left 31.05.2001) Philip McLoone BSc David Morrison MB ChB MRCPI MPH (left 10.10.01) Gillian Norrie BSc David Ogilvie MA MB BChir MPH DRCOG DF Karen Scanlon BA Helen Sweeting PhD Hilary Thomson MPH Katrina Turner PhD Patricia Walls MSc (left 31.03.01) Patrick West PhD Daniel Wight PhD Rory Williams DPhil Lisa Williamson MPhil Robert Young BSc
GRADUATE STUDENTS: Margaret Callaghan MSc (CSO-funded) Rosemary Davidson BSc (MRC-funded) Carolyn Davies BSc (MRC-funded) Pamali Goonetilleke MPhil (MRC-funded) Helen Harper MSc (MRC-funded) Dominique Harvey MA (MRC-funded) Shona Hilton MSc (MRC-funded) Rosemary Howkins MPhil (Wellcome Trust-funded; left 30.09.01) Anne Mills MA (MRC-funded) Rosaleen O’Brien MSc (MRC-funded) Peter Seaman MA (MRC-funded)
HONORARY/ATTACHED/VISITING RESEARCH STAFF: Joy Adamson PhD, Department of Social Medicine, University of Bristol Fred Cartmel BSc, Department of Sociology, University of Glasgow (left 06.06.01) Ian Deary BSc PhD MBChB MRC Psych F, Department of Psychology, University of Edinburgh (left 01.02.02) Mehrangiz Ebrahimi-Mameghani MSc, Department of Human Nutrition, University of Glasgow Raymond Illsley CBE, PhD, Visiting Professor, School of Social Sciences, University of Bath Ilmo Keskimäki MD DMed Sci, National Research and Development Centre for Welfare and Health (STAKES), Helsinki, Finland Kristina Manderbacka PhD, National Research and Development Centre for Welfare and Health (STAKES), Helsinki, Finland Nanette Mutrie DPE MEd PhD Barbara Thompson OBE, PhD, Department of Obstetrics & Gynaecology, University of Aberdeen Michael van Beinum BSc MBChB MPhil, Lanarkshire Health Board Phil Wilson MA DPhil MB BChir MRCP FRCGP DCH, Department of General Practice, University of Glasgow Stuart Wood MD FRCGP, Department of General Practice, University of Glasgow
SUPPORT STAFF: Kate Campbell, Survey Support Officer Andrew Craney HND, Receptionist Sharon Davidson BA, Project Administrator Catherine Ferrell MA, Survey Manager Patricia Fisher HNC, Research Support Officer John Gilchrist* HNC, Computing Officer Val Hamilton MLitt Elaine Hindle HNC, Survey Support Officer Barbara Jamieson MSc, Unit Administrator Fiona McDonald, PA to Professor Macintyre Edna McIntyre*, Secretarial Assistant Jean Money*, Secretarial Assistant/Accounts Guy Muhlemann PhD, Computer Systems Manager Carol Nicol MSc, Programmer/Analyst Louise O’Neill, Receptionist Margaret Reilly, Research Support Officer Mary Robins HNC, Librarian Amanda Thomson* MA, Managing Editor, Social Science and Medicine
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The West of Scotland Twenty-07 Study: ‘Health in the Community’
The 'West of Scotland Twenty-07 Study: Health in the community' is a resource for all Unit programmes. Its aim is to investigate the social processes producing or maintaining differences in health by key social positions (in particular, social class, gender, area of residence, age, ethnicity, and family composition). Three age cohorts (born 1932,1952 and 1972, and aged 15, 35 and 55 at first contact in 1987/88) are being followed up using home-based interviews and postal questionnaires, and we hope to continue this until 2007 (i.e., for twenty years).
The study design has two components:
1) Regional Samples. Around 1,000 people in each age group were sampled from 52 postcode sectors in the Central Clydeside Conurbation, which includes the City of Glasgow. This is a socially heterogeneous region with a population of 1.7 million, and the postcode sectors were chosen to reflect a continuum of social deprivation. The interviews (in 1987/8, 1990/1, 1995/6 and 2000/2) are wide-ranging, and include questions on paid and unpaid work, housing, income, family composition, social support, stress, life events, leisure activities, health promoting and health damaging behaviours, beliefs and values, and many other material, cultural and psychological factors, along with measures of physical and mental health and well being. Other measures include height, weight, girth, blood pressure, respiratory function, reaction times, and (in 1995/6 only), cardiovascular reactivity and salivary immuno-globulin-A.
2. Locality Samples. Two localities in Glasgow City with contrasting socio-residential characteristics were chosen for more intensive study. The aim is to collect data both on the residents and on the area, and to explore processes by which place of residence might influence health and the ability to lead a healthy life. The diagram shows the (approximate) location of our study localities, the NW and SW, and of the four more homogeneous neighbourhoods into which we have split them for further analysis. It also indicates some of the socioeconomic characteristics of these neighbourhoods. The West End is a middle class Victorian urban neighbourhood, and Garscadden is an adjacent inter-war high status local authority housing estate. Mosspark is a similar estate but located near the poorest area, Greater Pollok, which is a deprived peripheral housing scheme. Data were collected from residents in the three age cohorts (initial sample sizes around 300 per cohort per locality) in 1987/8, 1992, and 1997. Both regional and locality samples are being re-interviewed in 2000-2 using computer-based personal interviews administered by trained nurses.
Randomly or purposively selected sub-samples from the region and localities are used for more intensive studies on particular topics. Currently these include studies of educational and labour market trajectories (Cartmell, page 40), identity and health among people of Irish and non-Irish descent (Walls, page 33), the social construction of gender and health (Emslie and Hunt, page 14), and influences on GP consultations (Mills, page 6).
33 2119 8 9 Study Localities and Neighbourhoods 7 52 6 1991 Census Characteristics. Garscadden West End 56 NW Locality: Garscadden, West End SW Locality: Greater Pollok, Mosspark 64 2420 10 Overcrowded 28 29 Social Class 4 & 5 16 Mosspark Male Unemployment Greater Pollok No Car
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6 The MRC Social and Public Health Sciences Unit
Social & Spatial Patterning of Health
Since the middle of the nineteenth century it has been observed in Britain that health and longevity vary both by social status and by area of residence. The aim of this programme is to study socioeconomic and spatial inequalities in health across time and across the life course, using data about individuals, households and areas, and a range of geographical and historical scales. During 2001 our work contributed to public debates about appropriate strategies to reduce inequalities in health, 18, 79,161,164, 232 and to an improved understanding of the influence of social and physical environments on health and illness.20, 81
The West of Scotland Twenty-07 study
Frequent GP consultations, socio-economic status and burden of ill-health: an analysis of Twenty-07 data (Hunt, with Sally Wyke, Scottish School of Primary Care, Jeremy Walker of Department of General Practice, Edinburgh University, and Phil Wilson, Department of General Practice, University of Glasgow) Previous research suggests that the burden of illness is the most important predictor of use of health services, but it remains unclear which aspects of morbidity are most predictive. Socio-economic circumstances are recognised as important indicators of frequent use of general practitioner services. However, although it’s recognised that this may be mediated through high burdens of illness, or greater social isolation, in those from poorer socio-economic circumstances, few population based studies of frequent attenders have had sufficiently detailed data on different aspects of morbidity to investigate this. Analyses using detailed self-reported morbidity data from the Twenty-07 Study showed that frequent attendance was associated with the number of minor conditions reported, the number of serious conditions reported, higher levels of anxiety, and lower self-assessed health. No measures of socio-economic circumstance or social support remained significantly associated with frequent attendance when the greater burden of ill-health in poorer and less well-supported groups was considered.153
Consulting in primary care: a qualitative study of the influence of social factors and illness (PhD project: Mills, supervisors Hunt and Dr Sally Wyke) Analyses of consultation patterns in the Twenty-07 Study show that the total burden of morbidity is important in explaining variation in consultation (as well as frequent attendance), but even models with very detailed indicators of morbidity, social position and social support leave more than 70% of variation in consulting unexplained. This suggests the importance of exploring other influences on consulting using more qualitative methodologies, particularly amongst people who are known to have a relatively high burden of morbidity. To do this we are purposively subsampling people from the Twenty-07 Study who are known to have high levels of morbidity, to compare people who are relatively infrequent users of primary care with those who are high users. The study is exploring the range of resources on which people draw to manage chronic illness, with particular emphasis on the place of primary care health services.
Disability in early old age (Hunt, with Dr Joy Adamson and Prof. Shah Ebrahim, Department of Social Medicine, Bristol University) Analyses of the factors which predict the acquisition of disability in early old age (using the oldest cohort of the Twenty-07 Study) are being undertaken as part of a collaboration funded by an MRC Fellowship awarded to Dr Joy Adamson. Initial analyses to date have been cross-sectional, but longitudinal analyses will explore factors which exacerbate or ameliorate various forms of disability as people approach their seventies.
Caring and Self-Esteem (Dr. Deborah Osborne, National Ageing Research Institute, Victoria, Australia, Professor Mary Gilhooly, Centre of Gerontology and Health Studies, University of Paisley, and Der). A longitudinal analysis was undertaken of the oldest cohort on the West of Scotland Twenty-07 Study to find out how caregiving is associated with self-esteem. The hypothesis being tested was that the effects of caregiving on self-esteem might depend on the socioeconomic status of the caregivers. Preliminary results show that caregiving bolstered the self-esteem of all participants regardless of their SES, although this effect faded over time. However, variations by employment status were evident. 25629_Txt 9/8/02 9:21 AM Page 6
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Reaction times and intelligence differences (Der and Ford with Professor Ian Deary, Department of Psychology, University of Edinburgh) We examined the associations between scores on a test of general mental ability (Alice Heim 4: AH4) and reaction times in the oldest cohort of the Twenty-07 Study (n=c900). AH4 total scores correlated -0.31 with simple reaction time, -0.49 with 4-choice reaction time, and -0.26 with intra-individual variability in both reaction time procedures.41 This is the first report of reaction time and psychometric intelligence in a large, normal sample of the population. It provides a benchmark for other studies and suggests larger effect sizes than the majority of previous studies, which have tended to be on young student samples. Further papers examining the social distribution and changes over time in reaction times are in preparation (using HOPE data, see below, as well as Twenty-07 data).
Physical activity (Mutrie, Hannah and Berger) We have undertaken a comprehensive categorisation of physical activity in the 1995 data of the Twenty-07 study.226 Initial analysis established that men were more active than women and that activity levels declined across age cohorts; while there was no strong social class gradient in general activity levels, there was a social class gradient for sport. We have shown that competitive sport is not 'for all', as only small percentages of the adult population in West of Scotland participate.70 We suggest that walking offers the greatest potential for promoting increased physical activity in the population 37,91,92,175 Materials from our research have been distributed by the Department of Transport, Region and Environment throughout the UK to encourage active commuting to work.92 We have evidence that individualised approaches to physical activity promotion, based on behaviour change models, will increase activity for normal and clinical populations.23,76,116
We have also reviewed the relationship between physical activity and mental health, and concluded that physical activity can promote mental health and prevent or treat mental illness.1,22 We have shown from the Twenty-07 data that some modes of activity, such as housework, may not have a positive effect on mental health.
Ursula Berger, Research Associate on the Twenty-07 Study
Relationship between diet and socio-demographic and lifestyle characteristics (Mehri Ebrahimi-Mameghami, with Dr Jane Scott, Department of Human Nutrition University of Glasgow) A varied diet is known to protect against chronic diseases and is associated with prolonged longevity. We have examined the relationship between food variety and selected socio-demographic and lifestyle characteristics. Amongst the 35 year-old cohort, men and subjects who consume alcohol are more likely to be "less varied eaters" (consume < 20 biologically different foods per week) than women and non-alcohol users. Future analysis will investigate whether food variety is predictive of health outcomes in this population.
Expert groups recommend that individuals restrict their weight gain over adulthood to less than 5 kg. Initial analysis has revealed that approximately one third of subjects in the two adult cohorts has gained 5kg or more during the period of 1987-1995. Future analysis will study predictors of weight gain and the relationship of weight gain to health outcomes.
Mehri Ebrahimi-Mameghami, Researcher on the Twenty-07 Study
Socioeconomic and spatial patterning of longitudinal changes in body size and functioning in two age cohorts (McLoone, Ellaway & Ford) Using data for the two adult cohorts (aged 35 and 55 at first contact in 1987/8) in the Regional sample of the Twenty-07 study, we have investigated changes in the social distribution of six physical health measures (height, weight, body mass index, lung capacity, systolic and diastolic blood pressure) at two time points (1987/8 and 1995). At both sweeps, social class gradients were apparent for height, weight and forced expiratory volume in men, and in height and forced expiratory volume in women. However, preliminary analysis found no evidence that social class or area patterning in these six health measures widened as the two populations aged, suggesting that social gradients had been generated earlier in life. The analysis will be extended to 2000-2002 data to provide a 13 year follow up. 25629_Txt 9/8/02 9:21 AM Page 7
8 The MRC Social and Public Health Sciences Unit
Social & Spatial Patterning of Health
The relationship between social capital/social cohesion, perceptions of the neighbourhood, and health (Ellaway, Macintyre and McKay) It has been proposed that an unequal income distribution is associated with poorer health, and that a lack of social cohesion might be the explanation. Social cohesion has usually been measured indirectly via proxy measures such as participation in local community groups. In the 1997 postal sweep of the Twenty-07 Study we used the Neighbourhood Cohesion Index (Buckner 1988). Respondents who were older, lived in owner-occupied houses in more affluent areas, and who were not working outside the home, reported significantly more positive assessments of neighbourhood cohesion, independent of sex, social class and family circumstances. There were also significant associations between neighbourhood cohesion and self assessed health, mental health, and number of symptoms, after controlling for socio-demographic factors.46 We have previously reported that belonging to a local association was not associated with self perceived health or recent symptoms, after controlling for individual age, sex and social class, but that aggregate membership at the postcode sector level was associated with better self-reported health after controlling for individual characteristics. The effect of social capital on health, if it exists, may thus operate through collective rather than individual mechanisms. To test this hypothesis further, we have sent a postal questionnaire, focusing on a number of dimensions of social cohesion, collective efficacy, social trust, community participation etc, to a random sample of adults from the electoral roll resident in our West of Scotland Twenty-07 study Localities (achieved sample size = 2355, response rate 44%). We plan to compare the relative contributions of aggregate neighbourhood levels of social capital, measured by this survey, and individual levels of social capital, measured in the Twenty-07 study, to health and everyday life among our locality respondents. We examined gender differences in perceptions of the neighbourhood using 1997 data from our Twenty-07 study localities. Whether or not one observes gender differences in perceptions of area depends on the particular domain used; eg, there were no gender differences in perceived neighbourhood cohesion, but women had significantly more negative assessments than men of problems in the local area. Gender differences seem to be related to domestic circumstances, the most negative perceptions being in women with children who were not employed outside the home. This lends some support to the idea that women at home with children may be more exposed, or more sensitive, to features of their local neighbourhood than men or women in employment. Poor opinions of the neighbourhood were more strongly associated with mental health among men, and more strongly associated with physical symptoms amongst women.8
Localities 10 years on (Flint, Ellaway & Macintyre) We first studied environmental characteristics of the West of Scotland Twenty-07 study localities in 1987. In 2001 we updated information about the demographic, service provision, collective social functioning and socio-economic characteristics of the localities in 1997, and compared these with data collected in 1987. It appears that the North West Locality continues to have better service provision, as in 1987, but that for some services the gap between the Localities has been slightly reduced (e.g. the number of shops per thousand residents). This reduction seems to be due to improvements in the South West Locality rather than declining service provision in the North West.225 We have also built up a catalogue of photographs for the study localities, so that we can examine public visual expressions of their social and physical environments.45
Other studies Trans-generational and life course influences on birth outcome and health - the Aberdeen Study (Grant of £160K from MRC to Macintyre, and Dr. David Leon and Dr. Bianca de Stavola, Department of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, and Dr. Doris Campbell and Dr. Marion Hall, Department of Obstetrics, Gynaecology & Reproductive Physiology, University of Aberdeen) The study is following up 15,000 primary school children born between 1950 and 1955. In December 1962 these children, then aged 7 to 12 years and at school in Aberdeen, undertook a series of standardised reading tests and provided information about parental occupation, family circumstances, and number of siblings. Information was also obtained from school test records, including IQ at ages 7 to 9, and school health records on height, weight, visual and hearing acuity. For the 90% of these children who were born in Aberdeen, information was extracted from maternity records about maternal and perinatal characteristics. 25629_Txt 9/8/02 9:21 AM Page 8
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For a random 1:5 sample, detailed interviews were conducted with the mother on issues such as common childhood infections, family circumstances, attitudes and child behaviour. We have traced the current vital status of the study members born in Aberdeen, and have circulated those still alive, and traced to Scottish addresses, with a questionnaire, collecting information on historical and current socioeconomic circumstances, self-reported height, weight, health and fertility histories. Those resident in England are now being contacted. We also plan to collect data from historical sources about the neighbourhood and school characteristics in Aberdeen in the 1950s and 1960s.
Healthy Old People in Edinburgh (HOPE) study (Grant of 60K from the Chief Scientist Office to Dr. John Starr, Centre for Study of the Ageing Brain, University of Edinburgh, Professor Ian Deary and Dr. Elizabeth Austin, Department of Psychology, University of Edinburgh, and Macintyre. 1999 - 2001.) The Healthy Old People in Edinburgh Study involved 603 community-resident healthy people, aged 70 years and over, resident in Edinburgh, and first studied in 1990/1. Participants were followed up in 1994/5, 1997/8 and 1999/2000. The aim is to determine key predictors of, and associations with, successful ageing. At the fourth wave 201 participants were visited and adequately re-tested. Among those first studied in 1990/1, the lowest subsequent mortality rates were, unusually, among the non-classified occupational group, who in this case comprised mostly women who had never worked. Other than an association between condensation in the home and disability, none of the household social network or socio-environmental variables were significantly associated with wellbeing, fitness, or self-perceived health. The lack of socioeconomic or environmental associations with successful ageing may stem both from the nature of this cohort (successful survivors at 70), and from the Edinburgh environment (there was little variation in reported access to local facilities and amenities).
Early Life Predictors of Cognitive Change and Physical and Mental Health Inequalities in Old Age: a pilot/feasibility study (Grant from MRC to Professor Ian Deary, Dr. Harry Campbell, Dr. John Starr and Professor David Porteous, University of Edinburgh, Professor Lawrence Whalley, University of Aberdeen, Dr. Valerie Wilson, Scottish Council for Research in Education, Dr. James Chalmers, Information & Statistics Division, National Health Service Scotland, and Macintyre) In 1947 the Scottish Mental Survey (SMS 1947) collected validated cognitive ability test scores for almost all children born in Scotland in 1936 (n=70,000+). The aims of this pilot/feasibility study were to assess the feasibility of tracing and recruiting SMS 1947 survivors for interview and medical testing, and linking SMS 1947 data to health records. A sub-sample of 400 people in Aberdeen was successfully traced, recruited, and tested and found to be agreeable to most of the testing procedures. The pilot project also permitted the identification of additional archival data for sub-samples of SMS 1947 (including birth data for those born at Simpson Memorial Maternity Pavilion in Edinburgh, chest x-rays at age 22 in Edinburgh, and mid-life data from the West of Scotland Collaborative Study). Funds will now be sought to undertake the full follow-up.
Material & social characteristics of areas and their relationship to the health of residents (Cummins: grant of £264K from MRC Health of the Public Research Programme to Macintyre, Ellaway, and Professor Michael Marmot and Mai Stafford, Department of Epidemiology & Public Health, University College London Medical School, and Robert Erens, National Centre for Social Research, 2000-2003). A number of studies in the UK and elsewhere report that area of residence predicts health, over and above the characteristics of the individuals living in that area. We are interested in exploring what features of the local environment might influence health, and how.81 This study has two components: a community-based questionnaire investigating levels of social cohesion, density of social networks and levels of social control (conducted by the London team); and the collection of data on neighbourhood level social and material infrastructure (conducted by the Glasgow team). We have collected a wide range of data about publicly and privately provided services and amenities, and collective social functioning, in 182 wards in England and 81 postcode sectors in Scotland. These data will be linked to measures of health in the same neighbourhoods (derived from the Health Survey for England and the Scottish Health Survey) in order to investigate whether: (i) residents in areas with lower levels of social capital have poorer health, (ii) residents in areas with poorer material characteristics have poorer health, and (iii) the effects on health of material characteristics and social capital vary according to the socio-demographic characteristics or region. 25629_Txt 9/8/02 9:21 AM Page 9
10 The MRC Social and Public Health Sciences Unit
Social & Spatial Patterning of Health
Housing tenure and car access: why do they predict health and longevity? (Hiscock, grant of £120K from ESRC Health Variations Programme to Macintyre and Ellaway, and Professor Ade Kearns, Department of Urban Studies, University of Glasgow, 1996 - 1999) This project investigated the social meaning and practical significance of housing tenure and car access, which have been shown to be associated with health and longevity. It examined the psychological, social and physical mechanisms by which ownership of, or access to, such assets might contribute to socioeconomic variations in health. This study had two components: a postal survey of adults living in the West of Scotland (achieved sample of 2,867 individuals, response rate 50%), and in-depth interviews with a sub-sample of 43 respondents. All health measures studied in the postal survey were significantly associated with tenure and car access. Although these relationships were less strong after control for income or socioeconomic class, they were still present.80 Socioeconomic and socio-demographic characteristics predict one's ability to access socially desirable assets such as owner occupation and access to private transport; these resources in turn confer two types of health promoting benefits: psychosocial ones relating to control, status, and security, and more practical ones relating to protection from health damaging features of the immediate environment such as damp or cold in the home, noisy or abusive neighbours, and inconvenient, dirty, slow and dangerous forms of public transport. The benefits conferred by owner occupation and car access varied between differently situated population groups, and both tenure and car access were more predictive of health among men than among women.14,66,67,68
Lifestyle and Physical Environmental Factors Associated with Overweight and Obesity (Billie Giles-Corti, Department of Public Health, The University of Western Australia, and Macintyre). The aim of this project was to examine associations between overweight or obesity, lifestyle, and social and physical environmental factors. It involved a cross-sectional survey of healthy, sedentary workers and home-makers, aged 18-59 years, living in areas of high and low deprivation in metropolitan Perth, Western Australia. An environmental scan was made of recreational facilities and features of the built environment. In contrast to previous findings from the West of Scotland, the level of deprivation in the area of residence was not associated either with the distribution of recreational facilities or with the prevalence of overweight or obesity. However, both self-perceived and directly measured features of the physical environment were associated with obesity; for example, perceiving no shop within walking distance, and having poor access to recreational facilities and footpaths predicted obesity. This suggests that the concept of obesogenic environments warrants further consideration.
