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PubMed2004

Clinical value of the total white blood cell count and temperature in the evaluation of patients with suspected appendicitis.

OBJECTIVES: The total white blood cell (WBC) count and temperature are often expected to be elevated in patients with appendicitis. Clinicians often use the results of these parameters in making a judgment about the presence or absence of disease. The objective of this study was to assess the discriminatory value of the total WBC count and presenting body temperature in patients presenting to the emergency department (ED) with signs and symptoms suggestive of appendicitis. METHODS: This was a prospective consecutive case series in a university ED with an annual census of 38,000. All patients presenting to the ED in whom the diagnosis of appendicitis was the attending physician's primary consideration were enrolled. Measures included age, gender, symptoms, physical findings, patient temperature as taken in the ED, initial total WBC count, and discharge diagnosis. Admitted patients were followed up until surgical or clinical outcomes, and discharged patients were followed up by telephone two weeks after the initial visit. All statistical analysis was performed using StatsDirect version 1.9.8. RESULTS: A total of 293 patients were enrolled over a two-year study period. The total WBC count was measured in 274 cases, and the temperature was measured in 293 cases. There were 130 male patients and 163 female patients. The mean age of the patients was 30.8 years (range, 7-75 years). Appendicitis was confirmed in 92 patients. In this study group of patients, a total WBC count >10,000 cells/mm(3) had a sensitivity of 76% (95% confidence interval [95% CI] = 65% to 84%) and a specificity of 52% (95% CI = 45% to 60%). The positive predictive value (PPV) was 42% (95% CI = 35% to 51%), and the negative predictive value (NPV) was 82% (95% CI = 74% to 89%). The positive likelihood ratio (LR) was 1.59 (95% CI = 1.31 to 1.93), and the negative LR was 0.46 (95% CI = 0.31 to 0.67). A temperature >99.0 degrees F had a sensitivity of 47% (95% CI = 36% to 57%) and a specificity of 64% (95% CI = 57% to 71%). The PPV was 37% (95% CI = 29% to 46%), and the NPV was 72% (95% CI = 65% to 79%). The positive LR was 1.3 (95% CI = 0.97 to 1.72), and the negative LR was 0.82 (95% CI = 0.65 to 1.01). The areas under the curve for the receiver-operating characteristic (ROC) curve were 0.72 (95% CI = 0.65 to 0.79) and 0.59 (95% CI = 0.52 to 0.66) for an elevated total WBC count and an elevated temperature, respectively. CONCLUSIONS: An elevated total WBC count >10,000 cells/mm(3), while statistically associated with the presence of appendicitis, had very poor sensitivity and specificity and almost no clinical utility. There was minimal statistical association between a temperature of >99 degrees F and the presence of appendicitis. The ROC curve suggests there is no value of total WBC count or temperature that has sufficient sensitivity and specificity to be of clinical value in the diagnosis of appendicitis. Clinicians should be wary of reliance on either elevated temperature or total WBC count as an indicator of the presence of appendicitis.

Adolescent↗
PubMed2006

Meta-analysis of survival in African American and white American patients with breast cancer: ethnicity compared with socioeconomic status.

PURPOSE: The extent to which socioeconomic disadvantages and inadequate health care access account for the disproportionately elevated mortality hazard observed in African American compared with white American patients with breast cancer is poorly defined. METHODS: We identified 20 studies reported between January 1980 and June 2005 that provided survival analyses in patients with breast cancer after adjusting for ethnicity and some measurement of socioeconomic status. These studies also adjusted for age and stage of disease at time of diagnosis. RESULTS: The pooled outcome data yielded estimates for the mortality hazard in 14,013 African American and 76,111 white American patients with breast cancer. Studies varied in their methods for assigning socioeconomic status, with most relying on area-wide measures such as census tract and census block data. The combined analysis (adjusted for age, stage, and socioeconomic status) revealed that African American ethnicity was associated with a statistically significant excess mortality risk in overall survival (mortality hazard, 1.27; 95% CI, 1.18 to 1.38) and in breast cancer-specific survival (mortality hazard, 1.19; 95% CI, 1.10 to 1.29). CONCLUSION: Our pooled analysis demonstrated that African American ethnicity is a significant and independent predictor of poor outcome from breast cancer, even after accounting for socioeconomic status by conventional measures. These findings support the need for further investigation of the biologic, genetic, and sociocultural factors that may influence survival in African American patients with breast cancer.

