Does a local Alcohol Health Champion programme have a measurable impact on health and crime outcomes? A natural experiment evaluation of Communities in Charge of Alcohol (CICA) based on triangulation of methods.

BACKGROUND AND AIM: Drinking alcohol may cause harm to an individual's health and social relationships, while a drinking culture may harm societies as it may increase crime rates and make an area feel less safe. Local councils in Greater Manchester, UK, developed the Communities in Charge of Alcohol (CICA) intervention, in which volunteers were trained to give alcohol-related advice to the public and taught how to influence policies to restrict when, where and how alcohol is sold. As part of a larger study, the aim of the current project is to measure the impact of CICA on health and crime outcomes at the lower super output (LSOA) geographical aggregation. DESIGN: Quantitative evaluation using four time series analytic methods (stepped-wedge design, and comparisons to local controls, national controls and synthetic controls) with findings triangulated across these methods. A cost-benefit analysis was carried out alongside the effectiveness analysis. SETTING AND PARTICIPANTS: The general public in Greater Manchester, UK, between 2010 and 2020. MEASUREMENTS: The primary outcome of interest was alcohol-related hospital admissions. Secondary outcomes were accident and emergency (A&E) attendances, ambulance callouts, recorded crimes and anti-social behaviour incidents. FINDINGS: Triangulation of the results did not indicate any consistent effect on area-level alcohol-related hospital admissions, A&E attendances, ambulance callouts, reported crimes or anti-social behaviour associated with the implementation of CICA. The primary stepped-wedge analysis indicated an increase in alcohol-related hospital admissions following the implementation of CICA of 13.4% (95% confidence interval -3.3%, +30.1%), which was consistent with analyses based on other methods with point estimates ranging from +3.4% to 16.4%. CONCLUSION: There is no evidence of a measurable impact of the Communities in Charge of Alcohol (CICA) programme on area-level health and crime outcomes in Greater Manchester, UK, within 3 years of the programme start. The increase in alcohol-related hospital admissions was likely the result of other temporal trends rather than the CICA programme. Possible explanations include insufficient follow-up time, too few volunteers trained, volunteers being unwilling to get involved in licensing decisions or that the intervention has no direct impact on the selected outcomes.

'A priori' external contextual factors and relationships with process indicators: a mixed methods study of the pre-implementation phase of 'Communities in Charge of Alcohol'.

BACKGROUND: It is widely recognised that complex public health interventions roll out in distinct phases, within which external contextual factors influence implementation. Less is known about relationships with external contextual factors identified a priori in the pre-implementation phase. We investigated which external contextual factors, prior to the implementation of a community-centred approach to reducing alcohol harm called 'Communities in Charge of Alcohol' (CICA), were related to one of the process indicators: numbers of Alcohol Health Champions (AHCs) trained. METHODS: A mixed methods design was used in the pre-implementation phase of CICA. We studied ten geographic communities experiencing both high levels of deprivation and alcohol-related harm in the North West of England. Qualitative secondary data were extracted from pre-implementation meeting notes, recorded two to three months before roll-out. Items were coded into 12 content categories using content analysis. To create a baseline 'infrastructure score', the number of external contextual factors documented was counted per area to a maximum score of 12. Descriptive data were collected from training registers detailing training numbers in the first 12 months. The relationship between the baseline infrastructure score, external contextual factors, and the number of AHCs trained was assessed using non-parametric univariable statistics. RESULTS: There was a positive correlation between baseline infrastructure score and total numbers of AHCs trained (Rs = 0.77, p = 0.01). Four external contextual factors were associated with significantly higher numbers of lay people recruited and trained: having a health care provider to coordinate the intervention (p = 0.02); a pool of other volunteers to recruit from (p = 0.02); a contract in place with a commissioned service (p = 0.02), and; formal volunteer arrangements (p = 0.03). CONCLUSIONS: Data suggest that there were four key components that significantly influenced establishing an Alcohol Health Champion programme in areas experiencing both high levels of deprivation and alcohol-related harm. There is added value of capturing external contextual factors a priori and then testing relationships with process indicators to inform the effective roll-out of complex interventions. Future research could explore a wider range of process indicators and outcomes, incorporating methods to rate individual factors to derive a mean score. TRIAL REGISTRATION: ISRCTN81942890, date of registration 12/09/2017.