Area, diet & health: socio-spatial variations in urban food price and availability (PhD Project: Cummins, supervisor Macintyre) Previous research has suggested that the foods recommended in current health guidelines may be more expensive and more difficult to obtain in poorer areas. This may, in part, help to explain why adherence to healthy eating guidelines is lower in more deprived places. This project investigated this "supply-side" explanation by systematically examining area variations in the price and availability of standard food items in the Greater Glasgow Health Board area. A survey of all "multiple stores" (n = 79) and a random sample of "non-multiple stores" (n = 246), using 57 food items derived from the Family Budget Unit's "modest but adequate" diet, was undertaken in 1997. Contrary to findings in previous research, we found food stores to be located more frequently in more deprived health board localities and postcode districts, and food items to be no more expensive in more deprived than in more affluent neighbourhoods.39 Official government documents have recommended policies to combat the existence of food deserts, however what little evidence there is for their existence is limited and contradictory.38 Interventions to improve poor physical access to food in deprived areas must be based on updateable, systematic and robust evidence. 25629_Txt 9/8/02 9:21 AM Page 10
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Gender and Health
There has been substantial recent interest in gender differences in health. Current research is beginning to take a far more critical view of gender, and of its links with health. There has been an increasing emphasis on theoretical developments in gender studies (particularly masculinities), and in the similarities as well as differences between men and women which are found in empirical research. We are currently undertaking a number of studies on both the patterning of various health indicators by gender and of the relationship between gendered constructions of identity and health, using a range of methodologies.
Kate Hunt, Head of the Gender and Health Programme
Gender and morbidity/mortality Scoping review of evidence on gender and coronary heart disease and lung cancer (Hunt, Elwy, Petticrew) This project was undertaken on behalf of the World Health Organisation (WHO) in response to growing concerns about the increasing toll of non-communicable diseases (NCDs) worldwide. NCDs such as heart disease and lung cancer are estimated to account for around 19 million deaths worldwide, and about 46% of total deaths from these causes occur in the developing world. Heart disease is often seen both by the public (see below) and by health professionals as a 'male' disease. However, ischaemic heart disease (IHD) is the leading cause of deaths worldwide in women as well as men, accounting for an estimated 14.6% of deaths in women and 12.8% in men.
In view of the enormity of the literature on NCDs worldwide and the time constraints imposed, we limited our scoping review to recent literature, published in the English language in the period 1996-2000 inclusive, reporting evidence on gender and CHD and lung cancer. Even with this restricted focus, nearly 4000 abstracts were reviewed on heart disease alone. The current evidence was heavily dominated by studies conducted in particular countries, concentrated in those countries with greater female advantage in life expectancy (generally in the more developed countries). For example, 88% of over 300 relevant papers on CHD (identified from nearly 4000 abstracts) were based in countries falling within the highest two quintiles of gender difference in life expectancy. One third of all papers were from the United States alone. When papers from seven countries ranging across the quintiles of gender difference in life expectancy were examined in more detail, the lack of a gender focus was striking. Furthermore, although all selected studies had to include both men and women to satisfy one of the review's inclusion criteria, few systematically commented on or discussed differences and similarities in their results for men and for women.
Although the gendered distribution of risk factors for these NCDs (such as smoking) vary strikingly worldwide, much of the epidemiology and understanding of diseases such as heart disease and lung cancer are dominated by the aetiological models that pertain in the more developed world. However, the risks for and consequences of these diseases for men and women may be very different in different economic and cultural settings.221 25629_Txt 9/8/02 9:21 AM Page 11
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Gender and Health
Gender differences in minor morbidity amongst men and women working full-time in the same white-collar jobs (Emslie, Hunt and Macintyre) Most existing research on gender differences in health has compared men and women in aggregate, without taking full account of their different occupational distributions. We have previously reported on two studies which examined men's and women's perceptions of paid employment and their experiences of minor morbidity when working full-time in two white-collar organisations, a bank (n=2176) and a university (n=1641). These studies collected data on health and health behaviour using self-completed questionnaires. We have extended these analyses to examine patterns of key health behaviours, and to compare gender differences in mental health in these and another large group of white-collar workers in the British Civil Service (in collaboration with colleagues at University College London and St Bartholomew's and Royal London School of Medicine and Dentistry).
Recently concerns have been expressed about the effect of media images which equate female attractiveness with extreme thinness, although most research to date has focused on very young women. Our questionnaires included questions on body weight and body image. Women were less likely (and significantly so in the Bank) than men to be overweight (BMI over 25 kg/m2). However, even after controlling for job grade, organisation, self-esteem and BMI, women were much more likely than their male colleagues to consider themselves to be too heavy for their height in both organisations. They were nearly 4 times as likely as to see themselves as being overweight in the University, and 10 times more likely to do so in the Bank.50
We also compared self-reported drinking and smoking amongst men and women in these two organisations. There were no significant gender differences in current smoking in either organisation, but men were significantly more likely than women to report drinking 'heavily'. Employment grade was associated with both outcomes; clerical employees were around twice as likely as their more senior colleagues to smoke, but were significantly less likely to report drinking 'heavily'. Both men and women with high masculinity scores (as measured by the Bem Sex-Role Inventory) were significantly more likely to smoke. Those with high masculinity scores were also more likely to report 'heavy' drinking in the Bank. These associations with high masculinity scores and health damaging behaviours in both men and women point to the importance of considering gender role orientation and contemporary constructions of masculinity and femininity in understanding health behaviours.48
We have also examined mental health and gender in three white-collar organisations, the Bank, the University and the British Civil Service. Although gender differences in mental health are expected and usually seen, most research fails to control for the gendered distribution of social roles, and does not compare men and women in similar positions. When we compared GHQ scores in men and women in the three organisations, controlling for domestic and social circumstances and engagement in paid work, women had slightly higher levels of psychiatric morbidity, but gender differences were much smaller than those commonly reported or general population samples.49 25629_Txt 9/8/02 9:21 AM Page 12
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Gender, disability and occupational exposures (Hunt, with Dr Joy Adamson and Prof. Shah Ebrahim, Department of Social Medicine, Bristol University) By their late fifties over a quarter of the oldest cohort of the Twenty-07 Study had some evidence of locomotor disability. When adjusting for gender, those in manual social classes were over two and a half times more likely to have locomotor disability than those in the non-manual social classes. Adjustment for cumulative exposures to physical occupational hazards substantially attenuated the association between social class and locomotor disability, suggesting that most of the observed association between social class and locomotor disability, at early old age, is explained by a combination of degree of affluence and occupational exposures. However, before controlling for socio-economic position and occupational exposures the association between gender and locomotor disability was underestimated. Women's increased risk of having a locomotor disability (adjusted for household social class) was strengthened after adjustment for additional measures of socio-economic position and for cumulative occupational exposures, and women were over two times more likely than men to report locomotor disability (p<0.001).
Co-morbidity amongst men and women with and without 'Rose' angina (Hunt, with Dr Helen Richards, Highlands and Islands Health Research Institute, University of Aberdeen, and Jeremy Walker, Department of General Practice, Edinburgh University) Experience of co-morbidity in men and women in the older two cohorts of the Twenty-07 study, who have been assessed for 'angina' using the Rose Angina questionnaire is being examined. Rose angina (RA) 'cases' reported significantly more conditions than non-cases (median number 4.0 and 2.0 respectively; p < 0.01), and those with more severe angina reported more conditions than those with less severe angina. Eighty per cent of RA cases had 3 or more (other) chronic conditions, in contrast to 35% of RA non-cases. The unadjusted odds of having a co-morbid condition were significantly elevated for women across a range of condition groups, whilst for men, the relative odds were only significantly elevated for musculo-skeletal and mental health conditions in the younger cohort; and for other cardiovascular, respiratory and mental health conditions in the older cohort. When adjustments for common behavioural and socio-economic risk factors were made, some differences in the relative risk of comorbidity by gender remained. The relative odds remained significant for all major condition groups amongst women in the younger cohort and for all except mental health conditions in the older cohort. In men, the adjusted odds were only significantly elevated for musculo-skeletal conditions in the younger cohort; and for other cardiovascular and respiratory conditions in the older cohort.
Changing relationships between gender role orientation and health in different generations (Hunt) There have been a number of recent critiques of the prevailing paradigm of research on gender and health in the latter part of the twentieth century. One such criticism has centred on the ahistoric and decontextualised way in which much evidence for gender differences has been used, despite substantial changes in gender relations which are likely to have affected the experience, opportunities, and attitudes of different cohorts of women (and men).15,69 Analysis of the Twenty-07 data, which has unusually rich longitudinal data on gender, including occupancy and experience of gender-related roles, attitudinal data on gender equality, and measures of gender role orientation (GRO), has examined whether relationships between GRO and health are similar in different generations. The data show substantial differences in the experiences of two older cohorts of women (those born in the early 1930s and early 1950s), and a lack of consistency between measures of GRO and health. The fact that these differences are apparent even within a relatively confined geographical locale and over a relatively short period of time points to the need to take more account of the broader (social, historical or political) context.69 25629_Txt 9/8/02 9:21 AM Page 13
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Gender and Health
Social construction of gender and health (Emslie and Hunt) A more detailed exploration of the ways in which changes in constructions of gender may have impacted on health of the three generations studied in the Twenty-07 study is ongoing. Qualitative interviews are ongoing with sub-samples from the Twenty-07 study, comparing men and women who have more typical biographies for their age and sex with those who have less typical biographies, or those whose scores on measures of gender role orientation were atypical.
Gendered constructions of heart disease in lay epidemiology (Emslie and Hunt) Analyses of qualitative interviews with men and women in their forties suggest the profound extent to which people consider coronary heart disease (CHD) to be a 'male' disease. The language and metaphors used to describe the heart and its functioning were gendered. Furthermore, people's accounts of those who were both likely and, more surprisingly, unlikely 'candidates' for heart problems all centred on men. Only when specifically asked about particular relatives did people talk about women with heart problems. While accounts about male 'victims' focused on sudden, fatal heart attacks,51 accounts about female 'victims' usually concentrated on long-term illness caused by heart problems.52 These qualitative data were collected as part of a project concerned with lay understandings of health, and particularly perceptions about the inheritance of heart disease (see page 44). In this study the group that was most ambivalent about whether they had heart disease in their family were those at highest epidemiological risk, i.e., men from less affluent backgrounds.72 Allied quantitative analyses showed that women are more likely to report having a family history of heart disease than men.
Gender and smoking Smoking and gendered identity amongst women: 1890-1990 (Completed PhD:[120] Rose Elliott, Wellcome History of Medicine Unit, Glasgow University, supervisors Dr Marguerite Dupree, and Hunt) This project examined how smoking changed from being seen as an exclusively male habit and problem in the late nineteenth century in Britain to being of concern to women by the end of the twentieth century, both in terms of health and constructions of female identity.134 The project utilised a wide range of materials to examine links between women's smoking and identity throughout the century. This included: an examination of papers on smoking in the British Medical Journal, and a review of papers in the Public Records Office over the century; an analysis of accounts of smoking in existing oral history archives;224 interviews with key players in the public health debate around smoking in the second half of the century; and oral history interviews with two groups of women (growing up in the 1920s and the 1970s).133,134 A series of oral history interviews with a comparable sample for men is ongoing to examine the extent to which women's gendered constructions of smoking133,134 are shared by men from the same generations.
Gender, gender role orientation (GRO) and smoking in three generations (Hunt, Hannah) Ongoing analysis of the relationships between smoking, GRO and class in men and women in all three cohorts of the Twenty-07 Study has demonstrated that these differ in each of the sex/age groups. These differences are perhaps to be expected given that we were examining this relationship amongst people born in the early 1930s (who reached adulthood when smoking was at its height), the early 1950s (who reached adulthood as active promotion of smoking, particularly to women, continued despite wider acceptance of smoking-related disease), and the early 1970s, reflecting the complex and changing ways in which smoking has been linked with changing gendered identities throughout the twentieth century (see above). 25629_Txt 9/8/02 9:21 AM Page 14
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Smoking and the media: an analysis of gender and smoking in Thunderbirds (Hunt) Thunderbirds, a cult children's puppet show made originally in the 1960s when smoking prevalences among both men and women were high, was re-released to new audiences of young viewers in 2000. Given interest in the impact of smoking scenes in films on the smoking behaviour of older (teenage) children, we analysed the imagery of smoking presented in this children's series. Smoking is seen in over 80% of the 32 episodes, and its depictions largely associate smoking with success, wealth, health, glamour, leisure, and, for one of the main female characters at least, chic rebellion. Such images are close to those which the tobacco industry still seeks to promote in a more restrictive advertising environment than existed when Thunderbirds was originally produced. (Hunt, in press)
Men's health Men's Health: Masculinity, identity, and health (PhD Project: O'Brien, supervisors Hart and Hunt) Although health science has frequently included men as research subjects, the relationship between men's health and men's gender remains under-researched. This PhD project explores men's perceptions of 'maleness', their identity as men, whether the 'practices of masculinity' undermine men's health, and how illness may challenge masculinity. The analysis examines the accounts from fifty-nine participants in fifteen focus group discussions. The groups were purposively sampled to explore different ways in which masculinity and health may be linked: for example, groups of men of different ages (range 15 to 72 years) were interviewed to explore the experience of, and responses to, social and personal change at different life stages; and the accounts of men in good health were compared to those from men who had experienced serious illness (prostate cancer, coronary heart disease, M.E, and mental illness) who described a loss of masculinity and the disruption to their gendered biographies. The analysis is ongoing and focuses on areas of men's lives where issues related to masculinity or health come to the fore.
"Unwarranted survivals" and "anomalous deaths" from coronary heart disease Hunt and Emslie, with Professor Watt and Alex McConnachie, Department of General Practice, and Dr Carol Hart, Department of Public Health, Glasgow University Our qualitative research on lay understandings of heart disease reinforced the importance of well-recognised 'anomalies' to accepted notions of 'coronary candidacy' (see page 14) which undermine medical advice to avoid coronary disease risks. We assessed survival at the extremes of highly visible risk (based on obesity and history of heavy smoking) in over 6000 men who participated in the Midspan Study in the 1970s. Differences in survival were dramatic. Over 80% of the deaths from heart disease in the "low visible risk" group were associated with other less obvious risks for heart disease, such as poor lung function, diabetes, previous heart disease and poorer social circumstances. Similarly, three quarters of the surviving men at high visible risk had protective factors such as being taller and having lower cholesterol levels, which may help to explain their unexpected survival).84
Masculinity and perception of gender roles among older men (Emslie and Hunt) Recent research on 'masculinities' has largely ignored the experiences of older men. Semi-structured interviews have been conducted with men purposively selected from the oldest cohort of the Twenty-07 Study. Analysis is ongoing and focuses on the process of 'becoming a man' in a particular geographical and historical context, experience of, and attitudes to, gender roles and the ways that particular forms of smoking and drinking are constructed as gendered activities.
Edna Mcintyre, Secretarial Assistant 25629_Txt 9/8/02 9:21 AM Page 15
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Sexual and Reproductive Health
This programme seeks to understand the social factors that either encourage or militate against sexual and reproductive health, and to identify means of preventing unwanted sexual outcomes and of promoting positive sexual health. Last year the programme did this in five strands. The first is the evaluation of sexual and reproductive health interventions, for young people and gay men. The second strand investigates continued sexual risk behaviour for HIV infection in gay men. Sexual health and gender is the main focus of strand three, and strand four is concerned with the occupational health of female and male sex workers. Finally, strand five is concerned with sexual and reproductive health in resource-poor countries.
Graham Hart, Associate Director of the Unit and Head of the Sexual and Reproductive Health Programme
Evaluation of sexual & reproductive health interventions
Does a specially designed teacher-led sex education programme reduce sexual risk-taking? A randomised controlled trial of SHARE in Scottish schools (Wight, Henderson, Buston, Hart: grant of £606K from MRC to Wight, Hart and Professors Sue Scott, University of Durham, Charles Abraham, University of Sussex, and Gillian Raab, Napier University, from 1996-2000) This study is evaluating whether a specially designed sex education programme in schools has any effect on young people's sexual risk-taking.113 Twenty-five schools were randomly allocated either to deliver the new SHARE programme4 or to continue with their existing sex education. Questionnaires were administered at the start of S3 and approximately six months post-programme at the start of S5, with 5,854 young people participating at follow-up. At baseline (mean age 14 years, 2 months) 18% of boys and 15% of girls reported having had intercourse. The most important correlate of sexual experience was low level of parental monitoring. Sixty per cent reported condoms were used throughout their last sexual episode. The key predictor for condom use was whether or not the respondent talked to their partner about protection before having sexual intercourse.65 At follow-up (mean age 16 years, 1 month) 31% of boys and 41% of girls reported having had intercourse.
An 'intention to treat analysis' shows that, in comparison with conventional sex education, the SHARE programme is evaluated more positively by pupils and leads to greater practical sexual-health knowledge. However, it has only a limited effect on the quality of relationships (less regret of first sexual intercourse with most recent partner) and no effect on condom use amongst the third of respondents who are sexually active at this age. It does not encourage or delay early sexual activity.113 Further analyses indicate that the lack of behavioural effects was not due to quality of delivery. Differences in rates of sexual activity by school have been analysed, controlling for all known predictors of sexual activity.151 Clear 'school effects' have been found, but it is not yet apparent whether they are attributable to features of the school or local area. 25629_Txt 9/8/02 9:21 AM Page 16
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A process evaluation investigated the extent and quality of delivery of sex education, the mechanisms through which it might work and contextual factors that might facilitate or impede effectiveness.25 This was done through teacher questionnaires and interviews, pupil interviews, group discussions and classroom observation. At baseline there was considerable variation in sex education provision, attributable primarily to the school's ethos, the role of key individual teachers with responsibility for sex education, the cohesion of the Guidance team, and the characteristics of individual classroom teachers.31 Teachers had varied approaches to dealing with sexual orientation and identity. Teacher interviews suggest that inclusive approaches are constrained by teacher discomfort, lack of support from senior management, worries about perceived lack of neutrality, and fear of negative pupil reactions.32 The main factors facilitating implementation of SHARE were the compatibility of the programme with existing PSE provision, intensive teacher training, and senior management support. The greatest constraints on delivery were competition for curriculum time, brevity of lessons, teachers' difficulties with skills-based lessons and, in some schools, the low priority accorded to sex education by senior management.33 Interviews with female pupils in six schools found that nearly all cited school as a useful source in learning about sex, though it tended to be seen as an introduction or supplement to other sources (friends, magazines and mothers). Lessons to develop skills were particularly valued and thought likely to influence behaviour positively in the future, though sex education was commonly thought to have been delivered 'too late.'34 Interviews with both male and female pupils found that the majority felt uncomfortable in sex education lessons, with gender dynamics in the mixed-sex lessons being the main problem. Discomfort manifested itself in reluctance to ask questions and/or to participate actively in lessons, as well as in disruptive behaviour. Four factors which reduced pupils' discomfort were: a protective teacher, a friendly teacher, trust between pupils, and fun sex education.29
An evaluation of a community-level sexual health intervention for gay men in Scotland (Hart, Williamson) The Gay Men's Task Force (GMTF) intervention aimed to reduce HIV-related risk behaviour amongst gay and bisexual men. Two papers on the evaluation of this intervention have now been published.54,114 In comparing Glasgow, where the GMTF took place, and Edinburgh, where routine services were provided, intervention effects were limited to those men who had direct contact with peer-educators, and were not evident at the community level.54 The changes that did occur were also limited to the up-take of HIV testing and hepatitis B vaccination: no impact on gay men's sexual behaviour was demonstrated. The second paper takes this analysis further, and interrogates the range of impacts that the GMTF had on those men who had some level of contact with the intervention.114 This finds that, amongst men who reported speaking with peer educators, 49% reported thinking about changing their sexual behaviour and 26% reported changing their sexual behaviour. Logistic regression demonstrated higher levels of HIV testing, hepatitis B vaccination and use of sexual health services amongst men who reported contact with the intervention. Peer education dose effects were apparent, with the likelihood of HIV testing, hepatitis B vaccination and use of sexual health services being greater amongst men who reported talking to peer educators more than once. In the absence of community-level effects, we believe that the GMTF trained volunteers to become indigenous health outreach workers, rather than peer educators, and that they were successful in facilitating access to sexual health services, but not in changing community level norms or behaviour with regard to safe sex. We have also compared our experiences with those of colleagues undertaking gym-based peer education in London: neither study was able to demonstrate normative change.13,145 A third wave of data collection in the bars of Glasgow and Edinburgh was completed in March 2002. These will be compared with the 1996 and 1999 data to evaluate longer-term intervention effects and to address other recent developments regarding gay men's sexual behaviour and HIV, such as increases in sexually transmitted infections. 25629_Txt 9/8/02 9:21 AM Page 17
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Sexual and Reproductive Health
The role of research evidence in formulating sex education policy in Scotland (PhD Project: Helen Harper, Supervisors: Wight, Petticrew MRC-funded studentship) This project offers a unique opportunity to understand the role that research plays in informing policy. It will investigate how evidence on effective sex education, including the outcomes of the SHARE sex education trial (described above), is used in policy-making. Factors which facilitate and impede the use of such evidence will be studied, as well as the relationships within and between policy-making organisations and research centres. In-depth interviews have begun with a range of individuals from various organisations that are involved in formulating sex education policy in Scotland. Documentary analysis is also planned.
