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"Green, Michael J."
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Interpreting mutual adjustment for multiple indicators of socioeconomic position without committing mutual adjustment fallacies
Research into the effects of Socioeconomic Position (SEP) on health will sometimes compare effects from multiple, different measures of SEP in “mutually adjusted” regression models. Interpreting each effect estimate from such models equivalently as the “independent” effect of each measure may be misleading, a mutual adjustment (or Table 2) fallacy. We use directed acyclic graphs (DAGs) to explain how interpretation of such models rests on assumptions about the causal relationships between those various SEP measures. We use an example DAG whereby education leads to occupation and both determine income, and explain implications for the interpretation of mutually adjusted coefficients for these three SEP indicators. Under this DAG, the mutually adjusted coefficient for education will represent the direct effect of education, not mediated via occupation or income. The coefficient for occupation represents the direct effect of occupation, not mediated via income, or confounded by education. The coefficient for income represents the effect of income, after adjusting for confounding by education and occupation. Direct comparisons of mutually adjusted coefficients are not comparing like with like. A theoretical understanding of how SEP measures relate to each other can influence conclusions as to which measures of SEP are most important. Additionally, in some situations adjustment for confounding from more distal SEP measures (like education and occupation) may be sufficient to block unmeasured socioeconomic confounding, allowing for greater causal confidence in adjusted effect estimates for more proximal measures of SEP (like income).
Journal Article
The scientific method : a guide to finding useful knowledge
\"I found this book to be a particularly engaging and useful treatment of scientific method and practice whereby the authors' target is to improve practice. There is a lot of subversion out there that they want to avoid with a content-positive approach. The book's themes for improving scientific practice are generated from earthy checklists, all concerned to improve compliance with the substantive content of science. It results in checklists for eleven user categories, from researchers to courts. The checklists all derive from key elements of the scientific method, summarized by eight criteria. I want to apply seven of these elements to my early work in experimental economics that will help me to see how this book can help you, which is its purpose\"-- Provided by publisher.
Book
Socioeconomic patterning of vaping by smoking status among UK adults and youth
Background
Smoking contributes significantly to socioeconomic health inequalities. Vaping has captured much interest as a less harmful alternative to smoking, but may be harmful relative to non-smoking. Examining inequalities in vaping by smoking status, may offer insights into potential impacts of vaping on socioeconomic inequalities in health.
Methods
Data were from 3291 youth (aged 10–15) and 35,367 adults (aged 16+) from wave 7 (2015–17) of the UK Household Longitudinal Study. In order to adjust for biases that could be introduced by stratifying on smoking status, marginal structural models were used to estimate controlled direct effects of an index of socioeconomic disadvantage (incorporating household education, occupation and income) on vaping by smoking status (among adults and youth), adjusting for relevant confounders and for selection into smoking states. We also estimated controlled direct effects of socioeconomic disadvantage on being an ex-smoker by vaping status (among adult ever-smokers;
n
= 18,128).
Results
Socioeconomic disadvantage was associated with vaping among never smoking youth (OR for a unit increase in the socioeconomic index: 1.17; 95%: 1.03–1.34), and among ex-smoking adults (OR: 1.17; 95% CI: 1.09–1.26), with little to no association among never smoking (OR: 0.98; 95% CI: 0.91–1.07) and current smoking (OR: 1.00; 95% CI: 0.93–1.07) adults. Socioeconomic disadvantage was also associated with reduced odds of being an ex-smoker among adult ever-smokers, but this association was moderately weaker among those who vaped (OR: 0.88; 95% CI: 0.82–0.95) than those who did not (OR: 0.82; 95% CI: 0.80–0.84;
p
-value for difference = 0.081).
Conclusions
Inequalities in vaping among never smoking youth and adult ex-smokers, suggest potential to widen health inequalities, while weaker inequalities in smoking cessation among adult vapers indicate e-cigarettes could help narrow inequalities. Further research is needed to understand the balance of these opposing potential impacts, and how any benefits can be maximised whilst protecting the vulnerable.