Black People↗
PubMed2000

The increasing incidence and prevalence of MS in a Sardinian province.

OBJECTIVE: To verify incidence rates and their temporal trend in a homogeneous, ethnically, and genetically distinct population of central Sardinia (the Nuoro province). BACKGROUND: Intensive epidemiologic studies carried out in Sardinia since the 1970s have suggested that the prevalence and incidence of MS are much higher in this Mediterranean island compared with those found on mainland Italy. METHODS: The study area had a population of approximately 274, 000 people in the 1991 census. The authors adopted a complete enumerative approach by reviewing all possible sources of case collection available in the investigative area. RESULTS: Based on 469 MS patients, the mean annual incidence for 1955 to 1995 was 4.18 per 100,000 (or 4.3 per 100,000 if age- and sex-adjusted to the European population). The incidence, averaging 1.95 per 100,000 during 1955 to 1959, rose progressively over time, reaching rates of 6.6 in the quinquiennium 1985 to 1989 and 6.4 per 100,000 in 1990 to 1995. On December 31, 1994, the crude prevalence, based on 415 MS patients alive in the study area, was 151.9 per 100,000 (156.6 if adjusted to the European population). CONCLUSION: These incidence and prevalence rates are the highest to date that have been estimated for a large community in southern Europe, and they constitute some of the highest rates in the world. Based on other surveys, these results reinforce the position of Sardinia as a higher and rising prevalence area for MS compared with other Mediterranean populations. Genetic and social-historic data strengthen the hypothesis of the environmental role and genetic factors among Sardinians in determining the notable difference in MS frequency between Sardinians and other Mediterraneans.

Adolescent↗
PubMedDate not supplied

[Mortality spatial patterns and socioeconomic differences in the city of Rio de Janeiro].

Health situation analysis has been used to understand complex health processes and to contribute to decision-making in public policies. This paper analyzes the spatial relationship between mortality patterns in the city of Rio de Janeiro (1996-1998) and socioeconomic profiles of neighborhoods. Mortality data were collected from the Municipal Health Department and population data were obtained from the National Census Bureau (IBGE) (1991 and 1996). Neighborhoods were aggregated through the K-means cluster method into 4 homogeneous socioeconomic groups, and the mortality indicators distribution was analyzed by different strata. General mortality, circulatory disease mortality, mortality from poorly defined causes, and mortality from violent causes all displayed large differences among socioeconomic groups. The spatial pattern of the socioeconomic strata allowed the identification of different living conditions, which involved specific mortality patterns. Higher socioeconomic strata presented low mortality figures for all causes.

Brazil↗
PubMed1991

Effects of paternal occupational exposure on spontaneous abortions.

BACKGROUND: Paternal exposure to mutagenic agents has been suggested to affect pregnancy outcome adversely. METHODS: A nationwide data base of medically diagnosed spontaneous abortions and other pregnancies and national census data was used to evaluate the effects of men's occupational exposures on risk of spontaneous abortion in 99,186 pregnancies in Finland. Census data from the years 1975 and 1980 provided information about the occupation, industry, and socioeconomic status. A job-exposure classification was developed to classify women and their husbands according to possible occupational exposures on the basis of their occupational title and industry. RESULTS: In 10% of the pregnancies, the husband was exposed to one or more of the mutagens, and the rate of spontaneous abortion was unaffected (OR = 1.0). Of the 25 specific mutagenic exposures evaluated, paternal exposure to four (ethylene oxide, rubber chemicals, solvents used in refineries, and solvents used in the manufacturing of rubber products) was associated with an increased relative risk of spontaneous abortion. In addition, the risk of spontaneous abortion was higher among wives of rubber products workers than among unexposed men. CONCLUSIONS: Although there is some biological rationale for the findings of this study, these findings need to be confirmed by studies in which individual exposures can be measured directly.

Abortion, Spontaneous↗
PubMed2004

Urban sprawl and risk for being overweight or obese.

OBJECTIVES: I examined the association between urban sprawl and the risk for being overweight or obese among US adults. METHODS: A measure of urban sprawl in metropolitan areas was derived from the 2000 US Census; individual-level data were obtained from the Behavioral Risk Factor Surveillance System. I used multilevel analysis to assess the association between urban sprawl and obesity. RESULTS: After I controlled for gender, age, race/ethnicity, income, and education, for each 1-point rise in the urban sprawl index (0-100 scale), the risk for being overweight increased by 0.2% and the risk for being obese increased by 0.5%. CONCLUSIONS: The current obesity epidemic has many causes, but there is an association between urban sprawl and obesity.