Gay men's sexual risk behaviour Sexual risk behaviour and relation to antiretroviral therapy in HIV positive gay men (Hart with Drs Judith Stephenson, John Imrie, Ian Williams, Oliver Davidson, Department of Sexually Transmitted Diseases, University College London. Funding: MRC, Oct 1998-Sept 2000; £201K) The purpose of this study is to describe systematically the sexual behaviours and sexual health needs of gay men who know they have HIV infection, and to explore the impact of new therapies on HIV-related risk behaviour. The study has quantitative and qualitative components. We have found that the assumption that men on antiretroviral therapy are more sexually active than those who are not - because of a 'return' of libido after the start of therapy - is incorrect.157 HIV positive men not receiving treatment were significantly more likely to report unsafe sexual behaviour than those who were on treatment. This may account for another of our findings: that HIV positive men not receiving treatment were more likely to have had a sexually transmitted infection in the last year than those who were on treatment.158 In qualitative interviews men spoke of different approaches to risk assessment in relation to viral load and reinfection, drawing on their experiences and the clinical advice given to them.40 This diversity is connected with various risk management 'styles' that reflected positions about HIV transmission risk, the characteristics of the partner and the sexual situation. This was further interrogated in relation to disclosure of HIV status. This was found to be partner and context dependent, and certainly did not result in disclosure to every partner.143 Further analysis is indicating that future interventions need to acknowledge the wider context of living with HIV, involve health care providers as well as patients and encourage further consumer participation of people with HIV in intervention design and delivery.
Catherine Ferrell, Unit Survey Manager 25629_Txt 9/8/02 9:21 AM Page 18
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Transitions in HIV management: the role of innovative health technologies (Hart, with Dr Paul Flowers, Department of Psychology, Glasgow Caledonian University; John Imrie, Department of Sexually Transmitted Diseases, University College London. Funding: ESRC, April 2001 - Mar 2003; £200K) The recent advent of highly active anti-retroviral therapy (HAART) for HIV disease has been responsible for dramatic reductions in AIDS deaths in developed countries. Alongside these new treatments, other innovative health technologies (IHTs) in the form of tests of viral load, and those that assess viral resistance and measure drug concentration levels, have changed dramatically the experience of being HIV positive in recent years. From being an acute, life-threatening disease AIDS has become a chronic condition requiring long-term management. This has resulted in radical shifts in the HIV positive identity and nature of people's understandings of the risks of HIV. This research will undertake a comparative analysis of the management of HIV IHTs in two cities (London, Glasgow) and in a range of health service and non-governmental organisations. Following a literature review and media analysis (addressing both the construction of IHTs in HIV management and their efficacy and utility) we will undertake an interview-based ethnography of HIV management across the two settings. The research focuses upon transitions: in bodies of knowledge, embodiment, identity, risk management, roles and responsibility. We investigate these transitions at both the individual level and in terms of the social organisation of HIV services. The study also seeks to contribute to our understanding of the transformation of the meanings of illness and health as HIV management becomes increasingly medicalised, and new risks associated with medical intervention (e.g. side effects and drug resistant virus) proliferate.
Sexual health and gender Screening for Chlamydia Trachomatis: the social implications (Hart, with Dr Barbara Duncan, Department of Psychology, Glasgow Caledonian University; 1997-2002) Following government recommendations that screening for the sexually transmitted infection (STI) Chlamydia trachomatis should be considered in the UK, we are undertaking three studies which are investigating the social implications of such an initiative. The first study employed individual interviews and focus groups with young Glaswegian women. Results suggested that women considered attendance at genitourinary medicine clinics to be stigmatising,98 and believed that male attitudes surrounding sexuality, sexual health and sexually transmitted infections may be a significant barrier to the success of Chlamydia screening.43,44 In response to these findings, we carried out the first part of an investigation of heterosexual men's attitudes to sexual health (including STIs and unplanned pregnancy). Eight individual interviews with men diagnosed with an STI and six focus groups with young men in the community have been carried out. Results indicated that heterosexual men's understanding of sexual health is generally limited and there may be significant barriers to improvement of such understanding. The second part of this project, which began early in 2002 with funding from Greater Glasgow Health Board, investigates attitudes to service use, and perceived gender differences in perceptions of responsibility for sexual health. Results from these studies will inform policy for a future service delivery, including the Chlamydia screening programme, and will provide insights into gender issues in sexual health.
Effectiveness of Interventions to Prevent STD/HIV in Heterosexual Men: Systematic Review (Elwy, Hart, Petticrew and Dr Sarah Hawkes, London School of Hygiene & Tropical Medicine) Heterosexual transmission of HIV is increasing globally. This is despite widespread efforts to prevent the spread of the disease through behavioural and educational interventions, and services aimed at offering free HIV testing and counselling. STDs, including HIV, are more easily transmitted from men to women than women to men. Apart from increased biological risk of transmission, women may also be at high risk of STDs and HIV because of gendered power relations, and may not be able to decline sexual intercourse with their partners or insist upon the use of barrier methods for protection. Yet there have been no attempts to systematically review studies which have reported on the efficacy of interventions to reduce the sexual risk behaviour of heterosexual men. Previous systematic reviews were limited to North American interventions; there are no reviews of the association between men's sexual attitudes and their sexual behaviour in other parts of the world. Also, few reviews in this area have assessed the effectiveness of interventions to prevent the spread of STDs, along with HIV, in heterosexual men. Given that efforts to prevent the spread of HIV through treatment of STDs in women and men have proven effective, it is imperative that systematic reviews to determine the effectiveness of interventions to prevent HIV infection include interventions targeting STDs. This systematic review takes account of the above limitations, and seeks to determine the most effective social and behavioural means of improving the sexual health of heterosexual men. 25629_Txt 9/8/02 9:21 AM Page 19
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Sexual and Reproductive Health
Contraceptive careers: influences, choices and risks among young women (PhD Project: Williamson, Supervisors: Buston, Sweeting) This project explores contraceptive use reported by a sample of young women in Scotland. It aims to describe young women's patterns of contraceptive use, considering whether these constitute 'contraceptive careers', and to identify the factors that affect these careers. A key question is the extent to which contraceptive use is for disease or conception prevention, and whether one these predominates at different times in young women's lives. The project investigates a variety of influences on young women, their choices, and subsequent risks. Longitudinal analysis of quantitative data from the SHARE sex education trial database is part of this study and is currently underway. Qualitative interviews will be used to explore the particular experiences of a sample of these young women in more detail.
Sexual Networks, Social and Geographical Space (Connell, Hart) There is a developing literature which seeks to understand the social factors which facilitate sexual network development and the transmission of infection. Issues which have arisen in this area include: the extent to which sexual networks are based on assortative sexual mixing or dissassortative sexual mixing, the role of serial monogamy (sequential sexual partnerships) and partner concurrency, and if there are times when people move between monogamy and concurrency. There is also increasing acknowledgement that sexually transmitted infections have a marked spatial distribution provoking questions such as: what are the characteristics of the social spaces in which sexual partners meet? Are there distinctive features of areas, separate from indicators such as deprivation or ethnicity, which contribute to STI transmission? How do social and geographic variables interact to account for higher rates of STIs in some areas compared to others? This study seeks to determine the way in which social and geographic spaces are associated with incident sexually transmitted infection, and their relative contributions to STI transmission among male and females aged 16-24 years in Glasgow. A review of the literature on sexual networks is also being undertaken to identify current gaps in knowledge.
Female and male sex workers: Occupational health Client violence against prostitutes working from street and off-street locations - A three city comparison (Hart, with Dr Marina Barnard, Centre for Drug Misuse Research, University of Glasgow; 1998-2000. ESRC funded, £174K) This study was supported by the ESRC Violence Programme and investigated the prevalence and causes of client violence against female prostitutes in Leeds, Edinburgh and Glasgow.36 We found that four out of five women working on the streets had experienced client violence at some point in the past, compared to just under half of women working indoors. Even within the last six months half of street-working women had experienced violence, from being slapped, punched or kicked through to attempted kidnap and rape. Although women working in flats and saunas experienced less violence in the last six months, a quarter of them had suffered a range of experiences from threats of physical violence through to robbery and attempted rape. Multiple logistic regression showed that working indoors was associated with higher levels of violence than was the city, drug use, and duration of (or age that women began) prostitution. Prostitutes working in Glasgow were six times more likely to have experienced recent violence than those working indoors in Edinburgh. Only 34% of prostitutes who had experienced violence reported it to the police, and this was reported more often by those working outdoors than indoors. Future reports will explore the women's experiences of violence and the strategies they adopt to reduce the risk of client violence and to defuse potentially violent situations. The study aims to explore the means by which prostitute vulnerability to client attack might be reduced at an individual, collective and institutional level.12 25629_Txt 9/8/02 9:21 AM Page 20
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Male Sex Workers: Occupational Health and Safety (Connell, Hart) It is increasingly recognised that the exchange of sexual services for money carries with it certain costs. Public concern over prostitution has frequently focused on sexually transmitted infections (STIs), particularly HIV, in populations of female prostitutes. This discourse of sexual risk has shaped the entire research agenda on male prostitution since the first appearance of AIDS. Whilst it is understandable that risk and exposure to HIV have been the primary focus of research endeavour in this field, this is a somewhat restricted perspective on male prostitution. Interviews conducted with male sex workers in Edinburgh and Glasgow highlight that the risk of acquiring and transmitting STIs is not the only significant health risk suffered by male sex workers. Other important factors relate to the mental health and physical safety of male prostitutes.122,123,124,125,127
The majority of men interviewed acknowledged that prostitution had affected their mental health. Respondents referred to periods of depression, isolation and a lack of self worth. In some cases male sex workers recounted instances of self-harm and suicide attempts. In terms of physical safety, respondents viewed prostitution as a risk taking practice. Reference were made to verbal threats, physical violence, sexual assault and rape by clients and sex work organisers. Male prostitutes also viewed members of the general public as a threat to their physical safety. Respondents recounted incidents of obscene and abusive phone calls, threats and the enactment of physical violence. An important finding is the lack of health and social service provision for male sex workers. There is also a clear need for support and advice on practical issues such as housing, education, employment and assistance to exit prostitution. A report on the research findings is now available.220
Sexual and reproductive health in developing countries Sexual behaviour of adolescents in rural Tanzania and the impact of an innovative sexual health intervention (Wight, with Dr David Ross and Professor Richard Hayes, London School of Hygiene and Tropical Medicine; 1999-2003; MRC Funded, £845K) This study aims to: (a) investigate the sexual behaviour of adolescents in rural Tanzania; (b) evaluate how an innovative sexual health intervention affects sexual behaviour; (c) assess the relative effectiveness of the four main components of the intervention; (d) analyse the relationships between reported sexual behaviour and the occurrence of STDs, and (e) evaluate different methods for collecting sexual behaviour data. The methods being used by the team of East African researchers are face to face and self-complete questionnaires, in-depth interviews, group discussions and participant observation (PO). To date Wight's analysis has focussed on contradictory norms around sexual behaviour and sexual violence.
While several norms seem to inhibit sexual activity (e.g. school pupils should not have sex, condoms should not be promoted, labouring teams should be single sex, single mothers are disreputable) others seem to condone or even encourage it (e.g. the understanding of sex as a resource to be exchanged, certain dance and marriage rituals).213 Three broad categories of unwanted sex have been identified. 'Rape' is generally limited to publically known violent sexual assaults, subject to some quasi-judicial response. More common is sexual violence that is not disclosed, usually because: (a) the victim might be thought to have contributed to the event or (b) an authority figure or friend acted as an intermediary. Third, some sexual encounters occur because of pressure from relatives, blackmail or the threat of violence.211
Department for International Development Knowledge Programme on HIV/AIDS and STIs (Allen, Wight and Hart, with Prof David Mabey, Dr Philippe Mayaud and colleagues at London School of Hygiene and Tropical Medicine) The Department for International Development has awarded the London School of Hygiene & Tropical Medicine and the MRC Social & Public Health Sciences Unit a five year Knowledge Programme on HIV/AIDS & Sexually Transmitted Infections. The Programme has nine key collaborating institutions in Africa and Asia. Its objectives are primarily epidemiological, but they include improving our understanding of the patterns and determinants of sexual behaviour and measuring the impact of new sexual health interventions. A post has been created in the Unit with three specific objectives: (a) to contribute to the development of sexual health programmes and to design process evaluations to complement outcome studies of sexual health interventions; (b) to further develop methods for sexual behaviour research, and (c) to develop the capacity of local researchers to conduct high standard qualitative research 25629_Txt 9/8/02 9:21 AM Page 21
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Measuring Health, Variations in Health and the Determinants of Health in Scotland
The health of the Scottish population is poorer than that of the UK population as a whole. This programme seeks to monitor the health of people in Scotland and devise better ways of measuring and monitoring health and its determinants. In particular we aim to improve our understanding of health inequalities in Scotland, and the means by which health gains can be realised. Support for the core staff is provided by the Chief Scientist Office of the Scottish Executive Health Department.
HeartAlastair Failure Leyland , Head of the Measuring Health Programme
(Gemmell with Professor John GF Cleland, Department of Cardiology, University of Hull, and Dr Aleem Khand, Department of Cardiology, Glasgow Royal Infirmary) This study examined the effect of previous, concomitant and subsequent diagnoses on the progression of heart failure in the 1992 cohort.75 Of the 9,718 patients who survived their first admission 61% had at least one cardiovascular re-admission and half of these had occurred within 6 months. Recurrent ischaemic events were responsible for worsening heart failure and/or early death in a large proportion of heart failure patients; however, there were a significant number of readmissions that were related to heart failure alone. A greater understanding of the impact of comorbidity in heart failure patients may help improve the quality of life and survival patterns of these patients.
Housing & health (Gemmell) The relationship between housing condition and ill health was further examined using information from the second sweep of the Twenty-07 Study.55 Employment status and house tenure were associated with both the presence of one or more chronic condition and one or more limiting condition. Respondents living in a house that was cold 'most of the time' in winter had increased odds of one or more limiting conditions (OR=3.48, 95% CI=1.33,9.09). Social class, car ownership, employment status, overcrowding, tenure, type of bedroom heating and whether the house was cold in winter were all associated with 'fair' or 'poor' self assessed health. Self assessed health recorded as 'fair' or 'poor' was more likely when the house was cold 'most of the time' in winter (OR=4.80, 95% CI=1.86,12.39). The presence of mould or
damp in the home was not associated with poor health. No household characteristics were associated with FEV1. Householders whose main form of heating was central heating were less likely to report feeling cold in winter and the average temperatures in the main room of these houses was 20oC. Over and above socio-economic factors, inadequate home heating was associated with poor health in those aged 55-60.
Inequalities in mortality in Great Britain (Leyland and McLeod) This project has been assessing the changing patterns of mortality in Great Britain between 1979 and 1998, and has placed particular emphasis on separating inequalities between regions and the differences within regions in the mortality rates of the constituent districts. Premature mortality rates are higher in Scotland than in other parts of Great Britain, and this difference has changed little over 20 years. The variation within regions - which can be thought of as a measure of the degree of inequality in mortality rates - seems to be independent of the comparative level of mortality but shows substantial differences between regions, with inequalities in premature mortality being highest in Scotland. There was a general upwards trend in inequalities in all regions over the 20 years, with by far the sharpest increase occurring in Scotland. Within Scotland the inequalities within Greater Glasgow Health Board are greater than elsewhere. Further work is exploring the contributions of age, sex and cause of death to these regional differences and the relative importance of place, age and cohort.
Multilevel modelling for public health and health services research (Leyland with Dr Peter Groenewegen, Netherlands Institute of Health Services Research, Ms Alice McLeod, Birkbeck College, Dr Ilmo Keskimäki, National Research and Development Centre for Welfare and Health, Helsinki and Professor Harvey Goldstein, Mathematical Sciences, Institute of Education) Work continued on the dissemination of multilevel modelling as a statistical methodology for the analysis of health data3,74,160 including methodological development.17,159,170 Two week-long courses were held in Helsinki and Stockholm and a further three day course in Utrecht. The courses proved extremely popular and comprised a combination of lectures, discussion, practical assignments and instruction in the use of the multilevel modelling software package MLwiN. 25629_Txt 9/8/02 9:21 AM Page 22
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National evaluation of Sure Start (Leyland with Professor Edward Melhuish and Professor Jay Belsky, Birkbeck College, Professor Jane Tunstill, Royal Holloway, Pamela Meadows, National Institute of Economic and Social Research, Dr Jacqueline Barnes, University College, London, and Mog Ball and Dr Zarrina Kurtz, freelance: funded by DfES) Sure Start is a Government initiative which represents a unique approach to early intervention for children 0-4, their families and communities. Rather than providing a specific service, the Sure Start initiative represents an effort to change existing services. This is to be achieved by reshaping, enhancing, adding value and by increasing co-ordination. The desired outcome of this effort is the enhancement of child, family and community functioning. The National evaluation is funded by the Sure Start Unit and will study the effectiveness of all Sure Start Programmes in England (260 programmes), lasting for 6 years. The evaluation is guided by three core questions: (1) do existing services change? (2) Are delivered services improved? (3) Do children, families and communities benefit? The National Evaluation of Sure Start is addressing these questions through five components: implementation evaluation, impact evaluation, local community context analysis, cost-benefit analysis and support for local services.
Patterning of presentation and survival for colorectal cancer in Scotland (McLeod and Leyland, with Diane Stockton and Helen Brown, Scottish Cancer Intelligence Unit, Information and Statistics Division, Edinburgh) This study was carried out in collaboration with the Scottish Cancer Intelligence Unit at ISD, and utilised recently available routine data on cancer registrations in Scotland. The short-term aim of the study was to describe patterns of presentation and survival according to patient characteristics (e.g. age, sex), small-area characteristics (e.g. socioeconomic deprivation), and organisational factors. The longer-term aim was to develop the methodology appropriate for such data, with a particular focus on multilevel survival analysis. The applied part of the research quantified factors associated with later presentation and reduced survival for colorectal cancer in Scotland, with a view to informing public health policy. The methodological aspects of the study aim to assess the general utility of the methods for the linked routine databases, both for other cancer groups and for future monitoring of priority health outcomes.169
Small area study of supply and demand determinants of healthcare resource use and estimation of relative needs for Primary Care Trusts in England (Leyland with Dr Matt Sutton, Department of General Practice, University of Glasgow, Professor Hugh Gravelle, Centre for Health Economics, University of York, Mr Stephen Morris and Professor David Parkin, Department of Economics, City University, Mr Mike Muirhead, ISD Scotland, Mr Michael Noble, Department of Social Policy and Social Work, University of Oxford, and Dr Frank Windmeijer, Institute for Fiscal Studies: funded by Department of Health) This project concerns the estimation of the supply and demand determinants of healthcare utilisation in England using a model which captures the influences of provider, general practice and population characteristics. Supply-side influences will be modelled to capture the effects of distance, waiting times, capacity and accessibility to other providers. The effects of variables that are themselves determined within the system are carefully modelled. Estimation techniques will allow for the multilevel nature of the data and the interactions amongst the determinants of use. Population characteristics will be chosen using a range of criteria including stability in definition over time, updateability, plausibility and ability to predict healthcare utilisation. The appropriateness of developing a composite index of need will be assessed. The empirical work will also assess the feasibility of estimating the age-related element of need as part of a single analysis.
Socioeconomic and regional patterning of coronary heart disease (Leyland with Dr Ilmo Keskimäki, National Research and Development Centre for Welfare and Health, Helsinki) Earlier research on coronary heart disease (CHD) mortality in Finland has shown clear socioeconomic and geographical differences. This study makes use of the linkage of the linkage of the Finnish Hospital Discharge Register and Causes of Death Register to the longitudinal database of the 1975-1990 population censuses. The consistency of the socioeconomic gradient across regions will be explored for CHD mortality. Moreover, mortality from Acute Myocardial Infarction (AMI) will be disaggregated into the first event rate, the case fatality rate among first events, the recurrence rate and the case fatality rate among recurrent events. The contribution of each of these components to the socioeconomic and geographical differences will be identified. 25629_Txt 9/8/02 9:21 AM Page 23
24 The MRC Social and Public Health Sciences Unit
Measuring Health, Variations in Health and the Determinants of Health in Scotland
Teenage pregnancies in Scotland (1981-96) (McLeod) This study was carried out to describe trends in teenage pregnancies in Scotland, at both the national and local level, and to investigate how pregnancies varied according to small-area characteristics. Conception rates were found to have increased in 1981-96 for both 13-15 and 16-17 year olds, while rates had remained constant for 18-19 year olds. Trends in conception rates varied across districts but differences between localities were largely maintained so that districts above the average at the start of the 80s were still above average in the mid-90s.85
The characteristics of populations near high risk potentially polluting factories, (Gemmell and McLoone) In epidemiological studies of environmental pollution and health, it is readily observed that the socio-economic characteristics of populations near industrial sites tend to be deprived. This fact has been mainly treated as a nuisance confounder in multivariate models rather than an issue of social inequality in itself. To address this we matched information on the location of factories involved in the most potentially polluting or technologically complex industrial processes in Scotland with data on the socio-economic and demographic characteristics of local populations, obtained from the 1991 census, for the areas in which these factories are located. Areas that contained a factory were slightly more affluent than those that did not contain a factory; the difference in mean deprivation score was 0.54 (95% CI (0.51,0.57)). Enumeration districts containing these types of factory had slightly lower levels of unemployed, migrants, and children. Socially rented accommodation and households without access to a car were also significantly lower as was population density. The pattern of increased affluence was similar across different factory types with the exception of waste disposal and recycling sites for which a lower proportion of the population than expected (14%) were in the most affluent quartile of deprivation scores. In conclusion we found that the populations resident in areas surrounding industries involved in technologically advanced and most potentially polluting processes in Scotland tended to be more affluent. However, utilising different expressions of nearness and different factory types may have highlighted different features.