How can communities influence alcohol licensing at a local level? Licensing officers' perspectives of the barriers and facilitators to sustaining engagement in a volunteer-led alcohol harm reduction approach.

Despite the World Health Organization's assertion that communities need to become involved in reducing alcohol harm, evidence of community engagement in alcohol licensing decision-making in England remains limited. The evaluation of the Communities in Charge of Alcohol (CICA) programme offers policymakers, Licensing authorities and public health practitioners, evidence regarding a specific volunteer-led, place-based approach, designed to enable community engagement in licensing with the aim of reducing localised alcohol harm. This study explored factors affecting the sustainable involvement of volunteers in alcohol licensing decision-making from six licensing officers' perspectives, through semi-structured interviews. Routinely collected crime, disorder, and hospital admissions data were reviewed for further context as proxy indicators for alcohol-related harm. Licensing officers perceived sustainable engagement to be impacted by: (i) the extent of alignment with statutory requirements and local political support; (ii) the ability of licensing officers to operationalise CICA and support local assets, and; (iii) the opportunity for, and ability of, volunteers to raise licensing issues. The perspectives of licensing officers indicate complexities inherent in seeking to empower residents to engage in licensing decision-making at a community level. These relate to statutory and political factors, funding, social norms regarding engagement in licensing decision-making, and the need for networks between critical actors including responsible authorities and communities. The evidence indicates that after increasing community capacity to influence alcohol availability decision-making at a local level, communities continue to struggle to influence statutory processes to affect alcohol availability where they live and work. More understanding of how to enable effective community engagement is required.

Quantitative Bias Analysis of the Association between Occupational Radiation Exposure and Ischemic Heart Disease Mortality in UK Nuclear Workers.

The scientific question of whether protracted low-dose or low-dose-rate exposure to external radiation is causally related to the risk of circulatory disease continues to be an important issue for radiation protection. Previous analyses of a matched case-control dataset nested in a large cohort of UK nuclear fuel cycle workers indicated that there was little evidence that observed associations between external radiation dose and ischemic heart disease (IHD) mortality risk [OR = 1.35 (95% CI: 0.99-1.84) for 15-year-lagged exposure] could alternatively be explained by confounding from pre-employment tobacco smoking, BMI or blood pressure, or from socioeconomic status or occupational exposure to excessive noise or shiftwork. To improve causal inference about the observed external radiation dose and IHD mortality association, we estimated the potential magnitude and direction of non-random errors, incorporated sensitivity analyses and simulated bias effects under plausible scenarios. We conducted quantitative bias analyses of plausible scenarios based on 1,000 Monte Carlo samples to explore the impact of exposure measurement error, missing information on tobacco smoking, and unmeasured confounding, and assessed whether observed associations were reliant on the inclusion of specific matched pairs using bootstrapping with 10% of matched pairs randomly excluded in 1,000 samples. We further explored the plausibility that having been monitored for internal exposure, which was an important confounding factor in the case-control analysis for which models were adjusted, was indeed a confounding factor or whether it might have been the result of some form of selection bias. Consistent with the broader epidemiological evidence-base, these analyses provide further evidence that the dose-response association between cumulative external radiation exposure and IHD mortality is non-linear in that it has a linear shape plateauing at an excess risk of 43% (95% CI: 7-92%) on reaching 390 mSv. Analyses of plausible scenarios of patterns of missing data for tobacco smoking at start of employment indicated that this resulted in relatively little bias towards the null in the original analysis. An unmeasured confounder would have had to have been highly correlated (rp > 0.60) with cumulative external radiation dose to importantly bias observed associations. The confounding effect of "having been monitored for internal dose" was unlikely to have been a true confounder in a biological sense, but instead may have been some unknown factor related to differences over time and between sites in selection criteria for internal monitoring, possibly resulting in collider bias. Plausible patterns of exposure measurement error negatively biased associations regardless of the modeled scenario, but did not importantly change the shape of the observed dose-response associations. These analyses provide additional support for the hypothesis that the observed association between external radiation exposure and IHD mortality may be causal.