Journal Article
Learning by drawing: understanding the potential of comics-based courses in medical education through a qualitative study
In recent years, medical educators have increasingly incorporated comics into their teaching to promote humanism and empathy and to encourage reflective practice. However, it remains unclear how and to what extent comics-based courses effectively address persistent challenges in medical education, such as the need for more engaging, multimodal learning strategies and the cultivation of emotional intelligence alongside clinical competencies. The aim of this study is to investigate the experiences of students who have enrolled in courses on comics and medicine during medical school. Students in North America who had taken such a course during the previous 5 years were invited to participate in an interview about their experiences. 17 students from 10 different medical schools in North America were interviewed. To explore the students’ views on the value of such courses to their medical education, we used a constructivist grounded analytic approach, employing thematic analysis to understand and interpret our interview. Students reported that comics-based courses support key aspects of their medical training that traditional pedagogical approaches may overlook, such as fostering self-reflection, enhancing empathy, and encouraging creative engagement with complex medical narratives. Moreover, comics contributed to their individual and collective professional identity formation by providing a space for introspection and shared discourse.
Journal Article
Inequalities in healthcare disruptions during the COVID-19 pandemic: evidence from 12 UK population-based longitudinal studies
ObjectivesWe investigated associations between multiple sociodemographic characteristics (sex, age, occupational social class, education and ethnicity) and self-reported healthcare disruptions during the early stages of the COVID-19 pandemic.DesignCoordinated analysis of prospective population surveys.SettingCommunity-dwelling participants in the UK between April 2020 and January 2021.ParticipantsOver 68 000 participants from 12 longitudinal studies.OutcomesSelf-reported healthcare disruption to medication access, procedures and appointments.ResultsPrevalence of healthcare disruption varied substantially across studies: between 6% and 32% reported any disruption, with 1%–10% experiencing disruptions in medication, 1%–17% experiencing disruption in procedures and 4%–28% experiencing disruption in clinical appointments. Females (OR 1.27; 95% CI 1.15 to 1.40; I2=54%), older persons (eg, OR 1.39; 95% CI 1.13 to 1.72; I2=77% for 65–75 years vs 45–54 years) and ethnic minorities (excluding white minorities) (OR 1.19; 95% CI 1.05 to 1.35; I2=0% vs white) were more likely to report healthcare disruptions. Those in a more disadvantaged social class were also more likely to report healthcare disruptions (eg, OR 1.17; 95% CI 1.08 to 1.27; I2=0% for manual/routine vs managerial/professional), but no clear differences were observed by education. We did not find evidence that these associations differed by shielding status.ConclusionsHealthcare disruptions during the COVID-19 pandemic could contribute to the maintenance or widening of existing health inequalities.
Journal Article
Pregnancy outcomes among medically complex populations with high risk of pregnancy mortality in Virginia: a retrospective observational study
Background
Abortion may be medically indicated to avert death or permanent harm of the pregnant person. However, some US states now prevent access to abortion for these patients. To evaluate the population for whom this may cause harm, we aimed to estimate the prevalence of severe chronic conditions and pregnancy complications for which induced abortion is indicated, the odds of pregnancy for patients with severe chronic conditions, and compare pregnancy outcomes including induced abortion for pregnancies where such indications are present with pregnancies where they are not.
Methods
In a retrospective observational study using the Virginia All-Payer Claims Database (2018–2019), we identified 1,502,965 female patients aged 14–55 with ≥ 6 months insurance coverage. Medical codes identified severe chronic conditions and pregnancy complications. Pregnancy outcomes were classified using an established algorithm.
Results
Among reproductive-aged people, 2.9% had severe chronic conditions that could threaten life with pregnancy. Among 101,582 people who experienced pregnancy, 5.6% had life-threatening complications before their third trimester. Severe chronic conditions were associated with reduced risk of pregnancy (OR: 0.44 [95% CI: 0.41–0.46]), but sickle cell disease patients had increased odds of pregnancy (OR: 2.42 [95% CI: 2.10–2.78]). Compared to pregnancies with neither early complications or severe conditions present, pregnancies involving severe chronic conditions had fewer live births (68.2% vs. 75.3%), more spontaneous abortions (16.9% vs. 12.2%), and more induced abortions (3.7% vs. 2.2%), while pregnancies with early complications also had fewer live births (61.7%) and more spontaneous abortions (25.2%;
p
< 0.01 for all comparisons). Abortion ratios (induced abortions per 1000 live births) in these data were 5–6 times lower than in Center for Disease Control abortion surveillance data for Virginia 2018–2019, indicating under-ascertainment of induced abortion.