The concentration of individual indicators of deprivation within small areas of Scotland (McLoone) Geographical measures of deprivation show spatial inequality in the socio-economic characteristics of populations residing in small areas. As a result, area interventions aimed at improving the circumstance of deprived populations have been part of government policy. We explored the spatial concentration of individual aspects of selected deprivation indicators across postcode sectors of Scotland. It was found that the concentration of these was not as high as readily assumed and that the selective targeting of resources on an area basis would miss more of the deprived than it would include. Whilst there are higher concentrations in poverty in some areas the poor sensitivity of area-based approaches means that they would miss out more of the poor than they would include.
Trends in small area mortality in Scotland (McLoone) Over the last twenty years or so the health experience of Scotland can be globally described by a mortality rate which has consistently fallen year on year. In some respect, a crude global change will mask deviations from the national trend. National change can vary by age, sex, area of residence or by socio-economic status. Deviations from the national trend have the potential to be epidemiologically and politically insightful. They provide 'evidence' of one sort or other. They provide empirical observations, which are essential to our understanding of the historical and possible contemporaneous effects of public health and social policy and the ways in which these have ameliorate or agitate the health experience of populations at the local level. We have been monitoring changes in small area mortality in Scotland by utilising GRO(S) and CACI small are population estimates. A crude summary of this work is that the mortality gap between populations resident in affluent and deprived areas continued to grow during the 1990s. By the end of the 1990s the mortality experience of deprived areas was still worse than that experienced within more affluent areas 18 years previously. This feature of increasing inequality was experienced across most age groups and in both sexes. 25629_Txt 9/8/02 9:21 AM Page 24
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Patterns of Cancer Mortality in Europe (PhD Project: Davies, supervisors Leyland with Professor Mike Titterington, Department of Statistics, University of Glasgow) Mortality data for the whole of Europe (50 countries) has been made available from the World Health Organisation's Atlas of Mortality in Europe. The data give, where available, the number of deaths by cause (27 separate causes or groups of causes) and the population in each age/sex group for regions within countries over two time periods (1980/81 and 1990/91). Previous research in cancer mortality throughout Europe has revealed large spatial variations within and between countries. Research also suggests the variations in cancer mortality can reflect differences in factors such as demographic structure of the population, lifestyle (e.g. diet, socio-economic status, smoking), exposure to various environmental factors, or genetic predispositions to cancers. This project initially examines the variation in all cancer mortality across regions and countries in Europe. Further disaggregation will allow the examination of the relationships between specific cancers explicitly, investigating whether patterns in cancer mortality differ across or within countries and regions. It is also of interest to identify the aetiological factors that may influence cancers. Without detailed data on individual mortality and exposure to risk factors it is still possible to explore the geographical variations in cancer mortality and their relationships with population characteristics through modelling forms of aggregated data. Along with the mortality and population data, other data were obtained at the region or country level that allowed some of the potential causal factors to be taken into account when modelling, eg food consumption, cigarette consumption, GDP, education level. Due to the hierarchical structure of the data, multilevel modelling techniques have been used to analyse the patterns of mortality with spatially smoothed disease maps allowing a clear visual exploration of such patterns.
Smoking Cessation (Norrie) Recent studies have examined predictors of smoking cessation but few have focused on the home environment and its effect on an individual's smoking behaviour. The British Household Panel Study was analysed to include these extra factors. Logistic regression for the outcome of smoking cessation was used to assess the influence of change in personal characteristics between waves 1 (1991) and 9 (1999). Home environmental factors were investigated with particular emphasis on the change in the spouse/cohabiting partner's smoking habits over the time period. After 9 years 28% of males and 23% of females had stopped smoking (OR 1.26, 95% CI 0.99-1.60). Baseline light smokers (10 cigarettes per day) had more than twice the rate of cessation of heavy smokers (> 20 cigarettes per day) with 36% stopping versus 17% (OR 2.65, 95% CI 1.77-3.95). Cessation occurred in 27% of subjects who lived with at least one other adult compared to only 18% of subjects who lived alone at baseline (OR 1.69, 95% CI 1.21-2.36). After adjusting for age, gender, socio-economic status, means-tested benefits dependency and self-reported health status, the household factors single occupancy and continued smoking status of spouse continued to be associated with smoking cessation. A subject whose spouse also stopped smoking had an adjusted OR of 4.19 (95% CI 2.59-6.77) of quitting compared to those whose spouse never stopped smoking, while those who lived alone had an adjusted OR of 0.65 (95% CI 0.43-1.00).
Gillian Norrie, Higher Scientific Officer Urban/rural differences in health (Levin) Previous research suggests that there are significant differences in health between urban and rural areas. The aim of this project is to describe the pattern and magnitude of urban/rural variation in health in Scotland and to examine the factors associated with health inequalities in urban and rural areas. Limiting long term illness (LLTI) data collected in the Census has been used as a health indicator and a variety of socio-economic factors investigated using multilevel Poisson regression. The areas with the highest Standardised Illness Ratios (SIRs; >125) are predominantly urban whilst the lowest (<75) are found in both urban and rural areas. Determinants of illness vary according to type of rurality. Previous studies have suggested that many socio-economic factors commonly used as a proxy for urban deprivation are inappropriate in modelling the health of rural communities. Under a rurality indicator of 1 to 5, urban to rural, models for areas comprising accessible and/or remote villages find few of those socio-economic factors considered significantly associated with illness and a relatively small reduction in total variation in these models once socio-economic factors are included. However, when rural communities are further split by minor road length the relative reduction in variation and therefore the model fit sees a great improvement. These findings suggest that rural areas are heterogeneous in terms of their social make-up with relation to health, and must be subdivided into rural types. Socio-economic factors found to be significant in models of health for urban areas are also seen to be significant in rural models; however, their interpretation is likely to differ. Further work will investigate definitions of rurality and rural deprivation in the study of geographical health patterns and will include analysis of morbidity and mortality data. Katy Leven, Research Associate 25629_Txt 9/8/02 9:21 AM Page 25
26 The MRC Social and Public Health Sciences Unit
Evaluating the Health Effects of Social Interventions
There is continuing interest in evidence-based approaches to improving health and tackling health inequalities, illustrated by the growing demand from decision-makers for rigorous evaluations of the effects on health of (for example) housing and urban regeneration initiatives. This programme of primary and secondary research aims to assess the health effects of social interventions. Support for the core staff is provided by the Chief Scientist Office of the Scottish Executive Health Department.
Evaluating interventions: Primary studies Health Impact assessment and related activities Our main research interests in this area lie in assessing the health effects of housing improvements, and traffic-calming interventions, and primary studies are underway in both these areas.
"Cross Faifley Safely": a longitudinal study of the effects of traffic calming (David Morrison, Greater Glasgow NHS Board; with Thomson and Petticrew) This study of the effects of traffic calming on a community in Glasgow began in late Summer 2000, following discussions with the local council and the local neighbourhood forum about the possible positive and negative effects of a planned traffic calming scheme. The study uses a "before-and-after" design involving a postal survey and the collection of routine data (including accident statistics). The "after" part of the study has been completed and is currently being analysed. This will allow an assessment of the net effects on a community of traffic-calming measures such as speed cushions and zebra crossings.
Mark Petticrew, Associate Director of the Unit and Head of the programme on Evaluating the Health Effects of Social Interventions
Assessment of the health impacts of rehousing in Renton: a prospective controlled study (Thomson, Morrison, Petticrew, with Stephen Singer and Stephen Gibson of Cordale Housing Association, Renton, West Dunbartonshire). Despite a wealth of survey data describing the poor health of those living in poor housing conditions, there are very few studies of the potential for improved housing to improve health. Working with Cordale Housing Association (HA) in West Dunbartonshire we are carrying out our own controlled evaluation of the health impacts of new housing. Cordale HA has secured funding for a major housing-led regeneration programme and we are collecting data to allow us to compare the health of residents who are rehoused with a control group of 200 health council tenants in a neighbouring area. Residents are interviewed in their homes before they move and again one year later. The interview consists of questions about their neighbourhood, social contact, health, illness and some physical measurements. Other area improvements are planned for Renton and we are looking at ways to assess the health impacts of those wider improvements on the wider population, as well as on those who have been rehoused.
Scotland's Housing and Regeneration Project: SHARP (Petticrew, Ellaway, Macintyre, and Professor Ade Kearns and Caroline Hoy of Department of Urban Studies); Scottish Homes and CSO, £300K) This joint project with Professor Ade Kearns of the Department of Urban Studies at the University of Glasgow started this year. The project is funded by Chief Scientist Office and Scottish Homes, and involves a large quasi-experimental Scotland-wide investigation of the health effects of urban regeneration and new social housing. Six hundred households will be recruited and followed for 3 years in a longitudinal assessment of the health and related effects of housing improvement. The study will employ a broad model of health which will incorporate measures of physical and mental health, health behaviours, wellbeing, social participation, social networks, and perceptions of neighbourhood. A control group will also be surveyed, and additional qualitative research will be used to explore these issues in more depth. 25629_Txt 9/8/02 9:21 AM Page 26
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Assessing the health impacts of swimming pool closure (Thomson) Incorporating community views is accorded a priority status within Health Impact Assessment. However, interventions being assessed in this manner often evoke strong emotions among some members of the community and the investigation of these perceptions needs careful thought. We have used a qualitative approach to study the health impacts of a swimming pool closure in Glasgow. To provide a rich comparison we have carried out focus groups with local residents in two areas where there have been contrasting experiences of regeneration; most particularly, in one area the opening of a swimming pool and in the other the closure of a swimming pool. Within resident reports we have looked specifically at where the issue of pool and leisure facilities fit into the wider account of where they live, and how place and health interact. Early results from this work support assertions in the literature that "place", as conceived among residents, incorporates aspects of person, history, and reputation as well as the physical and social environment. Evaluating complex interventions such as a community facility is always a thorny problem, but new methods need to be developed to add to understandings of health and place. Just as in previous evaluations, residents also find it difficult to isolate the impacts of a single intervention such as the swimming pool. The obvious physical health impacts of the pool closure may not be those which impact most on local residents' health. Qualitative work such as this highlights the importance of using a broad definition of health and place, and can illuminate ways in which local context influences health.
Evaluation of the health impacts of a major food superstore (Cummins, Higgins, Petticrew, with Professor Leigh Sparks and Anne Findlay at the Institute for Retail Studies at the University of Stirling); Department of Health, £95K) This is a two-year pilot project, funded by the Department of Health, involving the Tesco St Rollox (Springburn) development. The main aim of this pilot study is to investigate the health impacts of a major food superstore development in a deprived urban neighbourhood. We are using a two-wave, 'before and after', cohort study design using a postal questionnaire survey of a random sample of adults from the postcode address file in Springburn (St Rollox) (the intervention neighbourhood), and a similar control neighbourhood (Shettleston). We are also undertaking focus-group interviews with a sub-sample of respondents from the questionnaire survey. The questionnaire survey has collected a range of demographic and other data and includes questions relating to self-reported health, psychological well-being and food purchase and consumption patterns. A retail base survey was undertaken prior to the store opening and this was recently updated (May 2002). Preliminary results will be available in 2003.
Cassie Higgins, Research Associate on the Superstore Study
Scottish Healthy Living Centres Evaluation Petticrew, with Steve Platt, Kathryn Backett-Milburn, and David Rankin (RUHBC, University of Edinburgh); CSO, £200K. An intensive (case study) evaluation of the Healthy Living Centre (HLC) programme in Scotland will be undertaken over the period 2002-2004. The broad aim of the study will be to explore the pathways between activities, processes, contexts and outcomes in a purposive sample of HLC projects, using a longitudinal research design and intensive case study methods. Two projects will be selected in the near future, two more later in 2002, and the final two in spring 2003. At every project there will be about four weeks of fieldwork, conducted over two or more visits in order to explore the development of the project over time. Data analysis will seek to highlight differences and similarities between case studies as well as processes and linkages within projects.
Steve Platt and Richard Mitchell of RUHBC, and Mark Petticrew are also involved in another, related evaluation study (funded by the New Opportunities Fund) of the HLC programme across the whole of the UK. Access to comparable data from this study will increase the amount of intensive case material available to the research team and the opportunity to draw generalisable conclusions which will be of relevance and value to the wider health policy environment. 25629_Txt 9/8/02 9:21 AM Page 27
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Evaluating the Health Effects of Social Interventions
Scottish Executive Central Heating Programme: assessing impacts on health Petticrew, with: Steve Platt and Rich Mitchell of RUHBC, University of Edinburgh; Jane Hopton, Department of Community Health Sciences, University of Edinburgh; and Steven Hope and Chris Martin NFO System Three Scotland; Scottish Executive Development Department, £554k The Central Heating Programme constitutes one of the major elements of the Scottish Executive's Healthy Homes Initiative. All properties in the social rented sector which lack central heating, and properties in the private sector with a head of household or spouse over 60 years and which lack central heating, or the central heating system is broken and beyond repair, fall within the scope of the Programme. The policy objectives of the Programme include the protection of health insofar as it is at risk from energy inefficient, cold and damp homes, and fuel poverty. The main aim of this study is to assess the impact of the Central Heating Programme on recipients' health. More specific objectives include the measurement of change in health status among Programme recipients up to two years after installation, and the exploration of reasons for these changes (including changes in temperature and humidity, living conditions and use of the house, and fuel poverty). Baseline fieldwork will be carried out by System Three Scotland and will begin in winter 2002/2003.
Evaluating interventions: Systematic reviews and related activities We also have an ongoing programme of systematic reviews, as well as contributing to other methodological work in this field.
Systematic reviews of transport policies' effects on health (Morrison, Petticrew, Thomson) Transport policies have important health impacts through their effects on air pollution, noise, injuries, climatic change, and through the promotion of walking and cycling. However, current understanding of how transport policies can optimise health benefits and mitigate harmful effects is often more speculative than evidence-based. This review synthesises evidence from existing systematic reviews on the effects of transport interventions, whether national policies (e.g., use of safety belts) or local programmes (e.g., traffic-calming measures, promoting walking and cycling) for two purposes: firstly, to provide policymakers and planners with accessible, high-quality evidence when making decisions, and secondly to suggest where future research on the health effects of transport policies should best be directed. The work has recently been submitted for publication.171,173,174
Health Impact Assessment of housing investment: incorporating evidence Bridging the research, policy and practice gap (Thomson, Petticrew, Morrison) The systematic review of the health impacts of housing improvement which was published last year generated a lot of interest from academics, policy makers and practitioners. Following wide dissemination and consultation we have made efforts to summarise the findings in a range of formats to increase its relevance to policy and practice. For example, working with colleagues in the Scottish Health Impact Assessment network we have explored how the review could contribute to health impact assessment guidelines. Using the results of the review as well as additional observational data we have also developed some key questions which we believe should be considered in future housing Health Impact Assessments.109 A full report of the systematic review is available on our website or by post. 25629_Txt 9/8/02 9:21 AM Page 28
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"What works" in work? A systematic review of employment interventions and health Petticrew, Thomson, Hamilton, with Nessa Barry, Department of Public Health There now appears to be clear evidence from the Whitehall studies and from other sources that the psychosocial characteristics of work can have a negative impact on health. For example, it has been shown that a low status in the work hierarchy increases the risk of poor health, and it has been suggested that this effect may be mediated through the mechanism of psychological control over one's work environment. This prompts the question as to whether there exist effective interventions to improve the psychosocial working environment, for example, through increasing job controllability, which may in turn limit the damaging effects of some types of work. This ongoing review therefore aims to synthesise the results of studies of interventions which aim to improve health by these means.
Hierarchies, territories, and social status in monkeys: what do studies of other primates tell us about CHD and social status in humans? (Petticrew) The evidence that socioeconomic status is a major predictor of CHD appears indisputable, and many mechanisms have been proposed. Among these are psychological mechanisms, some of which draw heavily on animal models of the link between social stress and coronary atherosclerosis. These models derive mainly from pioneering work done by US researchers on groups of free-living cynomolgus monkeys, which has shown for example that disruption to the social structure in these groups increases the risk of coronary lesions. This systematic review is therefore examining these studies to assess the strength and consistency of evidence they provide. Searches are completed and data extraction is ongoing, and the review will be finished later in 2002.
Evidence-based policy ESRC Evidence-Based Policy and Practice Initiative: Centre for Evidence-Based Public Health Policy Petticrew and Macintyre, with Professors Hilary Graham (University of Lancaster and Margaret Whitehead (University of Liverpool); ESRC- funded, £308K The network (co-ordinated by Queen Mary and Westfield in London) brings together 7 centres across the UK which will provide an evidence-based resource to support policymaking. Our Centre for Evidence-Based Public Health Policy is part of this Network, and is actually a "distributed" Centre, linking with Professors Margaret Whitehead in the University of Liverpool and Hilary Graham in the Department of Applied Social Sciences in the University of Lancaster. We are carrying out a programme of policy-relevant systematic reviews and other research activities. Our other key activity is to liaise with the user community to identify areas where evidence is currently absent, and to identify and build up consensus on the nature and quality of evidence considered acceptable in public health. The latter task involves a number of workshops, the first of which took place at Cameron House in Scotland in April 2002, and which involved policy makers from the UK and beyond. A further workshop for researchers is currently being planned. This fits closely with our existing interests in the nature and use of evidence to support public health decision-making,79,183,232 one example of which was published last year as a case study examining the evidence submitted to the UK Independent Inquiry into Inequalities in Health.79 25629_Txt 9/8/02 9:21 AM Page 29
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Evaluating the Health Effects of Social Interventions
The health impact of new roads: a systematic review (Egan, Hamilton, Petticrew, Ogilvie) Road building has become an increasingly emotive issue: new roads have the potential to assist economic growth, ease congestion and improve access to remote communities, but they also raise safety and environmental concerns, whilst providing a focus for popular protest. Any attempt to accurately measure the human costs and benefits of road policy must take into account the effects on health. With this in mind, we have embarked on a systematic review of the positive and negative impacts of new road building on human health and wellbeing, covering accident injuries, health concerns associated with traffic pollution, and community severance.131
Matt Egan, Researcher on the ESRC Evidence-Based Public Health Policy Project
Other research
Evaluation of the development of a hospital-based smoking cessation programme (PhD Project: Callaghan, Supervisors: Hart, Petticrew. Funded by Chief Scientist Office of the Scottish Executive Department of Health) While there have been a large number of studies evaluating the outcome of smoking cessation services in primary and secondary care, there have been very few looking at how such services are implemented. Exploring the factors which promote and impede the implementation of new health care services can help to identify where changes need to be made, and can help increase their future impact and effectiveness. In order to explore these factors 22 members of staff in a large acute unit in Scotland were interviewed and 450 patients were surveyed. The project aims to find out (a) if patients perceive a need for a smoking service and wish to use such a service (b) the factors which facilitate or prevent the successful introduction of the smoking cessation clinic (c) How health promotion is understood by clinical staff and how it operates within an acute medical unit, and (d) What lessons can be learned which can inform the implementation of similar health promotion services. It is anticipated that the results will be applicable to the implementation of other health promotion services.
David Ogilvie, Specialist Registrar in Public Health 25629_Txt 9/8/02 9:21 AM Page 30
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Ethnicity, Religion and Health
Health varies as markedly among different ethnic and religious communities as among social classes, especially in societies that have experienced immigration or have substantial minority populations. Some ethnic health differences have been attributed to the process of migration, but this can only be an explanation for the first, migrant generation. This programme investigates the health consequences for migrants and subsequent generations of encounter with socio-economic disadvantage on the one hand, and of contact or conflict with the majority culture on the other. It studies factors mediating the association of ethnicity and religion with the social patterning of health.
Reviews and essays on ethnic minority issues Poverty, stress and racism as factors in South Asian heart disease (Williams and Harding) This presentation to a conference on the South Asian epidemic of coronary heart disease held by the South Asian Health Foundation reviewed the state of a hypothesis which in the 1980s appeared to be ruled out by the available evidence.215 In the 1990s, however, an emerging socio-economic gradient in South Asian CHD, and advances in research on stress and racism, have contributed to a revival of the hypothesis, which this paper seeks to state in its strongest current evidence-based form.
Rory Williams, Senior Research Scientist, Ethnicity Religion and Health Programme
Issues in Catholic disadvantage in the West of Scotland (Abbotts) This plenary paper given to the BSA Sociology of Religion study day on 'Mainstream Religions: Conflicts, Diasporas' reviewed our work on persisting Catholic disadvantage in Scotland in the context of research on Irish health in Britain, and draws a picture of the new lines of research which are now opening up.117
Multicultural health care: Britain (Williams and Harding) This commissioned chapter (in progress) reviews the extent to which multicultural philosophies have penetrated the organisation of health care in Britain, in comparison with other countries in Europe, North America and Australasia. It addresses questions about the claims of minorities on the state, the health status of these groups, how services are delivered and how effective/efficient they are, and the advantages and disadvantages of different delivery models.
Communication, interpretation and translation in nursing practice with ethnic minorities (Bradby) Minority ethnic group patients show both under- and over-use of different services, compared with the ethnic majority, and some of this variation may be due to difficulties of communication across both cultural and linguistic barriers. This chapter reviews issues of communication and interpretation facing nurses and their minority ethnic group patients.5 A lack of a shared common language is viewed as only one of a number of potential communication pitfalls in the encounter between health professionals and seekers of health services whose vocabulary, idiom, expectations and understandings may differ.