Age-related and socioeconomic inequalities in timeliness of referral and start of treatment in colorectal cancer: a population-based analysis.

BACKGROUND: Poorer colorectal cancer survival in the UK than in similar countries may be partly due to delays in the care pathway. To address this, cancer waiting time targets were established. We investigated if socio-demographic inequalities exist in meeting cancer waiting times for colorectal cancer. METHODS: We identified primary colorectal cancers (International Classification of Diseases, Tenth Revision C18-C20; n=35 142) diagnosed in the period 2001-2010 in the Northern and Yorkshire Cancer Registry area. Using multivariable logistic regression, we calculated likelihood of referral and treatment within target by age group and deprivation quintile. RESULTS: 48% of the patients were referred to hospital within target (≤14 days from general practitioner (GP) referral to first hospital appointment); 52% started treatment within 31 days of diagnosis; and 44% started treatment within 62 days of GP referral. Individuals aged 60-69, 70-79 and 80+ years were significantly more likely to attend a first hospital appointment within 14 days than those aged <60 years (adjusted OR=1.23, 95% CI 1.12 to 1.34; adjusted OR=1.19, 95% CI 1.09 to 1.29; adjusted OR=1.30, 95% CI 1.18 to 1.42, respectively). Older age was significantly associated with lower likelihood of starting treatment within 31 days of diagnosis and 62 days of referral. Deprivation was not related to referral within target but was associated with lower likelihood of starting treatment within 31 days of diagnosis or 62 days of referral (most vs least: adjusted OR=0.82, 95% CI 0.74 to 0.91). CONCLUSIONS: Older patients with colorectal cancer were less likely to experience referral delays but more likely to experience treatment delays. More deprived patients were more likely to experience treatment delays. Investigation of patient pathways, treatment decision-making and treatment planning would improve understanding of these inequalities.

Ischemic Heart Disease Mortality and Occupational Radiation Exposure in a Nested Matched Case-Control Study of British Nuclear Fuel Cycle Workers: Investigation of Confounding by Lifestyle, Physiological Traits and Occupational Exposures.

Epidemiological studies have suggested a link between low-level radiation exposure and an increased risk of cardiovascular disease, but the possibility of bias or confounding must be considered. We analyzed data from a matched case-control study nested in a cohort of British male industrial (i.e., blue-collar) nuclear fuel cycle workers using paired conditional logistic regression. The cases were comprised of workers from two nuclear sites who had died from ischemic heart disease (IHD) and were matched to controls on nuclear site, date of birth and first year of employment (1,220 pairs). Radiation doses from external sources and to the liver from internally deposited plutonium and uranium were obtained. Models were adjusted for age at start of employment at either site, decade of start, age at exit from study (death or censoring), process/other worker and socio-economic status. Included potential confounding factors of interest were occupational noise, shift work, pre-employment blood pressure, body mass index and tobacco smoking. Cumulative external doses ranged from 0-1,656 mSv and cumulative internal doses for those monitored for radioactive intakes ranged from 0.004-5,732 mSv. In a categorical analysis, additionally adjusted for whether or not a worker was monitored for internal exposure, IHD mortality risk was associated with cumulative external unlagged dose with a 42% excess risk (95% CI: 4%, 95%) at >103 mSv (highest quartile relative to lowest quartile), and 35% (95% CI: -1%, 84%) at >109 mSv 15-year lagged dose. The log-linear increase in risk per 100 mSv was 2% (95% CI: -4%, 8%) for unlagged external dose and 5% (95% CI: -2%, 11%) for 15-year lagged dose. Associations with external dose for workers monitored only for exposure to external radiation reflected those previously reported for the cohort from which the cases and controls were drawn. There was little evidence of excess risk associated with cumulative doses from internal sources, which had not been assessed in the cohort study. The impact of the included potential confounding variables was minimal, with the possible exception of occupational noise exposure. Subgroup analyses indicated evidence of heterogeneity between sites, occupational groups and employment duration, and an important factor was whether workers were monitored for the potential presence of internal emitters, which was not explained by other factors included in the study. In summary, we found evidence for an increased IHD mortality risk associated with external radiation dose, but little evidence of an association with internal dose. External dose associations were minimally affected by important confounders. However, the considerable heterogeneity in the associations with external doses observed between subgroups of workers is difficult to explain and requires further work.