Adult↗
PubMed2000

Birth defects and paternal occupational exposure. Hypotheses tested in a record linkage based dataset.

UNLABELLED: MAIN QUESTION: To test previously established hypotheses on associations of birth defects with paternal occupation on the basis of a Norwegian registry material. METHODS: The study comprised all births in Norway 1970 -1993 for which linkage with population censuses 1970, -80 and -90 on parents' job title could be obtained--about 1 million births (75% all births). The reference population was offspring of the group that did not belong to the actual occupation. RESULTS: Vehicle mechanics had an association with hypospadias--OR 5.19 (CI 1.31-14.24), painters had a non-significant association with spina bifida--OR 2.03 (CI 0.99-3.75) and printers with club foot--OR 1.61 (CI 0.89-2.90). Associations observed previously in off-spring of fathers in large occupational groups such as teachers, drivers, electricity related occupations, sales related occupations and agricultural workers were not confirmed in this dataset. CONCLUSIONS: The study gave further evidence of cause effect relationships in the confirmed positive associations, though without any clarification of possible mechanisms involved. Possible false negative findings might be caused by low statistical power due to small occupational groups or non-differential misclassification of exposure.

Adult↗
PubMed2000

Variation in hospital discharges for ambulatory care-sensitive conditions among children.

OBJECTIVE: Ambulatory Care-Sensitive Conditions (ACSCs), conditions for which ambulatory care may reduce, though not eliminate, the need for hospital admission, have been used as an index of adequate primary care. However, few studies of ACSC have focused on children. We estimated national hospitalization rates for ACSC among children and examined the behavior of the index between subgroups of children. METHODS: We used data from the 1990-1995 National Hospital Discharge Surveys (NHDS), the US census, and the National Health Interview Survey (NHIS) to calculate hospital discharge rates. Rates were estimated as the number of condition-specific hospital discharges from the NHDS divided by the population at risk, as estimated from the US census and NHIS. RESULTS: Predictably, ACSC hospitalization rates were significantly higher among children who were younger, black, had Medicaid insurance, and lived in poorer areas compared with their counterparts. However, the relationship between ACSCs and income and the distributions of conditions within the index varied significantly between children. CONCLUSIONS: ACSCs may indicate disparities in access and utilization of health care, however, the differing behavior of the index between subgroups suggests that inferences from examining rates of ACSCs may not be comparable for all children.ambulatory care-sensitive conditions, hospitalization rates.

Adolescent↗
PubMed2000

A method for constructing complete annual U.S. life tables.

OBJECTIVES: This report describes a method for constructing complete annual U.S. life tables and for extending the age coverage of the life table to age 100. Previously, annual life tables were based on an abridged methodology and were closed with the age category 85 years and over. In the United States, approximately one-third of the population survives beyond age 85 years. This fact, coupled with improvements in age reporting and the availability of higher quality old-age mortality data, recommends that the life table be closed at an older age. METHODS: The method, similar to that used to construct the decennial life tables, uses vital statistics and census data to calculate death rates for ages under 85 years and Medicare data for ages 85 years and over. Previously, the annual life tables were abridged, and used only vital statistics and census data. CONCLUSIONS: The complete life table methodology described in this report produces estimates of life expectancy at ages 100 years and younger that are consistent with previously published life tables. Complete life tables based on 1996 mortality data compared favorably with published 1996 abridged life tables and with the 1989-91 decennial life tables. The methodology was implemented beginning with final mortality data for 1997.

Adolescent↗
PubMedDate not supplied

[Estimation of the number of patients treated for hypertension, diabetes or hyperlipidemia in France: FLAHS study 2002].