Work on national and international datasets Mortality of South Asians by length of residence in England and Wales (Harding with Professor Balarajan, National Institute for Ethnic Studies in Health and Social Policy) This study investigated all-cause, cardiovascular and cancer mortality of South Asians by length of residence in England and Wales. The findings for cancer mortality suggest convergence to the rates for all England and Wales; but divergence is suggested with respect to cardiovascular disease mortality. 25629_Txt 9/8/02 9:21 AM Page 31
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Ethnicity, Religion and Health
Mortality of first and second generations of Indian, Pakistani, Bangladeshis and Black Africans living in England and Wales. (Harding) The 1991 Census was the first census to collect ethnic origin data. Previous studies of mortality of ethnic groups used country of birth as a proxy for ethnic origin. This study uses ethnic origin to investigate mortality, thereby overcoming past difficulties of excluding second generations born in the UK. It uses the ONS Longitudinal Study in which information on death registrations are linked to census records.
Cancer survival of minority groups in England and Wales (Harding) Research into cancer survival among ethnic groups is limited by the fact that entry of ethnic group for an incident case only became part of the minimum dataset in 1993. This study uses the ONS Longitudinal Study to investigate survival of South Asians, West Indians, Irish and Scots from commonly occurring cancers. For the Irish, cancer survival amongst both the first (Irish-born) and second generation (people with Irish-born parents) will be investigated.
Social mobility and health differences among South Asians and West Indians living in England and Wales (Harding) There is disproportionate persisting disadvantage amongst these migrants but there is also considerable social mobility. For South Asians and West Indians, the impact of downward mobility on limiting long-term illness was particularly striking - downward mobility appeared to be related to greater LLTI amongst migrants than amongst all other people. Mobility cannot be ruled out as a factor contributing to the socio-economic differentials in health amongst these migrants.
Assimilation patterns of ethnic groups in England and Wales and health in later life (Harding with Rosato, School of Health Sciences, University of Ulster, Jordanstown) Very little work has been done on patterns of assimilation in relation to health of migrants. Over time we would expect convergence towards the patterns of the host population in terms of social and economic circumstances, and health related behaviours. This study investigates changes in three aspects of social life (family structure, socio-economic status, place of residence) of different age cohorts of the largest ethnic groups present at the last two or three censuses, and relates the most dominant social trajectories to health status.
Mortality patterns of ethnic groups in Sweden (Harding with Orjan Hemstrom and Denny Vagero, Stockholm University,Sweden) There has been very little research on the health of migrants in Sweden. This study investigates cause-specific mortality for the major migrant groups, including those from other Scandinavian countries, Eastern Europe and the Middle East, and the role of socio-economic position.
Morbidity and mortality patterns of ethnic groups in Portugal (Harding with Paula Santana, Universidade de Coimbra, Portugal.) Mortality of minority ethnic groups in Portugal has never been studied. We are exploring the feasibility of using hospital data to examine differences in access to health care and of using the data around the 2001 Census to look at mortality patterns. Portugal has a large African population and we aim to compare mortality patterns of Africans in the UK and in Portugal. 25629_Txt 9/8/02 9:21 AM Page 32
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ONS Feasibility study into projecting ethnic populations (Harding with Professor Balarajan, National Institute for Ethnic Studies in Health and Social Policy; Professor Phil Rees, University of Leeds; Professor Mike Murphy, London School of Economics; Dr Ludi Simpson, City of Bradford Metropolitan District Council and University of Manchester; Professor John Salt, University College London, Dr. Marian Storkey, Greater London Authority; Deborah Sporton and Professor Paul White, University of Sheffield; Professor Dave King, Anglia Polytechnic; University Chris Shaw, Government Actuary Department; John Haskey Anne Scott and Lucy Vickers, Office for National Statistics) This is a collaborative venture, led by ONS, with academics of different expertise from various institutions to examine whether it is feasible, given the data available, to project ethnic populations at a national or local level. The report, which focuses mainly on the methodological difficulties, will be published later this year.
ONS Child Health Volume (Harding with Bev Botting, Ruth Yates, Nicola Cooper, Kath Moser, Claire Dighton and Kevin Davy, Office for National Statistics; Alison Macfarlane, National Perinatal Epidemiology Unit, Oxford; Lynda Clarke, LSHTM; Yvonne Kelly UCL) A collaborative project led by ONS to devote a volume to issues of the millennium concerning children. It will include ethnic issues such as children living in care, growth of children from mixed heritage and health inequalities.
Local studies - Irish or Catholic health Investigating cancer related knowledge, beliefs and attitudes and means of raising awareness amongst people of Irish ancestry. (Scanlon, Harding, Hunt, Petticrew, Williams with Rosato, University of Ulster, Belfast.) This study has been funded by Cancer Research UK and a researcher has been recruited to start in June, 2002. Excess cancer incidence and mortality amongst Irish people living in England and Wales has been reported in the past. The objective of this study is to gain an understanding of the knowledge base and beliefs of Irish people regarding cancers, and to adapt successful promotional cancer prevention methods to reflect ideas and situations commonly experienced by the Irish. Qualitative interviews will be undertaken in London, Manchester and Glasgow to investigate issues such as how Irish people perceive their own risk of cancer, how they perceive the risk of the community as a whole, and how they react to people with cancer. Successful modes of dissemination of promotional material will be explored in workshops.
Intergenerational study of Irish identity and health (Walls and Williams) Glasgow attracted Irish migrants from both Protestant and Catholic traditions, and also has a Scottish Catholic population, so permits an analysis of the ways in which religion and ethnicity may be linked or separated, and of the risk factors mediating between each mix of religious and ethnic identification and health. The study, initiated in late 1996, has involved: • a sample recruited for informal unstructured interviews, derived by snowballing from Irish and church organisations. • a sample drawn from the Twenty-07 Study localities sample, recruited for formal interviews, in which the four ethnic/religious groups are equally represented, with controls matched by gender and class.
Qualitative analyses focussing on the more representative second sample have shown the Catholic identifier to be dominant in west Scotland, and have described the family, community and working situations of Catholics. Papers are close to completion on the debate about the extent of anti-Catholic discrimination in west Scotland, and on sources of stress in the working situations of Catholics. In the context of this work, the political campaign to ensure a census question on religion so as to identify the situation of people of Catholic background in Scotland has been documented and analysed. 25629_Txt 9/8/02 9:21 AM Page 33
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Ethnicity, Religion and Health
Catholic health patterns in the 11-16 Study (Abbotts and Williams with West and Sweeting) Data from the first wave of the 11-16 study have shown socio- economic disadvantage, but no health inequality, for Catholic children27. Work is ongoing to test the evidence regarding whether this represents an age, period or cohort effect.
Religiosity and Health in the 11-16 study: (Abbotts and Williams with West and Sweeting) The relation of church attendance to mental health and bullying has been examined for children from the two main Christian denominations in the West of Scotland. For children in the majority group, the Church of Scotland, mental health was worse among those who attended church, and there was an excess of bullying; whereas among Catholics, mental health was better among those who attended church. We hypothesise that this interaction was due to conformity/non-conformity to peer group norms, as attendance levels were much higher among Catholics. Work is ongoing to explore whether a similar pattern holds as these children enter teenage years, when church attendance is likely to be more a matter of their own choice.
Local studies - Caribbean health The health of black Caribbean adolescents in London: impact of socio-economic conditions and family life. (Maynard and Harding) In the 1991 Census, about half of the 500,000 Black Caribbeans living in the UK were born in the UK. In Lambeth and Camberwell, as many as 1 in 7 children aged under 15 years are Black Caribbeans. Black Caribbeans are among the most economically disadvantaged people in the UK. The major health burden amongst this population is from hypertensive-related disorders and psychotic illness. Very little is known about the health of UK-born Black Caribbeans. High parental unemployment, greater than average downward mobility, deprived neighbourhoods, poor educational attainment, family disruption and racism are some of the underlying issues that may affect the health of these children. This study aims to test this hypothesis.
Local studies - South Asian health Health in young people aged 18-19 of South Asian and other origin in Glasgow (Bradby and Williams) The sample of 14-15 year olds interviewed in 1992 were reinterviewed in 1996 using a structured interview schedule, with a response rate of 60%. This follow-up study aimed to trace changes after school-leaving age with increasing experience of training or further education, work or unemployment, and adult sexual relationships. Abstinence from alcohol continues at high levels in this predominantly Muslim community. However, the low rates of smoking compared with non-Asians found in 1992 are no longer found among men in 1996. The uptake of smoking over the last four years is the subject of further investigation, nearing completion. We are exploring the hypothesis that a broader constellation of factors, connected with the marriage system and family honour, is responsible for the levels of abstinence and higher achievement of young British Asians. A number of theoretically selected focus groups have been interviewed to yield supplementary qualitative data on the processes at work, including those giving rise to differences between Muslim and non-Muslim Asians.
Dietary change among South Asians and Italians in Glasgow (Bush, Dr Annie Anderson, Department of Human Nutrition, Glasgow University, Bradby, grant of £128K from the ESRC's Nation's Diet Initiative to Williams and Professor Mike Lean 1992-5) South Asians and Italians in Britain have high and low heart disease mortality respectively, though both come from rural backgrounds where heart disease is low. Migrant and British-born women from both minorities were compared with general population women using a sociological interview and 7-day weighed diet. A further analysis argues that adverse anthropometric indicators of CVD risk in South Asian women in these samples are substantially explained by lifestyle factors and parity.59 In addition a study of body image and weight consciousness shows that migrant South Asians tend to equate large size with health, in contrast to Italian attitudes, and change in those born in Britain remains slow.28 25629_Txt 9/8/02 9:21 AM Page 34
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South Asian women's health and well being across differing residential areas in Glasgow (PhD project: Goonetilleke, supervisors Bradby and Ellaway) This qualitative study aims to explore how the experience of health relates to experience of the local area among South Asian women living in an inner city area with a high concentration of South Asians, and among those living in a suburban area with a low concentration of this group. It looks at two settings in Glasgow: Pollokshields, the inner city area, and Newton Mearns/Giffnock, which are suburbs adjacent to Pollokshields in the south side of the city. Over forty in-depth interviews have been conducted, transcribed and coded and, together with material generated through participant observation at community centres and places of worship in the Pollokshields area, are currently being analysed. The links between familial and community resources, women's feelings of isolation, and over-surveillance or enjoyment of a supportive relationship are being explored139.
Local studies - Chinese health The mental health of Chinese women in Britain (Bradby with Gill Green, Anita Chan, Maggy Lee, Kimmy Eldridge, HSSI, University of Essex) The under-use of primary and secondary National Health Services by Britons of Chinese origin relative to other ethnic groups, despite factors that might predispose, particularly to mental health problems, has been investigated in this ESRC-funded project. A qualitative study was made of Chinese women's strategies and help-seeking behaviour that explored individual experience of, and group attitudes to, mental distress. Purposive sampling was used to recruit 42 women aged 29-60 from primary care groups, secondary mental health trusts and Chinese associations who had consulted a general practitioner and in addition had experienced mental distress and/or had used traditional Chinese medicine. Semi-structured interviews were undertaken, all bar two in a Chinese language. The ways in which service provision fails to meet the needs of this group have been explored, with consideration of whether this constitutes a form of institutional racism58.
Local studies across several minorities A systematic exploration of the location and content of graffiti of a racist and sectarian nature in Glasgow (Ellaway, Bradby & McKeown) The aim of this pilot project was to map the extent of racist and sectarian graffiti in three selected areas in Glasgow City. We found some evidence to suggest that graffiti is used to mark territory with regard to sectarian issues, but found few examples of racist graffiti in an area with a higher concentration of Asian residents, nor was it being used by residents in that area to mark territory. Although we found very graphic examples of sectarian graffiti on the walls of occupied housing, most graffiti occurred away from housing and appeared on industrial sites and derelict property. In our three selected areas, the incidence of sectarian and racist graffiti was outnumbered by other graffiti.132 223 230
250 Racist Graffiti
Catholic/Republican/ 200 Anti-Protestant Graffiti
Protestant/Loyalist/
150 Anti-Catholic Graffiti
100
50
0
Glenpark Street Bridgeton Calton East Ibrox/Govan Pollokshields
Racist & sectarian Graffiti in Selected Areas of Glasgow 25629_Txt 9/8/02 9:21 AM Page 35
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Young People’s Health and Health Behaviour
There is currently considerable concern about the health of young people who are subject both to tradi- tional structural and cultural influences such as those associated with social class and newer 'postmodern' influences, such as those of the media, which appear to have particular power to shape identity, behaviour and attitudes in youth. This programme seeks to understand the range of influences on young people's health and health behaviours, particularly those associated with the family, school, peer group and youth culture, which may either mediate broader social structural influences or cut across them to promote common experiences, behaviours or attitudes.
Patrick West, Senior Research Scientist, Head of the Youth and Health Programme Patrick was recently appointed Professor in the Faculty of Medicine at the University of Glasgow
The West of Scotland 11 to 16 (now 16+) Study The 11 to 16 Study originated as an extension to the Twenty-07 Study and is a longitudinal, school-based survey of health and health behaviours in a cohort of 2586 young people resident in the Central Clydeside Conurbation (CCC). The cohort was first surveyed at the end of primary school in 1994 when aged 11, and was subsequently followed up in secondary school at age 13 in 1996, and again at 15 in 1999. A wide range of information was obtained principally via self-complete questionnaire, including material circumstances, family life, school life and lifestyles, but in addition at age 15 a computerised version of the Diagnostic Interview Schedule for Children (Voice DISC), which produces psychiatric diagnoses, was included. The study has benefited from high response rates throughout, although differential attrition between age 11 and 15 has meant the sample became less representative of the population, losses being greater among lower class respondents, school truants, and those rated by teachers at age 11 as being of lower ability and having more emotional and behavioural problems. To compensate for these non-response biases, a weighting scheme was developed which can be applied to data at each phase of the study. At age 15, weighting has little effect on the prevalence of most health, and health behaviour outcomes, but as expected, rates of behavioural problems are elevated.233
To enable follow-up of the 11 to 16 cohort into the post-school period, at age 15 home addresses were obtained for the great majority of respondents. The next phase of the study, now called '16+', is currently being piloted on 18/19 year-olds. The '16+' study will not only allow us to investigate the influence of contemporary labour market experiences on health, but will also consolidate the comparative database with the Twenty-07 cohort surveyed 12 years earlier at the same age. In contrast to previous studies (including Twenty-07), which have involved nurses interviewing respondents in their own homes, in '16+' we are piloting a new method which involves respondents coming to us, aided we hope by a financial incentive. At the field station, respondents complete two questionnaires, receive an interview by a nurse using the CAPI method, have physical measures taken, and self-administer the Voice-DISC previously used at age 15.
To date, no data are available from the '16+' study. Papers and analyses produced over the past year are based on '11 to 16' data and covered a range of methodological and substantive issues:
Family process and children's psychological wellbeing and adjustment (Sweeting) The majority of quantitative studies of family life and family members' well-being rely on single informants in relation to both factors, and are open to the criticism that any observed association may be attributable to the same person providing information on both. This analysis, in contrast, is based on data provided by multiple informants (11 year olds and their parents in respect of family process; children, parents and teachers in respect of child well-being and adjustment). Although the strongest relationships between family process and child well-being and adjustment do occur in respect of reports from the same informant, the existence of cross-informant relationships demonstrates that this methodological issue cannot entirely account for the associations obtained, and that the links, in particular between child-parent conflict and poorer psychological well-being and adjustment, are 'real'.100 25629_Txt 9/8/02 9:21 AM Page 36
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Comparing reports from 11 year olds and their parents in respect of parental economic activity and occupation (West and Sweeting) It is widely assumed that children, especially younger children and those in poorer circumstances, are unreliable informants of parental occupation and related characteristics, thereby precluding the measurement of social class in much research involving children. In a comparison of reports of parental economic activity and occupation by children and their parents in the baseline 11 to 16 survey, this assumption was found to be unwarranted. The findings showed lower levels of missing data among children compared to parents and '(very) good' levels of agreement (as indicated by the Kappa statistic) about both economic activity and occupation. These results, which were similar for boys and girls and those in different material and family circumstances, also suggest that children may sometimes provide more valid reports than parents themselves. In the particular fieldwork conditions employed in this study, therefore, children as young as 11 from diverse social backgrounds can provide reliable, and possibly very valid, reports of parental socioeconomic characteristics. With few additional resources, most studies of child-only informants could reproduce the 11 to 16 fieldwork procedures to obtain good data on social class.110
Social class and smoking, drinking and drug use at age 15: the effect of different definitions (Sweeting and West) Evidence on the relationship between social class and smoking among teenagers is inconsistent, one possible reason being that studies adopt different definitions of a 'smoker'. At age 15, 'current smoker' (occasional and regular) was the only category not significantly related to class, a pattern however which obscures two opposite trends; that of regular (weekly) smoking showing a positive class gradient, occasional (less than weekly) smoking showing the reverse. With increasingly stringent definitions (7, 35 or 70 cigarettes per week), the ratio of smokers from unskilled backgrounds to smokers from professional backgrounds rises markedly.101 A similar change in patterning occurs with respect to experience of illicit drugs: a very slight gradient is observed with "drug use ever", which increases when weekly drug use is examined, and increases still further with when daily use is examined. With respect to drinking, only heavy alcohol consumption is class-related. These analyses show that conclusions about whether smoking, drinking and drug use among teenagers is related to social class depend on the definitions adopted. In general, the heaviest use, with the most severe consequences for longer-term health, occurs among those from semi- and unskilled social class backgrounds.191
Characteristics of local areas and smoking, drinking and cannabis use (Sweeting and West) Despite pervasive media images connecting teenage substance use with unsafe areas and poor facilities, very little research evidence is available on the issue. Among 15 year-olds in the CCC, higher rates of heavy smoking and drinking and weekly cannabis use were found among respondents who rated their local areas as less safe and tidy, and among those who rated the area as having poorer facilities (sports provision, public transport and places for young people to meet). These associations were independent of social class, and appear to be substance-specific, safety having a stronger relationship with smoking and drinking, and facilities a stronger relationship with cannabis and none at all with drinking. While the direction of causality in these relationships remains unclear, the fact that they are substance-specific suggests it is unlikely they are simply the result of negative affect.190
Carol Nicol, Programmer/Analyst and John Gilchrist, Computing Officer 25629_Txt 9/8/02 9:21 AM Page 37
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Young People’s Health and Health Behaviour
Gender differences in health from early to mid adolescence (Sweeting and West) This analysis used self-report health measures obtained at 11, 13 and 15 in order to test the hypothesis that there is an emerging or increasing female excess in general ill-health and physical symptoms, as well as psychological distress, during early to mid adolescence. Generally high levels of health problems at age 11 tended to increase with age, these increases being greater for females than males, not only in respect of psychological distress and 'malaise' symptoms, but also limiting illness, 'poor' self-rated health, headaches, stomach problems and dizziness. The result, by age 15, was the emergence of a female excess in general ill-health and 'malaise', and a substantial strengthening of a sex differential in 'physical' symptoms and psychological distress already apparent at 11 years. The results are discussed in relation to explanations for the adult female excess in poorer health, and the emergence of a female excess of depression during adolescence.103
Gender differences in weight related concerns from early to mid-adolescence (Sweeting and West) The period from early to mid adolescence has been seen as of key importance for the development of female body dissatisfaction, though very few studies have been able to link this with actual body mass index (BMI). In this analysis, we examined concerns about weight (worries about putting on weight and being on a slimming diet) among 11, 13 and 15 year-olds whose BMIs were defined as within the 'lower', 'middle' or 'overweight' categories for their age and sex. While for both sexes, weight concerns increased with BMI at each age, among females such concerns were also apparent among a significant minority of those who were of 'lower' weight, and particularly so at age 15. At this age, 41% of 'lower' weight females were worried about putting on weight compared with 5% of males, and 8% were on a slimming diet compared with <1% of males. Among those of average ('middle') BMIs, 75% of 15 year-old females were worried about putting on weight and 26% were on a slimming diet, the comparable figures for males being 22% and 3%. These findings indicate that while males generally become more comfortable with their weight between early and mid-adolescence, the reverse is the case for females irrespective of their actual body size.104
Teasing and bullying: characteristics of victimised children (Sweeting and West) At both 11 and 13 years, around 10% of children report being teased and/or bullied most or every day, with a further 5% being teased and/or bullied on a weekly basis and 30% less often. Although the public stereotype that bullied children differ from their peers in respect of attributes such as appearance, disability or school performance is generally supported by a diverse literature, some authors dispute this. At age 11, the experience of victimisation did not differ according to social class, race, physical maturity or height. However, it was more likely among boys, children rated as less physically attractive, those who were overweight, had a disability such as a sight, hearing or speech problem, and those who performed poorly at school. Each of these effects was independent and thus additive. We conclude that children who are targets for teasing or bullying are also dealing with problems or differences that may in turn have contributed to initiation of victimisation.100
The structure of young people's leisure: comparing patterns across time and culture (Young, Sweeting and West with Sakari Karvonen, Stakes, Helsinki & Ossi Rahkonen, Dept of Social Policy, University of Helsinki) Though extensive research has been carried out to determine the structure of adult leisure, typically using exploratory factor analysis, relatively little work has been conducted on youth. Using the Twenty-07 and 11 to 16 studies, together with a study of young people in Helsinki conducted in 1998, we compared the structure of leisure activities among 15 year-olds across time (1987/1999) and culture (Glasgow/Helsinki) using confirmatory factor methods, and tested for temporal and cross-cultural equivalence in leisure structure. The results supported a 4-factor model of leisure (sports/games, conventional, commercial and street-based leisure) for the 11 to 16 and Twenty-07 samples, thus confirming equivalence of structure over time. By contrast, only partial support for cross-cultural equivalence with the Helsinki sample was found. Furthermore, the latent structure in all three samples was considerably more complicated than previous work suggested.237 25629_Txt 9/8/02 9:21 AM Page 38
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Cross-national comparison of social class, lifestyles and health behaviours (West, Sweeting, Young with Sakari Karvonen, Stakes, Helsinki & Ossi Rahkonen, Dept of Social Policy, University of Helsinki) The extent to which young people's lifestyles are related to social class, their relationship with health behaviours, and variations in these relationships between countries, is of central relevance to an assessment of the extent to which post-modern (global) influences have replaced those associated with traditional (local) social structures. A comparison between 15 year-olds in Glasgow and Helsinki revealed a remarkably similar pattern of relationships. In both locations, involvement in commercial leisure was unrelated to class, as was sports/games in Glasgow, while conventional lifestyles (more middle-class) and street-based lifestyles (more working-class) were class associated. Furthermore, while lifestyles were strongly related to smoking, drinking and drug use (street-based and commercial leisure orientations elevating rates, sports/games reducing them) social class was of negligible consequence for health behaviours in both Glasgow and Helsinki. We conclude that while there remains a link between social class and some lifestyles, notably in relation to street-based leisure, for the most part young people's lifestyles cut across class and national boundaries and have similar consequences for health behaviour.73,204
Changes in psychological distress (GHQ caseness) over time (West & Sweeting) This analysis compared levels of psychological distress, as measured by the General Health Questionnaire (GHQ), and personal and performance worries, between the two cohorts of 15 year-olds in the Twenty-07 and 11 to 16 studies. Between 1987 and 1999, rates of GHQ caseness increased significantly for females (from 19% to 33%), but not for males (13% to 15%), a change particularly affecting females from non-manual and skilled manual social class backgrounds. With one notable exception (unemployment), the percentage worrying 'a lot' about a range of issues also increased over time, a gender gap emerging in respect of worries about school performance, with females worrying more. While the effect of personal worries, about looks and weight for example, persisted over time for both sexes, the effect of performance worries on GHQ caseness only emerged for females in 1999. We interpret these findings against the background of an increase in educational expectations for females, which together with more traditional concerns about personal identity, appear to have elevated levels of stress, with adverse consequences for their mental health.205,207
The Twenty-07 Study Apart from comparative analyses, the youngest cohort of the Twenty-07 Study continues to provide the basis for several analyses, most of which in the past year have focussed on labour market issues. 25629_Txt 9/8/02 9:21 AM Page 39
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Young People’s Health and Health Behaviour
Reconceptualising Youth transitions: Patterns of Vulnerability and Processes of Social Exclusion (Cartmel with West, Sweeting and Andy Furlong, Dept of Sociology, University of Glasgow and Andy Biggart, University of Ulster) This project, supported by a grant of £120,000 from the Scottish Executive (Dept of Industry and Education and Social Exclusion) and Scottish Enterprise, is an extension of the Twenty-07 study, involving both secondary analysis of existing data and new data to be collected via a qualitative component. It focuses on the range of trajectories followed by young people as they make the increasingly complex transition from school to work, and capitalises on the much longer follow-up period of the Twenty-07 study compared with most other surveys.