Lifetime cumulative exposure to rubber dust, fumes and N-nitrosamines and non-cancer mortality: a 49-year follow-up of UK rubber factory workers.

OBJECTIVES: To examine associations between occupational exposures to rubber dust, rubber fumes and N-nitrosamines and non-cancer mortality. METHODS: A cohort of 36 441 males aged 35+ years employed in British rubber factories was followed-up to 2015 (94% deceased). Competing risk survival analysis was used to assess risks of dying from non-cancer diseases (respiratory, urinary, cerebrovascular, circulatory and digestive diseases). Occupational exposures to rubber dust, rubber fumes, N-nitrosamines were derived based on a population-specific quantitative job-exposure matrix which in-turn was based on measurements in the EU-EXASRUB database. RESULTS: Exposure-response associations of increased risk with increasing exposure were found for N-nitrosomorpholine with mortality from circulatory diseases (subdistribution hazard ratio (SHR) 1.17; 95% CI 1.12 to 1.23), ischaemic heart disease (IHD) (SHR 1.19; 95% CI 1.13 to 1.26), cerebrovascular disease (SHR 1.19; 95% CI 1.07 to 1.32) and exposures to N-nitrosodimethylamine with respiratory disease mortality (SHR 1.41; 95% CI 1.30 to 1.53). Increased risks for mortality from circulatory disease, IHD and digestive diseases were found with higher levels of exposures to rubber dust, rubber fumes and N-nitrosamines sum, without an exposure-dependent manner. No associations were observed between rubber dust, rubber fumes and N-nitrosamines exposures with mortality from asthma, urinary disease, bronchitis, emphysema, liver disease and some digestive diseases. CONCLUSIONS: In a cohort of rubber factory workers with 49 years of follow-up, increased risk for mortality from circulatory, cerebrovascular, respiratory and digestive diseases were found to be associated with cumulative occupational exposures to specific agents.

Job-exposure matrix for historical exposures to rubber dust, rubber fumes and n-Nitrosamines in the British rubber industry.

OBJECTIVES: To develop a quantitative historical job-exposure matrix (JEM) for rubber dust, rubber fumes and n-Nitrosamines in the British rubber industry for 1915-2002 to estimate lifetime cumulative exposure (LCE) for a cohort of workers with 49 years follow-up. METHODS: Data from the EU-EXASRUB database-rubber dust (n=4157), rubber fumes (n=3803) and n-Nitrosamines (n=10 115) collected between 1977 and 2002-were modelled using linear mixed-effects models. Sample year, stationary/personal measurement, industry sector and measurement source were included as fixed explanatory variables and factory as random intercept. Model estimates and extrapolations were used to construct a JEM covering all departments in both sectors of the rubber manufacturing industries for the years 1915-2002. JEM-estimates were linked to all cohort members to calculate LCE. Sensitivity analyses related to assumptions about extrapolation of time trends were also conducted. RESULTS: Changes in rubber dust exposures ranged from -6.3 %/year (crude materials/mixing) to -1.0 %/year (curing) and -6.5 %/year (crude materials/mixing) to +0.5 %/year (finishing, assembly and miscellaneous) for rubber fumes. Declines in n-Nitrosamines ranged from -17.9 %/year (curing) to -1.3 %/year (crude materials and mixing). Mean LCEs were 61 mg/m3-years (rubber dust), 15.6 mg/ m3-years (rubber fumes), 2483.2 µg/m3-years (n-Nitrosamines sum score), 18.6 µg/m3-years (N-nitrosodimethylamine) and 15.0 µg/m3-years (N-itrosomorpholine). CONCLUSIONS: All exposures declined over time. Greatest declines in rubber dust and fumes were found in crude materials and mixing and for n-Nitrosamines in curing/vulcanising and preprocessing. This JEM and estimated LCEs will allow for evaluation of exposure-specific excess cancer risks in the British rubber industry.

Lifetime exposure to rubber dusts, fumes and N-nitrosamines and cancer mortality in a cohort of British rubber workers with 49 years follow-up.