The study used a cross-sectional survey of the general population living in metropolitan France in April 2002. A national sample of 5,000 adults, representative of the French population, 15 years of age or older, received at their home a questionnaire mailed by SOFRES medical. The sample was designed to provide estimates of the prevalence of hypertension in the general population and in persons older than 60 years of age, a subgroup on which prevalence of treated cardiovascular risk factors is unknown in France. The questionnaire included questions related to diagnosis of hypertension, awareness of their usual BP, current SBP/DBP values, prescribed medicine for hypertension dyslipidemia and diabetes. In FLAHS 2002, a number of 3,499 (70%) questionnaires were suitable for analysis. Estimates of prevalence were standardized by the direct method to the age distribution of the French population given by the 1999 national French census (INSEE 2000). Analysis on 2,363 subjects older than 35 years and indicates that 35% are currently treated for one or more risk factor. Overall, 8,036,000 received antihypertensive medication, 1,877,000 were treated for diabetes and 6,074,000 for dyslipidemia. Prevalence of treated hypertension increased with age from from 4.2% (35-44 years) to 51.8% (> 75 years) and 70% of treated hypertensives were older than 60 years. Subjects treated for two risk factors were 3,201,000 and those treated for three risk factors were 640,000. The FLAHS 2002 represents the best available data to estimate the prevalence of treated patients for a cardiovascular risk factor in the general French population. Thirty-five percent of the population 35 years of age or older representing around 11 millions persons were taking medications for the treatment of hypertension, diabetes or dyslipidemia in France.

Adult↗
PubMed2006

Influence of ethnicity on the frequency of nasal surgery.

OBJECTIVE: To determine whether surgery for nasal obstruction differs in frequency between ethnic groups. METHOD: Ethnicity data was collected from all patients attending otolaryngology clinic appointments and compared to census data. Odds ratios with confidence intervals were calculated for attendance at otolaryngology clinics, rhinology clinics, undergoing septoplasty, septorhinoplasty and/ or turbinate surgery for each ethnic group over a 3-year period. RESULTS: The ethnic groups of the 39493 outpatient attendees closely mirrored demographic data from the 2001 Census. Non-Chinese Asian ethnic groups were more likely to undergo septal surgery than the general (mainly white) population (odds ratio 1.44, 95% CI 1.25 to 1.66, p < 0.00001), whereas Black groups (odds ratio 0.31 [0.23 - 0.41], p < 0.00001) and Chinese (odds ratio 0.28 [0.11 - 0.70], p = 0.00311) were much less likely. Similar results were found for rhinoplasty and turbinate surgery. CONCLUSIONS: There is strong statistical evidence for large differences in the frequency of surgery for nasal obstruction between ethnic groups. Asian groups were more likely to undergo surgery, whereas Chinese and Blacks were less likely than the general population, which was predominantly white in this study. This may be due to anatomical variations, differences cultural views towards surgery, or inequalities in clinician's attitudes.

Ambulatory Care↗
PubMed1998

Relation of traditional risk factors to intrauterine growth retardation among United States-born and foreign-born Mexican Americans in Chicago.

OBJECTIVES: To determine the relation of traditional sociodemographic characteristics to the small-for-gestational age rates of urban Mexican Americans. DESIGN: A cross-sectional study. METHODS: We performed a stratified analysis of 1982-1983 Illinois vital records and 1980 U.S. Census income data. The authors analyzed the 1982-1983 Illinois vital records and 1980 U.S. Census income data to determine whether maternal sociodemographic characteristics are associated with the small-for-gestational age (weight-for-gestational-length < 10th percentile) rates among Mexican Americans in Chicago. RESULTS: The small-for-gestational age rate was 2.1% for infants with U.S.-born mothers (N = 2,253) compared to 1.4% for infants with foreign-born mothers (N = 8,746); relative risk 1.5 (95% confidence interval 1.1-2.1). For the U.S.-born cohort, maternal education, marital status, parity, prenatal care, and community income were associated with small-for-gestational age rates. In contrast, with the exception of marital status, these commonly cited risk factors were not associated with the small-for-gestational age rates of infants with Mexican-born mothers. The U.S.-born:Mexico-born small-for-gestational age rate ratio fluctuated around 2 among mothers with a high-risk (maternal age < 20 years, < 12 years education, unmarried marital status) demographic profile. CONCLUSIONS: We conclude that traditional sociodemographic risk factors have different reproductive outcome consequences for U.S.-born and foreign-born Mexican-American mothers.

Adolescent↗
PubMed2001

Estimating risks in declining populations with poor data.