Analysis of existing data, derived from a monthly labour market history diary of occupational status from age 15 to 23, has identified two distinct types of trajectory termed linear and non-linear respectively. The linear trajectory is characterised by smooth movement from education to employment with little unemployment over the eight-year period and few changes in occupational status. In contrast, the non-linear trajectory is associated with periods of unemployment (each with a duration of over three months), numerous status changes and backtracking. About half the sample followed linear transitions, these young people in general having more 'successful' outcomes than those who experienced non-linear transitions. Although non-linear transitions were experienced by young people from all social classes, they were more common among those from manual backgrounds, and the experience of one major component (unemployment) was strongly related to deprivation. A small core of young people whose transitions could be described as chaotic were identified. This group only comprised about 6% of the cohort, yet their early labour market histories were heavily dominated by unemployment. A further 12%, who had experienced uneven routes in the labour market, may be described as vulnerable.119,137
In addition to the quantitative component, a sub-sample of 60 young people representing diverse transitions were interviewed to obtain more detailed biographical and experiential data. These data highlight the importance of personal resources such as determination and persistence together with strong family support in obtaining employment and overcoming other barriers in the labour market. There was very little evidence to support the view that young people are work-shy or unrealistic in their aspirations, the great majority going to great lengths to find work and downgrading their aspirations relatively quickly, even when they had invested heavily in training and skill development. There was also little evidence to suggest that current policy initiatives were helping young people cope with key hurdles. Indeed, the threat of withdrawal of benefits, far from fostering engagement with the labour market, appears to provide an incentive for young people to engage either in the informal economy or crime.121
Physical activities in Glasgow and Dunedin, New Zealand (West with Tony Reeder, Social & Behavioural Research in Cancer Group, and Richie Poulton and Barrie J Milne, Dunedin Multidisciplinary Health & Development Study, Department of Preventive and Social Medicine, Dunedin) Comparative data on physical activities among young people are still quite rare. The opportunity presented by two cohorts resident at opposite ends of the globe (Glasgow and Dunedin), but born within one year of each other and surveyed at the same ages (15 and 18), is therefore of considerable interest. The comparison between the cohorts reveals that Dunedin 15 year-olds not only had higher participation rates in most physical activities than their Glaswegian counterparts, but also participated in a broader range of activities and, with one or two exceptions (e.g. football for males), did so more frequently. Among those who had left school (age 18), the differences were still apparent, and markedly so for females. Interestingly, the gender difference (females' lower levels of participation in both countries) is less apparent in New Zealand despite the 'macho' image often associated with Kiwi culture.111 25629_Txt 9/8/02 9:21 AM Page 40
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Related Projects Teenage Health in Schools (THiS) Study (Gordon and Turner) The Teenage Health in School (THiS) study aims to explore whether school and peer processes can explain variations in the smoking profiles of secondary schools which are similar in terms of their pupils' socio-economic characteristics. Following on from the demonstration of 'school effects' on health behaviours in the 11 to 16 Study,201,208,209 during January and March 2001 surveys were conducted in 6 secondary schools, all characterised by high levels of deprivation but, based on their earlier participation in 11 to 16, predicted to vary in their smoking profiles. In each school, 13 (S2) and 15 (S4) year-old pupils completed questionnaires containing questions on health, lifestyles, attitudes to school and friendships, the latter permitting sociometric analysis. From these data, two schools (one 'high' smoking, one 'low' smoking) were selected for the next qualitative phase of THiS. During May and June 2001, a total of 31 one-to-one interviews were conducted with teachers and non-teaching staff members, and 15 single-sex discussion groups were held with 13 year-old pupils. Four discussion groups were also conducted with parents of some of these pupils. In a repeat exercise, involving 3 schools serving advantaged areas, predicted school effects were not confirmed.
Currently, systematic comparisons are being made between the two selected schools, using the Nvivo package for qualitative data. Preliminary analyses have explored processes that support or inhibit a health agenda in schools, and have identified tensions within the Health Promoting School (HPS) concept. In the first of these, arising from pilot work in one secondary school, data on school staff as health exemplars (one of the original WHO criteria for the HPS), were examined. The analysis of data provided by staff and pupils revealed little support for the notion that staff should act as health exemplars by showcasing positive health behaviours. However, each party expressed the view that staff should not openly display negative health behaviour during school time, although pupils felt that even if staff were to do so, this would not influence their (pupils') view of the health behaviour in question. As both pupils and staff placed a value on positive pupil-staff interaction, and shared the view that pupils were likely to model staff interpersonal behaviours (e.g. showing respect and being fair) the potential for staff to model interpersonal behaviours was emphasised. Therefore, while there was little currency for the notion of staff acting as health exemplar, the argument that staff can exercise a key role in the social realm remains intact.56
In the second, arising from the main study, the question of the extent to which levels of pupil smoking are associated with staff enforcement of smoking restrictions in the two schools was examined. Although both schools were 'officially' signed up to a policy that prohibited pupil smoking in schools, staff decisions were motivated predominantly by personal values and perceptions concerning their roles and responsibilities. Several factors hindered the capacity of staff to intervene when confronted with pupil smoking. While the risk of fire in the school buildings prompted intervention when smoking was witnessed indoors, where this risk was absent, decisions were largely context-dependent, or motivated by personal and professional values. Concerns about staff-pupil relationships, attention to pupils' wider welfare, lack of authority, and staff levels of discomfort were salient issues inhibiting intervention. Additionally, some expressed a philosophical resistance to intervening and acting as disciplinarians on smoking matters. Such barriers to intervention expose tensions inherent within the HPS concept, signalling the need for public health protagonists and policy makers to find ways of enforcing school smoking bans that are compatible with schools' social and educational aims.57,140 25629_Txt 9/8/02 9:21 AM Page 41
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Young People’s Health and Health Behaviour
Peer group structure, attitudes to school and health behaviours (West, Sweeting, Young, Turner and Gordon with Mike Pearson, Dept of Mathematics, Napier University, Edinburgh) The peer group is often identified as a major (usually negative) influence on young people yet both its structure and correlates remain poorly documented. Following on from a previous project conducted in one secondary school,176,177 This provides the opportunity to examine peer group structures and their relationship with pupil attitudes and health behaviours (e.g. smoking) in 9 schools with varying levels of deprivation, and for 2 year groups in each. Information on friendships, provided by pupils in the survey, is being analysed via the NEGOPY programme to produce pictures (sociograms) of the peer group structure (e.g. groups, liaisons, dyads) of whole year groups (S2 and S4), on to which the attitudes and health behaviours of individuals can be mapped (see diagram). These data will be used to address a number of questions, among which are the extent to which peer group structure varies between schools and year groups and the extent to which there is variation in the patterning of attitudes and health behaviours by peer group structure. The sociograms of particular school year groups will also be considered alongside the qualitative component of THiS, and information gathered in focus groups with pupils should inform interpretation of the sociometric data.
School effects on adolescent pupils' health behaviours and school processes associated with these effects (PhD project: Henderson, supervisors West and Prof Gillian Raab, Napier University) The concept of the HPS is now widely accepted as a framework by which schools can attempt to promote healthy lifestyles among their pupils. However, evaluations of this concept have to date lacked methodological rigour, the focus being predominantly on school health education provision and other school processes, with little attention to health outcomes. This PhD thesis aims to further our understanding of the links between processes and outcomes, and draws on data collected in a study of 8 secondary schools conducted in the early 90s which used both quantitative and qualitative methods. The former involved 446 pupils, aged 13 (S2) and 15 (S4), who completed questionnaires in 'examination conditions' relating to family background, lifestyles, health education, attitudes towards school, attitudes towards health, knowledge and health behaviour. In the qualitative component, 96 pupils from the S4 sample were interviewed on a one-to-one basis, as were 96 teachers. Quantitative analysis demonstrated a school effect for both current smoking and weekly alcohol consumption after adjusting for gender, year at school, the interaction between gender and year at school, parents' social class, family composition and parental health behaviours. The qualitative data, which was collected and transcribed in advance of the quantitative data, has been coded in Nvivo and analysis is underway. Completion of the qualitative analysis will establish whether or not there is a link between pupil health outcomes and associated school processes. It is hoped that this research will also assist the interpretation of data collected in other contemporary studies of school effects, and further the development of health education in school settings. 25629_Txt 9/8/02 9:21 AM Page 42
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Behaving badly: psychiatric and sociological perspectives on young people with 'conduct disorder' (PhD project: Harvey, supervisors West and van Beinum) Conduct disorder can be defined by reference to internationally agreed psychiatric criteria although the extent to which its principle manifestation - bad behaviour - is evidence of psychopathology, is problematic. An alternate view is that, at least in certain circumstances, the same behaviour might be both normative and purposeful. This distinction is rooted in the longstanding debate between medico-psychiatric and sociological perspectives on deviant behaviour, the former emphasising the non-rational nature of antisocial behaviour and viewing its causes as internal to the individual, the latter emphasising the rational basis of such behaviour and viewing it as an adaptation to particular social or cultural circumstances. The aim of this PhD project is to relate these contrasting perspectives to young people's accounts of their pathways into conduct disorder. The study will be predominantly qualitative in nature, participants being identified from a sub-sample of the '16+' cohort using profiles of conduct disorder from the Voice-DISC at ages 15 and 18. Of particular interest will be the comparison of individuals displaying transitory conduct disturbances with those who have a longer history of antisocial behaviour, a subgroup in which the likelihood of sustaining a criminal "career" is higher. Factors associated with conduct disorder in youth include unemployment, drug-taking, teenage pregnancy and disturbed personal relationships, all of which contribute to the financial costs and psychosocial strains incurred as a result of this antisocial behaviour. It is hoped that findings from this study may help to shape policy and to elucidate important areas for consideration within the social inclusion debate.
Young people's views on going to see the psychiatrist (van Beinum) Although there is an increasing recognition that health service users should have a voice in the design and delivery of services, little is known about what teenagers who have attended psychiatric services make of their experiences of going there. This study, which forms the basis of a part-time PhD, utilised a qualitative methodology to interview recently discharged teenage patients aged 12 to 19. Nearly all interviewees said that coming to a psychiatric clinic would be interpreted by peers as a sign of madness. The stigmatising nature of clinic attendance was, for many, compounded by characteristics of the clinical experience itself, including lengthy waiting times, lack of control over the clinical encounter and underlying fears and anxieties being only partially addressed by clinic staff. A dilemma for young people was that many were primarily concerned with the social presentation of a morally acceptable self - an issue that is of particular importance for teenagers, particularly when mental health is at stake - while, to them, clinicians seemed first and foremost concerned with diagnosis and treatment of illness. 25629_Txt 9/8/02 9:21 AM Page 43
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Other Research: Professional and lay understanding of science and of risk
The Unit has had a longstanding interest in public and expert understandings of medical science and of risk, and although this work has not constituted a core funded programme we feel it is increasingly important in the light of the post- genome challenge and public concerns about health risks (eg GM foods, immunisation, food safety).
Lay understandings of heart disease (Hunt and Emslie) Our research on lay understandings of heart disease has utilised both qualitative and quantitative methodologies. The primary aim of a qualitative study was to study people's ideas about their 'family histories' of heart disease and health-related behaviours. This involved semi-structured in-depth interviews with 61 men and women in their forties (from a range of social circumstances) who were purposively sampled from the younger generation of the Midspan Family Study (a clinical epidemiological study conducted in 1996 of adult offspring of participants in the Paisley-Renfrew Study).
Analysis showed that some people see themselves as definitely 'having' or 'not having' a family history of heart problems. However, others, and in particular men from less affluent backgrounds, are ambivalent. Many people drew a distinction between notions of `family risk' for their family as a whole and for themselves personally. Some people who thought that heart disease 'ran' in their family did not feel at increased personal risk themselves because they thought that they differed in crucial ways from affected family members. Whilst many of the factors which people considered in assessing their level of familial risk (e.g., the age and number of affected relatives) concurred with medical constructions of risk, others (e.g., the pattern of disease or likenesses to affected family members) did not, thus leading to a potential for misunderstanding in clinical encounters. Thus, lay and medical views of family history as a risk factor for heart disease overlap, but do not fully coincide.72 Such results have implications for the way in which people may interpret and react to future information about genetic risk.9
Our analyses also identified common cultural notions which may undermine coronary prevention advice. These beliefs are highlighted in a health promotion leaflet which we developed in collaboration with heart health specialists in Greater Glasgow Health Board Health Promotion Department229 One notion which appeared to undermine people's readiness to follow coronary prevention advice was the image of heart disease as a 'good way to go'. This was typically contrasted with a painful lingering death, usually from cancer. Two elements of this were apparent: in some deaths (particularly premature deaths ) its 'quickness' was emphasised; and in deaths amongst older people a heart attack was often portrayed as inevitable and 'natural.'51 This study also shows the extent to which people think of heart disease as a `male' disease.52 As a result, CHD signs, symptoms and risk factors may be underplayed among women.
Our data confirmed that lay notions of 'coronary candidacy' (the sorts of people who are most and least likely to get CHD) are widespread, but that the lack of certainty in predicting coronary events at an individual level is another barrier to behavioural change. This informed our views on parallels and differences in the importance and salience of the 'prevention paradox' in lay and professional epidemiology.71 Quantitative analyses (in collaboration with Alex McConnachie and Graham Watt, Dept of General Practice, and Carole Hart, Dept of Public Health) have used the parental generation in the Midspan Family Study to investigate the prevalence of anomalies to 'coronary candidacy' which figure highly in lay accounts.84
Lay understandings of the mechanisms of inheritance (Hunt and Emslie) In our qualitative interviews, we explored lay perceptions of inheritance. Respondents' understandings were heavily influenced by observations made within the context of their family, and accounts often emphasised family identity. While respondents often used scientific terms (e.g., 'genes'), their understandings rarely followed Mendelian models of inheritance. Views about modern genetic technologies and discourses about the evolution of the species were often mentioned in general discussion of inheritance. 'Social' and 'biological' forms of inheritance were inextricably linked in accounts; eye colour, illnesses and smoking behaviour could all be seen as "running in the family". 25629_Txt 9/8/02 9:21 AM Page 44
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Processes involved in the public understanding of biomedical science: a case study of educational packages (Carter: grant of £64K from MRC to Macintyre, Carter and Dr Mike Michael of the Department of Sociology, Goldsmith's College, London, 1997-1999) We undertook a detailed case study of a range of MRC educational interventions (on cystic fibrosis and sickle cell disease) designed to provide information to science students about medical research. We aimed to chart the conditions under which new biomedical information is accepted or discounted, and to examine the social processes involved in the production, transmission and reception of educational packages. Fieldwork was undertaken in three schools and a teacher training college. Focus groups were conducted both with students taking science subjects and those doing non-science subjects. In addition we interviewed the scientists who contributed to, and the writers who produced, the educational intervention. This research examined the ways in which educational scientific texts move across different domains and the practices whereby meaning is attributed to these texts; the ways in which emerging technologies in the biological sciences (especially the new genetics) may come to shape and colonise talk of biography and choice in parenthood and reproduction; and the dimensions and meanings of expressing an interest in science (e.g. intellectual challenge, duty, as a consumer, as a career, as a facet of popular culture).86
Lay perceptions of inequalities in health (PhD Project: Davidson, supervisors Hunt and Dr Jenny Kitzinger, Brunel University) There has been increased interest recently in the concept of relative deprivation and its role in generating inequalities. However, the psychosocial mechanisms which have been invoked to link relative deprivation to poorer health are premised on the notion that fine gradations of material inequality are perceived by people and that these are sufficiently important to impact not just on their psychological health, but also on longer term and more life-threatening conditions. At present there is little evidence to justify or refute such a premise. This project has used focus group discussions to gather information on lay perceptions of inequality. These data are complemented by an analysis of media coverage of inequality over specified periods, specifically in the month following publication of key government documents on public health.
Parental decision making in MMR vaccination: perceptions of risks, benefits and barriers (PhD project: Hilton, supervisors Petticrew, Hunt) The development of immunology as a scientific discipline is one of the great success stories of public health medicine. Not only is immunisation widely heralded as having been responsible for a huge decline in mortality and morbidity associated with infectious diseases, but it is also among the most cost-effective and widely used public health intervention. However, the paradox of this monumental public health success is that many parents have little or no experience of the diseases from which the vaccines protect. Consequently, the diseases no longer serve as a reminder of the need to immunise and issues about the efficacy of vaccines and concern about potential side effects of vaccines have assumed a more prominent focus. Indeed, in February 1998 publication of a paper suggesting a causal association between the MMR vaccine, bowel disease and autism dealt a huge blow to parents' confidence in the safety of the MMR vaccine. Whilst the current scientific evidence overwhelmingly supports the safety of MMR, within some parts of the United Kingdom the subsequent low uptake of MMR has led to outbreaks of measles, thus fuelling speculation of an impending measles epidemic. This qualitative study explores parents' perceptions about mass childhood immunisation, within the context of the current MMR controversy. At also aims to describe parents' perceptions of diseases and vaccines and to explain how these perceptions translate into the parental decision-making process about whether to immunise or not. 25629_Txt 9/8/02 9:21 AM Page 45
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Other unit news
Fundraising Unit staff have taken part in recent years in the Imperial Cancer Research Fund's "Race for Life," and in 2001/02 the runners included Helen Sweeting, Nanette Mutrie, Fiona McDonald, Lisa Williamson, Marion Henderson and Laura McKay. In March 2001 Patricia Fisher, Elaine Hindle, and Hilary Davison organised an auction in the unit as part of the Cancer Research Campaign's "Biggest Breakfast," raising a total of £330. In May 2002 Unit staff participated in Glasgow University's Munro Challenge, fielding a team which included Marion Henderson, Ursula Berger, Mary-Kate Hannah and Caroline Allen. Their efforts raised £100 for BHF Glasgow Cardiovascular Research Centre (see photo).