Conclusions
In a state with some abortion restrictions and some protections, thousands of patients experience severe chronic conditions or pregnancy complications for which induced abortion is indicated.
Journal Article
Home working and social and mental wellbeing at different stages of the COVID-19 pandemic in the UK: Evidence from 7 longitudinal population surveys
Home working has increased since the Coronavirus Disease 2019 (COVID-19) pandemic's onset with concerns that it may have adverse health implications. We assessed the association between home working and social and mental wellbeing among the employed population aged 16 to 66 through harmonised analyses of 7 UK longitudinal studies.
We estimated associations between home working and measures of psychological distress, low life satisfaction, poor self-rated health, low social contact, and loneliness across 3 different stages of the pandemic (T1 = April to June 2020 -first lockdown, T2 = July to October 2020 -eased restrictions, T3 = November 2020 to March 2021 -second lockdown) using modified Poisson regression and meta-analyses to pool results across studies. We successively adjusted the model for sociodemographic characteristics (e.g., age, sex), job characteristics (e.g., sector of activity, pre-pandemic home working propensities), and pre-pandemic health. Among respectively 10,367, 11,585, and 12,179 participants at T1, T2, and T3, we found higher rates of home working at T1 and T3 compared with T2, reflecting lockdown periods. Home working was not associated with psychological distress at T1 (RR = 0.92, 95% CI = 0.79 to 1.08) or T2 (RR = 0.99, 95% CI = 0.88 to 1.11), but a detrimental association was found with psychological distress at T3 (RR = 1.17, 95% CI = 1.05 to 1.30). Study limitations include the fact that pre-pandemic home working propensities were derived from external sources, no information was collected on home working dosage and possible reverse association between change in wellbeing and home working likelihood.
No clear evidence of an association between home working and mental wellbeing was found, apart from greater risk of psychological distress during the second lockdown, but differences across subgroups (e.g., by sex or level of education) may exist. Longer term shifts to home working might not have adverse impacts on population wellbeing in the absence of pandemic restrictions but further monitoring of health inequalities is required.
Journal Article
Youth vaping and smoking and parental vaping: a panel survey
Background
Concerns remain about potential negative impacts of e-cigarettes including possibilities that: youth e-cigarette use (vaping) increases risk of youth smoking; and vaping by parents may have impacts on their children’s vaping and smoking behaviour.
Methods
With panel data from 3291 youth aged 10–15 years from the 7th wave of the UK Understanding Society Survey (2015–2017), we estimated effects of youth vaping on youth smoking (ever, current and past year initiation), and of parental vaping on youth smoking and vaping, and examined whether the latter differed by parental smoking status. Propensity weighting was used to adjust for measured confounders and estimate average effects of vaping for all youth, and among youth who vaped. E-values were calculated to assess the strength of unmeasured confounding influences needed to negate our estimates.
Results
Associations between youth vaping and youth smoking were attenuated considerably by adjustment for measured confounders. Estimated average effects of youth vaping on youth smoking were stronger for all youth (e.g. OR for smoking initiation: 32.5; 95% CI: 9.8–107.1) than among youth who vaped (OR: 4.4; 0.6–30.9). Relatively strong unmeasured confounding would be needed to explain these effects. Associations between parental vaping and youth vaping were explained by measured confounders. Estimates indicated effects of parental vaping on youth smoking, especially for youth with ex-smoking parents (e.g. OR for smoking initiation: 11.3; 2.7–46.4) rather than youth with currently smoking parents (OR: 1.0; 0.2–6.4), but these could be explained by relatively weak unmeasured confounding.
Conclusions
While measured confounding accounted for much of the associations between youth vaping and youth smoking, indicating support for underlying propensities, our estimates suggested residual effects that could only be explained away by considerable unmeasured confounding or by smoking leading to vaping. Estimated effects of youth vaping on youth smoking were stronger among the general youth population than among the small group of youth who actually vaped. Associations of parental vaping with youth smoking and vaping were either explained by measured confounding or could be relatively easily explained by unmeasured confounding.
Journal Article