OBJECTIVES: To quantitatively evaluate exposure-response associations between occupational exposures to rubber dust, fumes and N-nitrosamines and cancer mortality in the UK rubber industry. METHODS: Competing risk survival analyses were used to examine cancer mortality risk in a cohort of 36 441 males aged 35+ years employed in the British rubber industry in 1967, followed up to 2015 (94% mortality). Exposure measurements are based on a population-specific quantitative job-exposure matrix for rubber dust, rubber fumes and N-nitrosamines from the EU-EXASRUB project. RESULTS: Exposure (lifetime cumulative (LCE))-response associations were found for N-nitrosomorphiline and all cancers (subdistribution HR (SHR) 1.48, 95% CI 1.39 to 1.57) and cancers of the bladder, stomach, multiple myeloma, oesophagus, prostate and pancreas, as well as for N-nitrosodimethylamine and all cancers (SHR 2.08, 95% CI 1.96 to 2.21) and cancers of the bladder, stomach, leukaemia, multiple myeloma, prostate and liver. LCE to the N-nitrosamines sum were associated with increased risks from all cancers (SHR 1.89, 95% CI 1.78 to 2.01) and cancers of the lung, non-Hodgkin's lymphoma and brain. LCE to rubber dust and fumes are associated with increased mortality from all cancers (rubber dust SHR 1.67, 95% CI 1.58 to 1.78; rubber fumes SHR 1.91, 95% CI 1.80 to 2.03) and cancers of the bladder, lung, stomach, leukaemia, multiple myeloma, non-Hodgkin's lymphoma, oesophagus, prostate, pancreas and liver. CONCLUSIONS: Consistent with previous studies, N-nitrosamines exposures are associated with mortality from cancers of the bladder, lung, stomach, leukaemia, multiple myeloma, oesophagus, prostate, pancreas and liver. The long follow-up with nearly complete mortality enabled estimations of lifetime cancer mortality risk from occupational exposures in the rubber industry.

Age-related inequalities in colon cancer treatment persist over time: a population-based analysis.

BACKGROUND: Older people experience poorer outcomes from colon cancer. We examined if treatment for colon cancer was related to age and if inequalities changed over time. METHODS: Data from the UK population-based Northern and Yorkshire Cancer Registry on 31 910 incident colon cancers (ICD10 C18) diagnosed between 1999-2010 were obtained. Likelihood of receipt of: (1) cancer-directed surgery, (2) chemotherapy in surgical patients, (3) chemotherapy in non-surgical patients by age, adjusting for sex, area deprivation, cancer stage, comorbidity and period of diagnosis, was examined. RESULTS: Age-related inequalities in treatment exist after adjustment for confounding factors. Patients aged 60- 69, 70-79 and 80+ years were significantly less likely to receive surgery than those aged <60 years (multivariable ORs (95% CI) 0.84(0.74 to 0.95), 0.54(0.48 to 0.61) and 0.19(0.17 to 0.21), respectively). Age-related differences in receipt of surgery and adjuvant chemotherapy (but not chemotherapy in non-surgical patients) narrowed over time for the 'younger old' (aged <80 years) but did not diminish for the oldest patients. CONCLUSIONS: Age inequality in treatment of colon cancer remains after adjustment for confounders, suggesting age remains a major factor in treatment decisions. Research is needed to better understand the cancer treatment decision-making process, and how to influence this, for older patients.

British rubber and cable industry cohort: 49-year mortality follow-up.