The 2001 Unit Awayday In November last year the unit decamped to Crieff Hydro Hotel for one day to take part in a range of teambuilding and other events. The day ended with an evening meal at which the 2001 MRC SPHSU Annual Quaich was presented to Patricia Fisher and Carol Nicol. 25629_Txt 9/8/02 9:21 AM Page 46
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Professional Activities by Unit Members 2001/2002
Editorships* and Editorial Boards AIDS Care* (Carfax) Critical Public Health (Carfax) Ethnicity and Health (Carfax) Gender and Education (Carfax) Health and Place (Pergamon) Health Education (MCB University Press) Health, Risk and Society (Carfax) Health, Risk and Society* (Taylor and Francis) Midwifery (Churchill Livingstone) Sexually Transmitted Infections (BMJ Publishing Group) Social Aspects of AIDS (Taylor and Francis) Social Science and Medicine* (Elsevier) Sociology of Health and Illness (Blackwell) Studies on Women Abstracts (Carfax) Journal of Youth Studies (Carfax) Youth and Policy (National Youth Agency)
National Scientific Committees BSA Medical Sociology Group Committee BSA Equality of the Sexes Committee BSA Scotland Committee BSA/SCOFF Sociology of Food Group Cabinet Office Social Exclusion Unit: Teenage Pregnancy Cancer Research Campaign/Department of Health Joint Programme on Black and Minority Ethnic Groups and Cancer (Advisory Committee) ESRC Committee on Youth Citizenship and Social Change ESRC National Strategy Committee on Longitudinal Studies MRC Advisory Board MRC Expert Team of Research Training Referees MRC Committee on Epidemiological Studies in AIDS MRC Health Services and Public Health Research Board MRC Working Group on Fluoridation and Health PPP Foundation Children and Adolescents Grants Committee Royal Geographical Society (Institute of British Geographers) Health Geography Research Group Scottish Council for Research in Education: External Evaluation of School Health Programmes Scottish Executive’s National Health Demonstration Project Steering Group Scottish Executive Working Group on Measuring Inequalities Scottish Needs Assessment Programme - Sub-Group on Health Promotion Research Scottish Needs Assessment Programme - Working Group on STD Services
Organisation of Conferences Evidence, Policy Practice Conference: Public Health Research in Scotland (Edinburgh), June 2002 25629_Txt 9/8/02 9:21 AM Page 47
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Publications and Presentations: 2001 to 2002
Listed by type of publication, alphabetically by author
Books and Edited Books 1. Biddle S, Mutrie N. The psychology of physical activity: 15. Hunt K. Social and economic trajectories and women’s health: determinants, well-being and interventions. London: Routledge, 2001. commentary. In: Kuh D, Hardy R (eds) A Life Course Approach to Women’s Health. Oxford University Press, (in press). 2. Der G, Everitt BS. A handbook of statistical analyses using SAS (2nd edition). Boca Raton: Chapman & Hall/CRC, 2001. 16. Lewsey J, Murray G, Leyland AH, Boddy FA. Using routine data to complement and enhance the results of randomised controlled trials. 3. Leyland AH, Goldstein H. Multilevel modelling of health statistics. In: Stevens A, et al. (eds). The Advanced Handbook of Methods in Chichester: John Wiley & Sons, 2001. Evidence Based Health Care: Insights from the NHS HTA Programme. London: Sage, 2001:149-165. Book Chapters 4. Abraham C, Wight D, Scott S. Developing the SHARE sex education 17. Leyland AH. Spatial Analysis. In: Leyland AH, Goldstein H (eds). programme: from theory to classroom implementation. In: Rutter D, Quine Multilevel modelling of health statistics. Chichester: John Wiley & Sons, L (eds). Changing Health Behaviour: Research and practice with social 2001:143-157. cognition models. Open University Press, 2001. 18. Macintyre S. Socio-economic inequalities in health in Scotland. 5. Bradby H. Communication, interpretation and translation. In: Social Justice Annual Report Scotland 2001. Edinburgh: The Scottish In: Dyson S, Culley L (eds). Sociology, ethnicity and nursing. Executive, 2001:116-121. Basingstoke: Macmillan, 2001:129-148. 19. Macintyre S, Hiscock R, Ellaway A, Kearns A. The fallacy of the 6. Davey B, Hart G. HIV and AIDS. Chapter 4. In: Davey B, Seale C equivalence of a range of household and area based indicators of (eds). Experiencing and Explaining Disease [3rd Edition]. material resources in the geography of health inequalities. In: Boyle P, Buckingham: Open University Press, (in press). et al. (eds). The Geography of Health Inequalities in the Developed World, (in press). 7. Ellaway A, Macintyre S. Housing and social exclusion, the problems of living in poor quality accommodation. In: Housing and Health. 20. Macintyre S, Ellaway A. Neighbourhoods and health: overview. London: British Medical Association, (in press). In: Kawachi I, Berkman L (eds). Neighbourhoods and health. Oxford: Oxford University Press, (in press). 8. Ellaway A, Macintyre S. Women in their place. Gender perceptions of neighbourhoods and health in the West of Scotland. In: Dyack I, 21. McLeod A. Multivariate multilevel models. In: Leyland AH, Goldstein Davis Lewis N, McLafferty S (eds). Geographies of Women’s Health. H (eds). Multilevel modelling of health statistics. Chichester: John Wiley London: Routledge, 2001: 265-281. & Sons, 2001:143-157.
9. Emslie C, Hunt K. Genetic Susceptibility. In: Cooper D (ed). 22. Mutrie N, Faulkner G. Physical activity and mental health. In: Encyclopedia of the Human Genome. Basingstoke: Macmillan, (in press). Donaghy M Mental health issues for physiotherapists. Taylor Francis, (in press). 10. Goldstein H, Leyland AH. Further topics in multilevel modelling. In: Leyland AH, Goldstein H (eds). Multilevel modelling of health 23. Mutrie N, Woods C. How can we get people to become more statistics. Chichester: John Wiley & Sons, 2001:175-186. active? A problem waiting to be solved. In: Riddoch C, McKenna J (eds). Perspectives in exercise and health. McMillan, (in press). 11. Hart G, Flowers P. Gay and bisexual men’s general health. In: Davidson N, Lloyd T (eds). Promoting Men’s Health: A Practitioner’s 24. Ross D, Wight D. What is the role of randomised trials in assessing Guide. London: Balliere-Tindall, 2001:225-234. sexual health interventions: Developing countries perspective. In: Stephenson J, Imrie J, Bonell C (eds). Effective Sexual Health 12. Hart G, Barnard M. Jump on top, get the job done: strategies Interventions: issues in experimental evaluation. Oxford: Oxford employed by female prostitutes to reduce the risk of client violence. University Press, (in press). In: Stanko E The Meanings of Violence. London: Taylor and Francis, (in press). 25. Wight D, Obasi A. Unpacking the Black Box: the importance of process data to explain outcomes. In: Stephenson J, Imrie J, Bonell C 13. Hart G, Elford J. Community-based sexual health interventions among (eds). Effective Sexual Health Interventions: issues in experimental gay men. In: Stephenson J, Imrie J, Bonell C (eds). Effective sexual health evaluation. Oxford: Oxford University Press, (in press). interventions: issues in experimental evaluation. London: Routledge, (in press).
14. Hiscock R, Ellaway A, Macintyre S, Kearns A. The significance of residence: Exploring the links between ontological security, housing tenure and place. In: Gurney C Placing Changes: Perspectives on Place in Housing and Urban Studies. Aldershot: Ashgate, (in press). 25629_Txt 9/8/02 9:21 AM Page 48
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Refereed Journal Articles 43. Duncan B, Hart G, Scoular A, Bigrigg A. A qualitative analysis 26. Abbotts J, Williams R, Ford G. Morbidity and Irish Catholic descent of the psychosocial impact of a diagnosis of Chlamydia trachomatis: in Britain: Relating health disadvantage to socio-economic position. implications for screening. British Medical Journal 2001; 322:195-199. Social Science and Medicine 2001; 52:999-1005. 44. Duncan B, Hart GJ, Scoular A. Screening and the construction 27. Abbotts JE, Sweeting H, Williams R, West P. Poor but healthy? of scepticism: the case of Chlamydia. Health 2001; 5:165-185. The youngest generation of Irish Catholics in West Scotland. Health Bulletin 2001; 59:371-378. 45. Ellaway A, Macintyre S. Contrasts in service provision [Gallery]. Journal of Epidemiology and Community Health 2001; 55:769. 28. Bush HM, Williams RGA, Lean MEJ, Anderson AS. Body image and weight consciousness among South Asian, Italian and general population 46. Ellaway A, Macintyre S, Kearns A. Perceptions of place and health women in Britain. Appetite 2001; 37:1-9. in social contrasting neighbourhoods. Urban Studies 2001; 38:2299-2316. 29. Buston K, Wight D, Hart G. Inside the sex education classroom: the importance of class context in engaging pupils. Culture, Health and 47. Elwy AR, Hart G, Hawkes S, Petticrew M. Effectiveness of Sexuality (in press). interventions to prevent STI/HIV in heterosexual men: a systematic review. Archives of Internal Medicine (in press). 30. Buston K. Adolescents with mental health problems: what do they say about health services? Journal of Adolescence (in press). 48. Emslie C, Hunt K, Macintyre S. How similar are the smoking and drinking habits of men and women in non-manual jobs? European Journal 31. Buston K, Wight D, Scott S. Difficulty and diversity: the context and of Public Health 2002; 12:22-28. practice of sex education. British Journal of Sociology of Education 2001; 22:353-368. 49. Emslie C, Fuhrer R, Hunt K, Macintyre S, Shipley M, Stansfeld S. Gender differences in mental health: evidence from three organisations. 32. Buston K, Hart G. Heterosexism and homophobia in Scottish Social Science & Medicine 2002; 54:621-624. school sex education: exploring the nature of the problem. Journal of Adolescence 2001; 24:95-109. British Medical Journal 2001; 50. Emslie C, Hunt K, Macintyre S. Perceptions of body image amongst 322:524-525. working men and women. Journal of Epidemiology and Community Health 2001; 55:406-407. 33. Buston K, Wight D, Hart G, Scott S. Implementation of a teacher-delivered sex education programme: obstacles and facilitating 51. Emslie C, Hunt K, Watt G. I’d rather go with a heart attack than factors. Health Education Research Theory and Practice 2002; 17:59-72. drag on. Lay images of heart disease and the problems they present for primary and secondary prevention. Coronary Health Care 2001; 34. Buston K, Wight D. The salience and utility of school sex education 5:25-32. to young women. Sex Education (in press). 52. Emslie C, Hunt K, Watt G. Invisible women? The importance of 35. Callaghan M, Raitt F, Siann G. Practising as a solicitor in Scotland. gender in lay beliefs about heart problems. Sociology of Health & Illness Professional and Gender Issues. Scottish Law and Practice Quarterly 2001; 23:201-231. 2001; 6:61-73. 53. Flowers P, Buston K. I was terrified of being different: exploring 36. Church S, Henderson M, Barnard M, Hart G. Violence by clients gay men’s accounts of growing-up in a heterosexist society. Journal towards female prostitutes in different work settings: questionnaire survey. of Adolescence 2001; 24:51-65.
37. Crawford F, Mutrie N, Hanlon P. Employee attitudes towards active 54. Flowers P, Hart GJ, Williamson LM, Frankis JS, Der GJ. Does commuting. International Journal of Health Promotion and Education bar-based, peer-led sexual health promotion have a community-level 2001; 39:14-20. effect amongst gay men in Scotland? International Journal of STDs & AIDS 2002; 13:102-108. 38. Cummins S, Macintyre S. Factoids in health policy: the example of food deserts. British Medical Journal (in press). 55. Gemmell I. Indoor heating, house conditions and health. Journal of Epidemiology and Community Health 2001; 55:928-929. 39. Cummins S, Macintyre S. A systematic study of an urban foodscape: the price and availability of food in Glasgow. Urban Studies (in press). 56. Gordon J, Turner K. School staff as exemplars - where is the potential? Health Education 2001; 101:283-291. 40. Davis MDM, Hart G, Imrie J, Davidson O, Williams I, Stephenson J. HIV is HIV to me: the meanings of treatment, viral load and reinfection 57. Gordon J, Turner K. Ifs, maybes and buts: factors influencing staff for gay men living with HIV. Health, Risk and Society 2002; 4:31-43. enforcement of smoking restrictions. Health Education Research Theory and Practice (in press). 41. Deary I, Der G, Ford G. Reaction time and intelligence differences: A population based cohort study. Intelligence 2001; 29:1-11. 58. Green G, Bradby H, Chan A, Lee M, Eldridge K. Equity and culture: Is the NHS failing to meet the needs of mentally distressed Chinese origin 42. Der G. Income and Health: Why are curves so appealing? women in England? Journal of Health Services and Policy (in press). International Journal of Epidemiology (in press). 25629_Txt 9/8/02 9:21 AM Page 49
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Refereed Journal Articles Continued 74. Keskimäki I, Karvonen S, Sund R, Leyland AH. Monitasomallien 59. Hans T, Anderson A, Bradby H, Williams R, Lean M. Ethnic kaytto terveystutkimuksessa [Multilevel modelling in health research]. differences in anthropometric and lifestyle measures related to coronary Sosiaalilaaketieteellinen Aikakauslehti [Journal of Social Medicine] heart disease risk between South Asian, Italian and general population (in press). British women living in the West of Scotland. International Journal of Obesity 2001; 25:1800-1805. 75. Khand A, Gemmell I, Rankin A, Cleland JGF. Clinical events leading to the progression of heart failure: Insights from a national database of 60. Harding S, Balarajan R. Longitudinal study of socio-economic hospital discharges. European Heart Journal 2001; 22:153-164. differences in mortality among South Asian and West Indian migrants. Ethnicity and Health 2001; 6:121-128. 76. Kirk AF, Higgins LA, Hughes AR, Fisher BM, Mutrie N, Hillis S, McIntyre P. A randomised controlled trial to study the effect of exercise 61. Harding S, Balarajan R. Mortality of third generation Irish people consultation on the promotion of physical activity in people with type 2 living in England and Wales. British Medical Journal 2001; 229-232. diabetes: a pilot study. Diabetic Medicine 2001; 18:877-882.
62. Harding S. Social mobility and self reported limiting long-term illness 77. Kirk AF, Hughes AR, Fisher M, Mutrie N, Hillis S, McIntyre P. among West Indian and South Asian migrants living in England and Measurement of physical activity in clinical populations. Diabetic Wales. Social Science and Medicine (in press). Medicine 2001; 18 (supplement 2):99.
63. Hart G, Wellings K. Sexual behaviour and its medicalisation: 78. Leyland AH. Comment on Smith PC, Rice N, Carr-Hill, R. Capitation in sickness and in health. British Medical Journal 2002; 342:896-900. funding in the public sector. Journal of the Royal Statistical Society Series A 2001; 164-245. 64. Hart GJ, Williamson LM, Flowers P, Frankis JS, Der GJ. Gay men’s HIV testing behaviour in Scotland. AIDS Care (in press). 79. Macintyre S, Chalmers I, Horton R, Smith R. Trying to use evidence to inform policy: a case study. British Medical Journal 2001; 65. Henderson M, Wight D, Raab G, Abraham C, Buston K, Hart G, 322:222-225. Scott S. Heterosexual risk behaviour among young teenagers in Scotland. Journal of Adolescence (in press). 80. Macintyre S, Hiscock R, Kearns A, Ellaway A. Housing tenure and car access: further exploration of the nature of their relationships with 66. Hiscock R, Macintyre S, Ellaway A, Kearns A. Explanations for health in a UK setting. Journal of Epidemiology and Community Health health inequalities between owners and social renters. Journal of Social 2001; 55:330-331. Issues (in press). 81. Macintyre S, Ellaway A, Cummins S. Place effects on health: 67. Hiscock R, Macintyre S, Ellaway A, Kearns A. Do cars provide how can we conceptualise, operationalise and measure them? psychosocial benefits to their users. Transportation Research Part D: Social Science & Medicine (in press). Transport and the Environment 2002; 7:119-135. 82. Mamode N, Docherty G, Lowe GDO, Macfarlane PW, Martin W, 68. Hiscock R, Kearns A, Macintyre S, Ellaway A. Ontological security Pollock JG, Cobbe SM. The role of myocardial perfusion scanning, and psychosocial benefits from the home: qualitative evidence on issues heart rate variability and D-dimers in predicting the risk of perioperative of tenure. Housing, Theory and Society 2001; 18:50-66. cardiac complications after peripheral surgery. European Journal of Vascular and Endovascular Surgery 2001; 22:499-508. 69. Hunt K. A generation apart? An examination of changes in gender-related experiences and health in women in early and late 83. Maynard M, Ness AR, Abraham L, Blane D, Bates C, Gunnell DJ. mid-life. Social Science and Medicine (in press). Selecting a healthy diet score: lessons from a study of diet and health in early old age (the Boyd Orr cohort). Public Health Nutrition (in press). 70. Hunt K, Ford G, Mutrie N. Is sport for all? Exercise and physical activity patterns in early and late middle age in the West of Scotland. 84. McConnachie A, Hunt K, Emslie C, Hart C, Watt G. Unwarranted Health Education 2001; 101:151-158. survivals and anomalous deaths from coronary heart disease: prospective survey of general population. 71. Hunt K, Emslie C. Commentary: the prevention paradox in lay British Medical Journal 2001; 323:1487-1491. epidemiology - Rose revisited. International Journal of Epidemiology 2001; 30:442-446. 85. McLeod A. Socioeconomic deprivation and small-area variation in teenage pregnancies: changes over time. British Medical Journal 2001; 72. Hunt K, Emslie C, Watt G. Lay constructions of a family history of 323:199-203. heart disease: potential for misunderstandings in the clinical encounter? Lancet 2001; 357:1168-1171. 86. Michael M, Carter S. The facts about fictions and vice versa: public understanding of human genetics. Science as Culture 2001; 10:5-32. 73. Karvonen S, West P, Sweeting H, Rahkonen O, Young R. Lifestyle, social class and health related behaviours - a cross cultural comparison 87. Miles K, Shaw M, Paine K, Hart GJ, Ceesay S. Sexual health-seeking of 15 year olds in Glasgow and Helsinki. Journal of Youth Studies 2001; behaviours of young people in the Gambia. Journal of Adolescence 4:393-413. 2001; 24:753-764. 25629_Txt 9/8/02 9:21 AM Page 50
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88. Morrison D, Petticrew M, Thomson H. Health Impact Assessment 103. Sweeting H, West P. Sex differences in health at ages 11, 13 and and beyond. Journal of Epidemiology and Community Health 2001; 15. Social Science & Medicine (in press). 55:219-220. 104. Sweeting H, West P. Gender differences in weight-related concerns 89. Morrison JM, Caroll L, Twaddle SE, Cameron IT, Grimshaw JM, in early to mid adolescence. Journal of Epidemiology and Community Leyland AH, Baillie HM, et al. A pragmatic randomised controlled Health (in press). trial to evaluate guidelines for the management of infertility across the primary-secondary interface. British Medical Journal 2001; 105. Thomson H, Petticrew M, Morrison D. Housing interventions and 322:1282-1284. health: a systematic review. British Medical Journal 2001; 323:187-190.
90. Mugglin AS, Cressie N, Gemmell I. Hierarchical statistical modelling 106. Thomson H, Ross S, Wilson P, McConnachie A, Watson R. Mothers’ of influenza epidemic dynamics in space and time. Statistics in Medicine use and attitudes towards Baby Check. British Journal of General Practice (in press). (in press).
91. Mutrie N, Carney C, Blamey A, Crawford F, Aitchison T, Whitelaw 107. Thomson H. Community amenities - a neglected health resource? A. Walk in to Work Out: A randomised controlled trial of a self-help Journal of Epidemiology and Community Health [Gallery] 2002; 56:81. intervention to promote active commuting. Journal of Epidemiology and Community Health (in press). 108. Thomson H, Petticrew M. Improving housing, improving health? Developing healthy housing policy. Evaluation and Research in Education 92. Mutrie N, Hannah M-K. Prevalence and social patterning of walking (special issue on Evidence-Based Policy) (in press). and cycling activity in the West of Scotland. Journal Sports Science 2002; 20:39. 109. Thomson H, Petticrew M, Douglas M. Health Impact Assessment of housing improvements: incorporating research evidence. Journal of 93. Nardone A, Frankis JS, Dodds JP, Flowers P, Mercey DE, Hart GJ. Epidemiology and Community Health (in press). A comparison of a high risk sexual behaviour and HIV testing amongst a bar-going sample of homosexual men in London and Edinburgh. 110. West P, Sweeting H, Speed E. We really do know what you do: European Journal of Public Health 2001; 11:185-189. A comparison of reports from 11 year olds and their parents in respect of parental economic status and occupation. Sociology 2001; 35:539-559. 94. Nelson A, Bradley M, Cullum N, Torgerson D, Petticrew M, Sheldon T. A systematic review of dressings for the treatment of pressure sores 111. West P, Reeder AI, Milne BJ, Poulton R. Worlds apart: a comparison and leg ulcers. Wound repair and regeneration (in press). between physical activities among youth in Glasgow, Scotland and Dunedin, New Zealand. Social Science & Medicine 2002; 54:607-619. 95. Petticrew M, Rodgers M, Booth A. Effectiveness of laxatives in adults. Quality in Health Care 2001; 10:268-273. 112. Westert G, Lagoe R, Keskimäki I, Leyland AH, Murphy M. An international study of hospital readmissions and related utilisation 96. Petticrew M. Systematic reviews from astronomy to zoology: myths in Europe and the U.S.A. Health Policy (in press). and misconceptions. British Medical Journal 2001; 322:98-101. 113. Wight D, Raab G, Henderson M, Abraham C, Buston K, Hart G, 97. Petticrew M, Sowden A, Lister-Sharp D. False negative results in Scott S. The limits of teacher-delivered sex education: interim behavioural screening programmes: medical, psychological and other implications. outcomes from a randomised trial. British Medical Journal (in press). International Journal of Technology Assessment in Health Care 2001; 17:164-170. 114. Williamson LM, Hart GJ, Flowers P, Frankis JS, Der GJ. The Gay Men’s Task Force: the impact of peer education on the sexual health 98. Scoular A, Duncan B, Hart G. “That sort of place....where filthy men behaviour of homosexual men in Glasgow. Sexually Transmitted Infections go....”: A qualitative study of women’s perceptions of Genitourinary 2001; 77:427-432. Medicine services. Sexually Transmitted Infections 2001; 77:340-343. 115. Woods C, Mutrie N, Scott M. A transtheoretical model based 99. Siann G, Callaghan M. Choices and Barriers: factors influencing intervention designed to help sedentary young adults become active. women’s choice of higher education in science, engineering and Health Education Research: Theory and Practice (in press). technology. Journal of Further and Higher Education 2001; 25:85-95. 116. Woods CB, Mutrie N, Scott P, Simpson C. An examination of the 100. Sweeting H. Our family, whose perspective? Journal of relationship between physical activity stage of change and body weight Adolescence 2001; 24:229-50. in young men and women. Journal of Sports Science 2002; 20:44-45.