Census data on endangered species are often sparse, error-ridden, and confined to only a segment of the population. Estimating trends and extinction risks using this type of data presents numerous difficulties. In particular, the estimate of the variation in year-to-year transitions in population size (the "process error" caused by stochasticity in survivorship and fecundities) is confounded by the addition of high sampling error variation. In addition, the year-to-year variability in the segment of the population that is sampled may be quite different from the population variability that one is trying to estimate. The combined effect of severe sampling error and age- or stage-specific counts leads to severe biases in estimates of population-level parameters. I present an estimation method that circumvents the problem of age- or stage-specific counts and is markedly robust to severe sampling error. This method allows the estimation of environmental variation and population trends for extinction-risk analyses using corrupted census counts--a common type of data for endangered species that has hitherto been relatively unusable for these analyses.

Aging↗
PubMed1993

Common somatic O and heat-labile serotypes among Campylobacter strains from sporadic infections in the United States.

Somatic O (formerly heat-stable) and heat-labile (HL) serotyping methods are commonly used to type Campylobacter jejuni and Campylobacter coli isolates. Although both systems are effective, the labor and time required for each have limited their application. These systems can be simplified by reducing the number of antisera used. To find an appropriate panel of antisera, we determined the distribution of common serotypes in the United States among a representative sample of 298 Campylobacter isolates. The strains, obtained between July 1989 and June 1990 from persons with sporadic cases of diarrhea, were collected from 19 randomly chosen counties in all geographic (census) regions of the United States. All strains were serotyped by the O and HL systems. By phenotypic methods, 288 C. jejuni, 9 hippurate-negative C. jejuni/C. coli, and 1 Campylobacter lari were identified. Of 57 O antisera, 24 typed 252 (84.6%) strains. Of the 55 HL antisera, 23 serotyped 253 (84.9%) strains. All strains were typeable in the unabsorbed O antisera. In the absorbed HL antisera, four strains were nontypeable and 14 were rough and untypeable. In each geographic region, 9 or more O and HL serotypes were found. Serotypes O:1, O:4, and O:13,16,43,50 and HL 1 were identified in all regions. The combination of both schemes gave greater discrimination than either system alone, but the maintenance of both requires a large resource investment. A serotyping scheme incorporating the 24 most prevalent O and 23 most prevalent HL serotypes could be useful for outbreak support and for surveillance. In the near future, we anticipate using a molecular subtyping method in combination with limited serotyping to distinguish Campylobacter strains.

Campylobacter↗
PubMed1999

The association between state housing policy and lead poisoning in children.

OBJECTIVES: This study examined the effect of an active program of household lead paint hazard abatement, applied over 22 years, on childhood lead poisoning in Massachusetts. METHODS: A small areas analysis was used to compare screening blood lead levels of children in Worcester County, Mass (n = 27,590), with those in Providence County, RI (n = 19,071). Data were collapsed according to census tract. RESULTS: The percentage of children with lead poisoning (blood lead level > or = 20 micrograms/dL [Pe20]) was, on average, 3 times higher in Providence County census tracts (3.2% vs 0.9% in Worcester County census tracts, P < .0001), despite similar percentages of pre-1950s housing in both counties. The ratio of Pe20 in Providence vs Worcester County census tracts was 2.2 (95% confidence interval = 1.8, 2.7), after adjustment for differences in housing, sociodemographic, and screening characteristics. This estimate was robust to alternative regression methods and sensitivity analyses. CONCLUSIONS: Massachusetts policy, which requires lead paint abatement of children's homes and places liability for lead paint poisoning on property owners, may have substantially reduced childhood lead poisoning in that state.

Child↗
PubMed2004

A comparative analysis of effects of early versus late prenatal WIC participation on birth weight: NYS, 1995.

OBJECTIVES: This study examined the effects of prenatal participation in the NYS WIC Program on birth weight through enhanced control of selection bias and gestational age bias. Program effects were assessed separately for White, Black, and Hispanic women and subpopulations defined by values of Kotelchuck index of adequacy of prenatal care utilization. METHODS: 1995 New York State Vital Statistics records were linked to WIC certifications, administrative and check redemption files, and to the 1990 federal census of NY county level data. The final data set contained 77,601 records. Birth weight among WIC participants who enrolled early and participated longer were compared to those who enrolled late and participated a shorter time. Selection bias was addressed using classification tree methods as part of a propensity score analysis. Gestational age bias was addressed by analyzing preterm and full-term pregnancies separately. RESULTS: Adjusted estimates showed a significant positive effect of longer prenatal WIC participation on birth outcomes for all groups studied. Infants born to WIC participants who enrolled early were heavier than those who enrolled late by, on average, 70 g for full-term and 129 grams for preterm. Black and Hispanic full-term infants experienced larger WIC effects than Whites (79, 75, 43 g, respectively). Looking at full-term pregnancies using Kotelchuck's index indicated that effects of longer prenatal WIC participation were greatest for the inadequate prenatal care group (83 g). CONCLUSION: Longer prenatal WIC participation was associated with an increase in birth weight overall and for all groups studied. The effect on birth weight of longer participation in WIC was greatest in Black and Hispanic, inadequate and no prenatal care groups.