BACKGROUND: The International Agency for Research on Cancer (IARC) has determined there is sufficient evidence that working in the rubber manufacturing industry increases the risk of cancers of the stomach, lung, bladder and leukaemia and lymphoma. OBJECTIVES: To examine mortality patterns of a prospective cohort of men from the rubber and cable manufacturing industries in Great Britain. METHODS: SMRs were calculated for males aged 35+ years at start of follow-up in 1967-2015 using the population of England and Wales as the external comparator. Tests for homogeneity and trends in SMRs were also completed. RESULTS: For all causes, all malignant neoplasms, non-malignant respiratory diseases and circulatory diseases, SMRs were significantly elevated, and also particularly for cancers of the stomach (SMR=1.26,95% CI 1.18 to 1.36), lung (1.25,95% CI 1.21 to 1.29) and bladder (1.16,95% CI 1.05 to 1.28). However, the observed deaths for leukaemia, non-Hodgkin's lymphoma (NHL) and multiple myeloma were as expected. Bladder cancer risks were elevated only in workers exposed to antioxidants containing 1-naphthylamine and 2-naphthylamine. CONCLUSIONS: This study provides evidence of excess risks in the rubber industry for some non-cancer diseases and supports IARC's conclusions in relation to risks for cancers of the bladder, lung and stomach, but not for leukaemia, NHL or multiple myeloma.

What are older smokers' attitudes to quitting and how are they managed in primary care? An analysis of the cross-sectional English Smoking Toolkit Study.

OBJECTIVES: To investigate whether age is associated with access to smoking cessation services. DESIGN: Data from the Smoking Toolkit Study 2006-2015, a repeated multiwave cross-sectional household survey (n=181 157). SETTING: England. PARTICIPANTS: Past-year smokers who participated in any of the 102 waves stratified into age groups. OUTCOME MEASURES: Amount smoked and nicotine dependency, self-reported quit attempts and use of smoking cessation interventions. Self-report of whether the general practitioner (GP) raised the topic of smoking and made referrals for pharmacological support (prescription of nicotine replacement therapies (NRTs)) or other support (counselling or support groups). RESULTS: Older smokers (75+ years) were less likely to report that they were attempting to quit smoking or seek help from a GP, despite being less nicotine-dependent. GPs raised smoking as a topic equally across all age groups, but smokers aged 70+ were more likely not to be referred for NRT or other support (ORs relative to 16-54 years; 70-74 years 1.27, 95% CI 1.03 to 1.55; 75-79 years 1.87, 95% CI 1.43 to 2.44; 80+ years 3.16, 95% CI 2.20 to 4.55; p value for trend <0.001). CONCLUSIONS: Our findings suggest that there are potential missed opportunities in facilitating smoking cessation in older smokers. In this large population-based study, older smokers appeared less interested in quitting and were less likely to be offered support, despite being less addicted to nicotine than younger smokers. It is unclear whether this constitutes inequitable access to services or reflects informed choices by older smokers and their GPs. Future research is needed to understand why older smokers and GPs do not pursue smoking cessation. Service provision should consider how best to reduce these variations, and a stronger effectiveness evidence base is required to support commissioning for this older population so that, where appropriate, older smokers are not missing out on smoking cessation therapies and the health benefits of cessation at older ages.

Identifying inequitable healthcare in older people: systematic review of current research practice.

BACKGROUND: There is growing consensus on the importance of identifying age-related inequities in the receipt of public health and healthcare interventions, but concerns regarding conceptual and methodological rigour in this area of research. Establishing age inequity in receipt requires evidence of a difference that is not an artefact of poor measurement of need or receipt; is not warranted on the grounds of patient preference or clinical safety; and is judged to be unfair. METHOD: A systematic, thematic literature review was undertaken with the objective of characterising recent research approaches. Studies were eligible if the population was in a country within the Organisation for Economic Co-operation and Development and analyses included an explicit focus on age-related patterns of healthcare receipt including those 60 years or older. A structured extraction template was applied. Extracted material was synthesised in thematic memos. A set of categorical codes were then defined and applied to produce summary counts across key dimensions. This process was iterative to allow reconciliation of discrepancies and ensure reliability. RESULTS: Forty nine studies met the eligibility criteria. A wide variety of concepts, terms and methodologies were used across these studies. Thirty five studies employed multivariable techniques to produce adjusted receipt-need ratios, though few clearly articulated their rationale, indicating the need for great conceptual clarity. Eighteen studies made reference to patient preference as a relevant consideration, but just one incorporated any kind of adjustment for this factor. Twenty five studies discussed effectiveness among older adults, with fourteen raising the possibility of differential effectiveness, and one differential cost-effectiveness, by age. Just three studies made explicit reference to the ethical nature of healthcare resource allocation by age. While many authors presented suitably cautious conclusions, some appeared to over-stretch their findings concluding that observed differences were 'inequitable'. Limitations include possible biases in the retrieved material due to inconsistent database indexing and a focus on OECD country populations and studies with English titles. CONCLUSIONS: Caution is needed among clinicians and other evidence-users in accepting claims of healthcare 'ageism' in some published papers. Principles for improved research practice are proposed.