101. Sweeting H, West P. Social class and smoking at age 15: the effect of different definitions of smoking. Addiction 2001; 96:1357-9.
102. Sweeting H, West P. Being different: correlates of the experience of teasing and bullying at age 11. Research Papers in Education 2001; 16:225-46. 25629_Txt 9/8/02 9:21 AM Page 51
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Conference Papers, Published Abstracts 132. Ellaway A, Bradby H, McKeown M. Racist and Sectarian Graffiti and Scholarly Presentations in Glasgow. BSA Medical Sociology Group Conference; York: 2001. 117. Abbotts JE. Catholic disadvantage in the West of Scotland. Plenary conference paper to the BSA Sociology of Religion study day; 133. Elliot R. Because everybody did it - or did they? Exploring women’s London: 2001. experiences of smoking 1930-2000 from oral history material. Social History Seminar, Department of Modern History; University of Glasgow: 118. Barnard M, Hart G. Behind closed doors: regulation and control in 2002. prostitution. ESRC Violence Programme: Policy Seminar; London: 2002. 134. Elliot R. Sacrificing everything for a cigarette: gendered narratives 119. Biggart A, Furlong A, Cartmel F, Sweeting H, West P. Young of risk in the context of women’s experiences of smoking, 1930-2000. people, unemployment and social exclusion: risk factors in the modern European Social Science and History Conference; The Hague: 2002. labour market. BSA Annual Conference: Reshaping the Social; Leicester: 2002. 135. Emslie C, Hunt K, Watt G. It’s a family affair: an overview of findings from the family history project. Department of General Practice, 120. Buston K. Addressing the sexual health needs of lesbian, gay and Glasgow University: 2001. bisexual young people. The Sexual Health Needs of Vulnerable Groups - Health Education Board for Scotland Seminar; Edinburgh: 2002. 136. Emslie C, Hunt K. A chip off the old block? Lay beliefs about inheritance amongst men and women in midlife in the West of Scotland. 121. Cartmel F, Furlong A, Biggart A, Sweeting H, West P. Managing BSA Medical Sociology Group Conference; York: 2001. Transitions: a biographical approach. BSA Annual Conference: Reshaping the Social; Leicester: 2002. 137. Furlong A, Cartmel F, Biggart A, Sweeting H, West P. Complex transitions: linearity in youth transitions as a predictor of ‘success’. BSA 122. Connell J. Male sex work: occupational health and safety. Annual Conference: Reshaping the Social; Leicester: 2002. Health in Transition: European Perspectives - European Society for Health and Medical Sociology, BSA Medical Sociology Group, 138. Furlong A, Cartmel F, Biggart A, Sweeting H, West P. Explaining 2nd Joint Conference: 2000. transitions through individualised rationality. BSA Youth Study Group Seminar: The Restructuring of Transitions; Glasgow: 2002. 123. Connell J. Male sex work: occupational health and safety in Edinburgh and Glasgow, Scotland. Australian Research Centre in Sex, 139. Goonetilleke P. South Asian women’s health and wellbeing across Health & Society, La Trobe University; Melbourne, Australia: 2001. different residential areas in Glasgow. BSA Medical Sociology Group Conference; York: 2001. 124. Connell J. Male sex work: occupational health and safety. 8th Annual Qualitative Health Research Conference; Banff, Canada: 2002. 140. Gordon J, Turner KM. Why do schools differ in pupil smoking rates? - an exploration of school staff accounts. BSA Medical Sociology 125. Connell J. The health and safety of male sex workers in Edinburgh Group Conference; York: 2001. and Glasgow. Greater Glasgow Health Board Strategy for Men’s Health Sub Group; Glasgow: 2002. 141. Harding S. Irish health: issues of continuities and discontinuities across generations. Launch of review on Irish health; House of Commons, 126. Connell J. Male sex work: occupational health and safety. London: 2000. XIVth International Aids Conference; Barcelona, Spain: 2002. 142. Harding S. Irish health and well-being: generation and change. 127. Connell J. Male sex work: occupational health and safety. The Sheffield Festival Health Forum; Sheffield: 2001. AIDS IMPACT: Biopsychosocial Aspects of HIV Infection, 5th International Conference; Brighton: 2001 143. Hart G J, Davis M, Imrie J, Davidson O, Williams I, Stephenson J. If I’m not asked directly then I don’t always tell people: Disclosure of HIV 128. Petticrew M, Egan, M. Critical Appraisal workshop. Evidence, status to sexual partners by gay men on HAART. International Congress policy, practice: public health research in Scotland Conference; of Sexually Transmitted Infections; Berlin: 2001. Edinburgh: 2002. 144. Hart G J. Peer education interventions: experience from Glasgow. 129. Duncan B, Hart G, Scoular A. The psychological costs of a Invited talk. AIDS IMPACT: Biopsychosocial Aspects of HIV Infection, diagnosis of chlamydia: implications for screening. Health Psychology 5th International Conference; Brighton: 2001. 2001 Conference; St. Andrews, Scotland: 2001. 145. Hart G J. Sexuality and sexual health: Peer Education. British 130. Egan M. Not as bad as all that: mental defectives, their families Psychological Society Annual Conference; Blackpool: 2002. and the state in early twentieth century Scotland. Scottish Regional Forum for the History of Medicine; Glasgow: 2001. 146. Henderson M, Wight D, Raab G. Social factors associated with early sexual debut and sexual risk taking in young people. The Medical 131. Egan M. The health impact of new roads - a systematic literature Society for the Study of Venereal Diseases Ordinary General Meeting; review. Leeds Health Air Pollution, Noise, Traffic and Emissions Research The Royal Society of Medicine, London: 2000. Network; University of Leeds: 2002. 25629_Txt 9/8/02 9:21 AM Page 52
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147. Henderson M, Wight D, Raab G. Heterosexual HIV risk behaviour 162. Macintyre S. Cancer and health education: The Scottish Culture. among young teenagers. XIII International AIDS Conference; Durban, Reducing cancer risk. Glasgow University School for Cancer Studies; South Africa: 2000. Glasgow: 2001.
148. Henderson M. Sex and the Young. Midlands Genitourinary 163. Macintyre S. Place effects on health: how can we conceptualise, Medicine Society; Sheffield: 2001. operationalise and measure them? ESF Scientific Programme on Social Variations in Health Expectancy in Europe; Düsseldorf: 2001. 149. Henderson M. Young people’s regret of sexual intercourse: extent, predictors and implications. British Psychological Society Conference; 164. Macintyre S. Evaluating the evidence on health equity. Manchester: 2001. Dissemination of scientific information for decision-making in health equity. (Joint Initiative between Pan American Health Organisation 150. Henderson M, Wight D, Raab G. Does a theoretically based (PAHO) and Funsalud), Instituto Nacional de Salud Publica (INSP); teacher-led sex education programme work? BSA Medical Sociology Cuemavaca, Mexico: 2001. Group Conference; York: 2000. 165. Macintyre S. How do healthy volunteers and patients contribute 151. Henderson M, Wight D, Williamson L. Schools’ effects on sexual to medical research? British Association Festival of Science, Medical behaviour that can not be attributed to sex education. BSA Medical Sciences section. Health & Society: Society’s contribution to medical Sociology Group Conference; York: 2001. research. University of Glasgow; Glasgow: 2001.
152. Henry R, Buston K. Challenging homophobia. 2001 A Sex 166. Macintyre S. Inequalities in health-related life circumstances. Education. Odyssey FPA Scotland; Glasgow: 2001. Invited plenary at the Public Health Conference: Improving the public’s health and developing the workforce; Ayrshire: 2001. 153. Hunt K, Wyke S, Walker J. Beyond the burden of illness? What factors predict general practitioner consultations? Scottish School 167. Macintyre S. Places, people and health. Invited plenary: Society for of Primary Care Annual Conference; Stirling University: 2001. Social Medicine Annual Scientific Meeting/International Epidemiological Association European Group Meeting; Oxford: 2001. 154. Hunt K. Gender and lay understandings of coronary heart disease. Department of Social Anthropology, Durham University: 2001. 168. Maynard M, Ness AR, Abraham L, Blane D, Bates C, Gunnell DJ. Social, health and lifestyle factors influencing diet in early old age. 155. Hunt K. The West of Scotland Twenty-07 Study. Making the most Quantitative analyses from the Boyd Orr Cohort and the National Diet of Scottish surveys. Royal Society of Edinburgh: 2001. and Nutrition Survey. 10th Annual Public Health Forum; Glasgow: 2002.
156. Huygens P, Wight D, Traore A, Desclaux A. Sciences de l’Homme 169. McLeod A, Leyland AH, Stockton D, Brown H. Presentation and et recherches sur le VIH/SIDA: Du comportement sexuel au suivi des survival from colorectal cancer in Scotland. Society for Social Medicine contextes et des réponses à l’épidémie. Plenary presentation: International Annual Scientific Meeting/International Epidemiological Association Conference on AIDS and STDs in Africa; Ouagadougou, Burkina Faso: European Group Meeting; Oxford: 2001. 2001. 170. McLeod A. Methods of inference for random parameters in 157. Imrie J, Stephenson JM, Davis MD, Williams IG, Hart GJ, generalised multilevel models. Amsterdam Conference on Multilevel Davidson OR. Sexual behaviour of gay men with HIV in relation to Analysis; Amsterdam: 2001. anti-viral therapy - a cause for concern? Medical Society for the Study of Venereal Diseases Spring Conference; Belfast: 2001. 171. Morrison D, Petticrew M, Thomson H. Transport policies’ effects on health: a review of the evidence. European Public Health Association; 158. Imrie J, Davis MD, Black S, Hart GJ, Davidson OR, Williams IG, Brussels: 2001. Stephenson JM. Meeting the sexual health needs of HIV-seropositive gay men is a pre-requisite to developing the next generation of 172. Morrison D. Health Impact Assessment. Greater Glasgow NHS prevention strategies. International Congress of Sexually Transmitted Board; Glasgow: 2001. Infections; Berlin: 2001. 173. Morrison D, Petticrew M, Thomson H. Transport policies’ effects 159. Leyland A H. Approximating likelihood functions for multilevel on health: a review of the evidence. Society for Social Medicine Annual Poisson models. Amsterdam Conference on Multilevel Analysis; Scientific Meeting/International Epidemiological Association European Amsterdam: 2001. Group Meeting; Oxford: 2001.
160. Leyland A H. Multilevel models in public health and health 174. Morrison D. Improving health through transport interventions: services research. Royal Statistical Society Edinburgh Local Group evidence from systematic reviews. UK Public Health Association Meeting; Edinburgh: 2001. 10th Annual Public Health Forum; Glasgow: 2002.
161. Macintyre S. Good intentions and received wisdom are not 175. Mutrie N, Comrie M. Gender issues in promoting participation enough. Evidence into Practice: Challenges and Opportunities for UK in physical activity. Proceeding of the 10th ISSP Conference; Skiathos, Public Health. Joint HDA/King’s Fund conference; Royal College of Greece: 2001. Physicians, London: 2001. 25629_Txt 9/8/02 9:21 AM Page 53
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Conference Papers, Published Abstracts 192. Thomson H, Petticrew M, Morrison D. The health effects of housing and Scholarly Presentations Continued improvements: a systematic review. Policy Forum, Scottish Executive; 176. Pearson M, West P. Drifting smoke rings: social network analysis Edinburgh: 2001. applied to a longitudinal study of friendship groups, smoking and drug-taking. The Sunbelt XII Conference, International Network for 193. Thomson H, Petticrew M, Morrison D. Evidence for the health Social Network Analysis; New Orleans: 2002. impact of housing improvements: a systematic review. 9th Annual Public Health Forum, UK Public Health Association; Bournemouth: 2001. 177. Pearson M, Michell L. Smoke rings: social network analysis applied to a longitudinal study of friendship groups, smoking and drug-taking. 194. Thomson H, Petticrew M. Reviewing and classifying evidence. The Sunbelt XII Conference, International Network for Social Network Effective Interventions Unit workshop, Scottish Executive; Stirling: 2001. Analysis; New Orleans: 2002. 195. Thomson H, Petticrew M, Morrison D. Measuring the health impacts 178. Petticrew M, Kearns A. Effectively tackling health and housing: of housing improvements. Health Impact Assessment Network; Glasgow: achieving an integrated approach to major social policies. QMW Public 2001. Policy Seminar; London: 2002. 196. Thomson H, Petticrew M, Morrison D. Evidence for the health 179. Petticrew M. Systematic reviews across disciplines: the example impact of housing improvements: a systematic review. Evidence-based of housing. Second Annual Campbell Collaboration Colloquium; policies and indicator systems: 3rd biennial conference; Durham: 2001. Philadelphia: 2002. 197. Thomson H, Petticrew M, Morrison D. Housing investment as 180. Petticrew M. Critical Appraisal. Public Health Institute of Scotland a public health measure: what is the evidence? Kings Fund Breakfast seminar; Glasgow: 2001. Seminar; London: 2001.
181. Petticrew M. Regenerating Health. Swinburne Institute for Social 198. Thomson H, Petticrew M, Morrison D. Synthesising evidence on Research Seminar; Melbourne, Australia: 2002. housing and health. Housing and Neighbourhoods and Health (HANAH) Scientific Advisory Group Meeting, University of Wales College of 182. Petticrew M. Evidence, hierarchies and typologies. Invited speaker, Medicine; Cardiff: 2001. Cochrane Public Health and Health Promotion Forum; St. Vincent Hospital: 2002. 199. Thomson H, Petticrew M. Assessing the health impact of a swimming pool closure in Glasgow. UKPHA Annual Public Health Forum; 183. Petticrew M. Evidence, health promotion and public health. Glasgow: 2002. Presentation to VicHealth, Melbourne, Australia: 2002. 200. Thomson H, Petticrew M, Morrison D. The health effects of housing 184. Petticrew M. Health Impact Assessment: Some “whys”, and a few improvements: a systematic review of intervention studies. Society for “hows”. Health Impact Assessment Forum; Melbourne, Australia: 2002. Social Medicine Annual Scientific Meeting/International Epidemiological Association European Group Meeting; Oxford: 2001. 185. Petticrew M. Housing and health. Department of Human Services, State Government of Victoria, Melbourne, Australia: 2002. 201. West P. School influences on health and health behaviours. Policy Forum, Scottish Executive; Edinburgh: 2001. 186. Petticrew M. Evaluating the health impacts of social interventions. Policy Forum, Scottish Executive Department of Health: 2002. 202. West P. Health Inequalities in infancy and childhood: the facts of the matter. Public Health Alliance; Glasgow: 2001. 187. Petticrew M. Reducing inequalities: views from upstream and downstream. Presentation to VicHealth Round Table on Health 203. West P. Young people and smoking: school effects, Smoking Inequalities: 2002. Cessation & Young People. HEBS/ASH; Edinburgh: 2001.
188. Petticrew M. False negatives: implications for public perceptions 204. West P. Class, lifestyles and health behaviours: a cross-cultural of screening. Invited speaker, La Trobe University, Melbourne, comparison. Global youth? Young people in the Twenty-First Century; Australia: 2002. Plymouth: 2001.
189. Stephenson JM, Imrie J, Davis MD, Black S, Hart GJ, Davidson OR, 205. West P, Sweeting H. Fifteen, female and stressed: changing Williams IG. Sexual risk behaviour of HIV-seropositive gay men attending patterns of mental health, meeting the needs of children and young a London outpatient clinic. International Congress of Sexually Transmitted people. The Notre Dame Centre for Children, Young People and Infections; Berlin: 2001. Families, 70th Anniversary Conference; Glasgow: 2001.
190. Sweeting H, West P. There’s nothing to do around here: 206. West P. Child poverty and health: the facts, Every Child matters: characteristics of the local area and teenage smoking, drinking and tackling poverty and child health inequalities. UKPHA; Manchester: 2001. drug use. UK Public Health Association 10th Annual Public Health Forum; Glasgow: 2002. 207. West P. Female and stressed: changing patterns of mental health. Scottish Guidance Association Workshop; Dunfermline: 2002. 191. Sweeting H, West P. The effect of different definitions of teenage substance use on associations with social class. BSA Medical Sociology Group Conference; York: 2001. 25629_Txt 9/8/02 9:21 AM Page 54
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208. West P. Do schools influence pupil’s health behaviours? Evidence 222. Egan M. The “manufacture” of mental defectives in late Nineteenth from the West of Scotland 11 to 16 Study. Department of Education and early Twentieth Century Scotland. PhD thesis, University of Glasgow, Seminar; Aberdeen: 2002. 2001.
209. West P, Sweeting H. School effects on health behaviours: evidence 223. Ellaway A, Bradby H, McKeown M. Racist and sectarian graffiti from the West of Scotland 11 to 16 study. BSA Medical Sociology Group in Glasgow: A pilot study (Photo report). MRC Social & Public Health Conference; York: 2001. Sciences Unit, Glasgow, 2002.
210. Wight D. Young people’s sexuality in East Africa and Britain. 224. Elliot R. Destructive but sweet: cigarette smoking among women Sexuality: Representation and Lived Experience. ESRC Seminar Series; 1890-1990. PhD Thesis, Glasgow University, 2001. York: 2001. 225. Flint J. The West of Scotland Twenty-07 Study: Health in the 211. Wight D, Plummer M, Wamoyi J, Mshana G, Salamba Z, Nyalali K. Community: The two study localities in 1997. MRC Social and Public Sexual violence and coercion in Mwanza: preliminary findings. Sexual Health Sciences Unit, Glasgow. Working Paper No.7, 2001. Violence and HIV Seminar. DfID Knowledge Programme on HIV and STIs; London School of Hygiene and Tropical Medicine: 2001. 227. Harding S, Balarajan R. Mortality data on migrant groups living in England and Wales: issues of adequacy and of interpretation of death 212. Wight D. The SHARE study: The challenge of training teachers for rates. ONS, (in press). a behavioural sex education programme. 2001 A Sex Education Odyssey. FPA Scotland Conference; Glasgow: 2001. 228. Heaney D, O’Donnell K, Scott T, Drummond N, Ross S, Moffat K, Paxton F, et al. A comparison of models of delivery of out of hours 213. Wight D, Plummer M, Wamoyi J, Mshana G, Ross D. Divergent general medical services in Scotland. Report to Scottish Executive Health sexual norms for young people in rural Northern Tanzania. International Department, 2001. Conference on AIDS and STDs in Africa; Ouagadougou, Burkina Faso: 2001. 229. Hunt K, Emslie C, Cornwallis L, Crawford F. Real people talking about heart disease: making sense of the messages and moving forward. 214. Wight D, Henderson M, Raab G. Preliminary reported behavioural Health Promotion Department, Greater Glasgow Health Board, Glasgow, outcomes from an RCT of a specially designed teacher-delivered sex 2001. education programme in Scotland. Progress and evaluation of adolescent sex education programmes: experiences from the developed countries; 230. McKeown M, Ellaway A, Bradby H. A systematic exploration Tylney Hall, Hampshire: 2000. of the location and content of graffiti of a racist and sectarian nature in Glasgow. MRC Social and Public Health Sciences Unit, Glasgow. 215. Williams R. South Asian heart disease: the contribution of poverty, Working Paper No.3, 2001. stress and racism. Invited lecture to the South Asian Health Foundation meeting on South Asian heart disease; Claridge’s Hotel: 2001. 231. McLoone P. Commercial income data: associations with health and census measures. MRC Social and Public Health Sciences Unit, Glasgow. 216. Williamson L, Hart G, Flowers P, Frankis J, Der G. The Gay Men’s Occasional Paper No.7, 2002. Task Force (GMTF): the impact of peer education on gay men in Glasgow. 4th National CHAPS Conference; London: 2001. 232. Petticrew M, Macintyre S. What do we know about the effectiveness and cost-effectiveness of measures to reduce inequalities 217. Williamson LM, Hart GJ, Flowers P, Frankis JS, Der GJ. Evaluation in health? In: Issues Panel for Equity in Health: The Discussion Papers. of a bar-based, peer-led sexual health intervention in Glasgow. AIDS Oliver, A, Cookson, R, McDaid, D. (eds) Nuffield Foundation, 2001. IMPACT: Biopsychosocial Aspects of HIV Infection, 5th International Conference; Brighton: 2001. 233. Sweeting H, Der G, West P. Bias, attrition and weighting in respect of the West of Scotland 11 to 16 Study Baseline, S2 and S4 surveys. Reports, and Unit Occasional Papers and Working Papers MRC Social and Public Health Sciences Unit, Glasgow. Working Paper 218. Arai L, Harding S. UK-born Black Caribbeans: generational changes No.9, 2001. in health and well-being. MRC Social and Public Health Sciences Unit, Glasgow. Occasional Paper No.6, 2002. 234. Thomson H, Petticrew M, Morrison D. Improving housing, improving health: the potential to develop evidence based healthy 219. Arai L, Harding S. Access to, and use of, health social and other housing policy. University of Durham, (in press). services and care by minority ethnic populations in the United Kingdom: a literature review. MRC Social and Public Health Sciences Unit, Glasgow. 235. Thomson H, Petticrew M, Morrison D. Housing improvement and Working Paper No.8, 2002. health gain: a summary and systematic review. MRC Social and Public Health Sciences Unit, Glasgow. Occasional Paper No.5, 2001. 220. Connell J, Hart G. An overview of male sex work in Edinburgh and Glasgow: the male sex worker perspective. MRC Social and Public 236. West P. Health inequalities in infancy and childhood: the facts of Health Sciences Unit, Glasgow. Occasional Paper No.8, 2002. the matter. Every Child Matters Conference Report. UKPHA, Manchester, 2002. 221. Doyal L, Hunt K, Payne S. Sex, gender and non-communicable diseases: an overview of issues and recent evidence. NCD cluster 237. Young R, Sweeting H, West P. Temporal and cross-cultural stability of the World Health Organisation, 2001. of adolescent leisure. MRC Social and Public Health Sciences Unit, Glasgow. Working Paper No.6, 2001.