Black or African American↗
PubMed2000

Associations among hospital capacity, utilization, and mortality of US Medicare beneficiaries, controlling for sociodemographic factors.

OBJECTIVE: To explore whether geographic variations in Medicare hospital utilization rates are due to differences in local hospital capacity, after controlling for socioeconomic status and disease burden, and to determine whether greater hospital capacity is associated with lower Medicare mortality rates. DATA SOURCES/STUDY SETTING: The study population: a 20 percent sample of 1989 Medicare enrollees. Measures of resources were based on a national small area analysis of 313 Hospital Referral Regions (HRR). Demographic and socioeconomic data were obtained from the 1990 U.S. Census. Measures of local disease burden were developed using Medicare claims files. STUDY DESIGN: The study was a cross-sectional analysis of the relationship between per capita measures of hospital resources in each region and hospital utilization and mortality rates among Medicare enrollees. Regression techniques were used to control for differences in sociodemographic characteristics and disease burden across areas. DATA COLLECTION/EXTRACTION METHODS: Data on the study population were obtained from Medicare enrollment (Denominator File) and hospital claims files (MedPAR) and U.S. Census files. PRINCIPAL FINDINGS: The per capita supply of hospital beds varied by more than twofold across U.S. regions. Residents of areas with more beds were up to 30 percent more likely to be hospitalized, controlling for ecologic measures of socioeconomic characteristics and disease burden. A greater proportion of the population was hospitalized at least once during the year in areas with more beds; death was also more likely to take place in an inpatient setting. All effects were consistent across racial and income groups. Residence in areas with greater levels of hospital resources was not associated with a decreased risk of death. CONCLUSIONS: Residence in areas of greater hospital capacity is associated with substantially increased use of the hospital, even after controlling for socioeconomic characteristics and illness burden. This increased use provides no detectable mortality benefit.

Aged↗
PubMed2006

Is there a "Scottish effect" for self reports of health? Individual level analysis of the 2001 UK census.

BACKGROUND: Scotland's overall health record is comparatively poor for a Western European country, particularly amongst people of working age. A number of previous studies have explored why this might be the case by comparing mortality in Scotland with England and Wales. A study in the 1980s showed that the higher prevalence of deprivation in Scotland accounted for Scotland's excess mortality risk. However, more recent studies suggest that deprivation now explains less of this excess. This has led to the suggestion that there is a yet unidentified "Scottish effect" contributing to Scotland's mortality excess. Recent research has also suggested that there could be an unidentified effect influencing Scotland's higher rate of heart disease. This paper explores whether there is also an unexplained Scottish excess, relative to England, in self reports of poor health. METHODS: Data came from the individual Sample of Anonymised Records, a 3% random sample of the 2001 UK census. Using logistic regression models, self reports of health (limiting illness and general health) from the working age populations (aged 25 to 64) of Scotland and England were compared. Account was taken of people's country of birth. Stratified analysis by employment status allowed further exploration of Scotland's excess. RESULTS: People born and living in Scotland reported higher levels of poor general health and limiting illness compared to people born and living in England. Adjustment for socioeconomic position and employment status largely explained the higher rates. In the stratified analysis a Scottish excess was seen only amongst the economically inactive born and living in Scotland. For those in employment, people born and living in Scotland actually had slightly lower odds of reporting poor general health and limiting illness than people born and living in England. CONCLUSION: This analysis suggests that higher rates of poor self reported health in Scotland can be explained by differences in employment and socioeconomic position and so there is unlikely to be an unidentified "Scottish effect" for self reports of health. Scotland's excess of poor general health and limiting illness amongst the economically inactive is probably attributable to its economic and employment history.

Adult↗