Religious activity, life expectancy, and disability-free life expectancy in Taiwan.

Research has implicated religious activity as a health determinant, but questions remain, including whether associations persist in places where Judeo-Christian religions are not the majority; whether public versus private religious expressions have equivalent impacts, and the precise advantage expressed as years of life. This article addresses these issues in Taiwan. 3,739 Taiwanese aged 53+ were surveyed in 1999, 2003, and 2007. Mortality and disability were recorded. Religious activities in public and private settings were measured at baseline. Multistate life-tables produced estimates of total life expectancy and activity of daily living (ADL) disability-free life expectancy across levels of public and private religious activity. There is a consistent positive gradient between religious activity and expectancy with greater activity related to longer life and more years without disability. Life and ADL disability-free life expectancies for those with no religious affiliation fit in between the lowest and highest religious activity groups. Results corroborate evidence in the West. Mechanisms that intervene may be similar in Eastern religions despite differences in the ways in which popular religions are practiced. Results for those with no affiliation suggest benefits of religion can be accrued in alternate ways.

The significance of education for mortality compression in the United States.

Recent studies of old-age mortality trends assess whether longevity improvements over time are linked to increasing compression of mortality at advanced ages. The historical backdrop of these studies is the long-term improvement in a population's socioeconomic resources that fueled longevity gains. We extend this line of inquiry by examining whether socioeconomic differences in longevity within a population are accompanied by old-age mortality compression. Specifically, we document educational differences in longevity and mortality compression for older men and women in the United States. Drawing on the fundamental cause of disease framework, we hypothesize that both longevity and compression increase with higher levels of education and that women with the highest levels of education will exhibit the greatest degree of longevity and compression. Results based on the Health and Retirement Study and the National Health Interview Survey Linked Mortality File confirm a strong educational gradient in both longevity and mortality compression. We also find that mortality is more compressed within educational groups among women than men. The results suggest that educational attainment in the United States maximizes life chances by delaying the biological aging process.

Late-life decline in well-being across adulthood in Germany, the United Kingdom, and the United States: Something is seriously wrong at the end of life.

Throughout adulthood and old age, levels of well-being appear to remain relatively stable. However, evidence is emerging that late in life well-being declines considerably. Using long-term longitudinal data of deceased participants in national samples from Germany, the United Kingdom, and the United States, we examined how long this period lasts. In all 3 nations and across the adult age range, well-being was relatively stable over age but declined rapidly with impending death. Articulating notions of terminal decline associated with impending death, we identified prototypical transition points in each study between 3 and 5 years prior to death, after which normative rates of decline steepened by a factor of 3 or more. The findings suggest that mortality-related mechanisms drive late-life changes in well-being and highlight the need for further refinement of psychological concepts about how and when late-life declines in psychosocial functioning prototypically begin. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Life course pathways to adult-onset diabetes.

Early life conditions, such as socioeconomic status (SES) and health, have the potential to set in motion multiple and reinforcing pathways that shape both the prevalence and onset of diabetes among older adults. Using data from the Health and Retirement Study (1998-2002) for persons age 51 years and older, we investigated the core mediating mechanisms linking early life conditions with diabetes prevalence in 1998 and onset over a 4-year follow-up period, focusing on adult achievement processes and obesity as key mechanisms. We found that father's education is negatively associated with diabetes prevalence for older men and women. However, no markers of early life SES are directly associated with older men's and women's onset of diabetes, and the negative effects of adult SES on diabetes onset pertain only to women. Early life health affects the onset of diabetes among women--but not the prevalence--and no evidence of this association was found for men. We found no evidence that obesity is an important mechanism connecting either early life or adult SES with diabetes development in men or women. We speculate that early life SES may accelerate the development of diabetes at younger ages, and that the pathways linking life course SES, early life health, and diabetes are partly gender-specific and biological in nature.