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PubMed2006

Military surgery at the turn of the century.

The authors present a summary of current postgraduate education status in the field of military clinical specializations with the focus on surgery and military surgery. Recent organizational changes in medical care within the Czech Army, along with changes associated with the new legal directives regulating the acquirement of professional and specialized medical qualification, will require a new approach to the training of surgeons and other physicians in the Czech Republic. This will involve new educational goals, adaptation of specialized curricula and introduction of systematic quality measurement methods of teaching and training.

Czech Republic↗

PubMed2002

Socioeconomic status and risk of HIV infection in an urban population in Kenya.

OBJECTIVE: To examine the relationship between socioeconomic status (SES), risk factors for HIV infection and HIV status in an urban population with high prevalence of HIV infection in sub-Saharan Africa. METHODS: Cross-sectional population survey of adults from the city of Kisumu, Kenya, in 1996. Around 1000 men and 1000 women aged 15-49 years were interviewed using a structured questionnaire, and most gave a venous blood sample for HIV testing. SES was represented by a composite variable of educational status, occupation and household utilities. Multiple regression was used to examine whether SES was associated with HIV infection or with risk factors for HIV infection. RESULTS: Human immunodeficiency virus prevalence was 19.8% in males and 30.2% in females. Higher SES was associated with a more mobile lifestyle, later sexual debut and marriage among both sexes, and with circumcision among men aged 25-49 and condom use among women aged 25-49. Higher levels of alcohol consumption were associated with an increased risk of HIV infection and were more common amongst those of higher SES. HSV-2 infection was strongly associated with an increased risk of HIV infection and was more common among those of lower SES. HIV was associated with a lower SES among females aged 15-24 whereas in males aged 15-24 and females aged 25-49 there was some indication that it was associated with higher SES. Among males aged 25-49 there was no association between HIV infection and SES. CONCLUSIONS: Risk of infection was high among groups of all SES. Risk profiles suggested men and women of lower SES maybe at greater risk of newly acquired HIV infection. New infections may now be occurring fastest among young women of the lowest SES.

Adolescent↗

PubMed1991

Mothers as agents of growth monitoring: implications for widespread community growth monitoring.

A total of 518 mothers, aged 18 to 45 years, were interviewed to study a variety of indicators and local standards used to assess the course of their children's growth. The features most frequently recognized by mothers as indicators of growth were related to maternal age, parity and educational status. The younger mothers (age less than or equal to 30 years and parity less than or equal to 3) used weight and health frequently to assess growth, while the older mothers recognized growth by comparison with other children and changes in mood (P less than 0.01). The latter two indicators were found to be a function of maternal experience. Unlike age and parity, age and education seemed to have no joint association with the various responses. We conclude and recommend that weight, health and stages of development are reliable and acceptable indices for community growth monitoring.

Adolescent↗

PubMed1999

Prediction of "intent", "discrepancy with intent", and "discrepancy with nonintent" for the patient with chronic pain to return to work after treatment at a pain facility.

OBJECTIVE: We previously determined that "intent" to return to work post pain facility treatment is the strongest predictor for actual return to work. The purposes of the present study were the following: to identify variables predicting "intent"; to predict membership in the "discrepant with intent" group [those chronic pain patients (CPPs) who do intend to return to work but do not]; and to predict membership in the "discrepant with nonintent" group (those CPPs who do not intend to return to work but do). DESIGN: A total of 128 CPPs completed a series of rating scales and yes/no questions relating to their preinjury job perceptions and a question relating to "intent" to return to the same type of preinjury job post-pain facility treatment. These CPPs were part of a grant study for prediction of return to work, and therefore their work status was determined at 1, 3, 6, 12, 18, 24, and 30 months posttreatment. Preinjury job perceptions and other demographic variables were utilized using stepwise discriminant analysis to identify variables predicting "intent" and predicting membership in the "discrepant with intent" and "discrepant with nonintent" groups. SETTING: Pain facility (multidisciplinary pain center). PATIENTS: Consecutive low back pain CPPs, mean age 41.66+/-9.54 years, with the most frequent highest educational status being high school completion (54.7%) and 60.2% being worker compensation CPPs. RESULTS: "Intent" was predicted by (in decreasing order of probability) postinjury job availability variables, job characteristic variables, and a litigation variable. "Discrepant with intent" was predicted by (in decreasing order of probability) for the 1-month follow-up time point, postinjury job availability variables, pain variables, a litigation variable, and a function perception variable, and for the final follow-up time point, pain variables only. "Discrepant with nonintent" was predicted by (in order of decreasing probability) for the 1-month follow-up time point, a job availability variable, a demographic variable, and a functional perception variable, and for the final follow-up time point a pain variable and a job availability variable. The percentage of CPPs correctly classified by each of these analyses was as follows: "intent" 81.25%, "discrepant with intent" 87.01% (at 1-month follow-up) and 74.03% (final follow-up), "discrepant with nonintent" 92.16% (at 1-month follow-up) and 75.00% (final follow-up). CONCLUSIONS: CPPs intentions of returning to their preinjury jobs are mainly determined by job availability and job characteristic variables but surprisingly not by pain variables. However, the results with "discrepant with intent" and "discrepant with nonintent" groups indicate that actual return to work is determined by an interaction between job availability variables and pain variables with pain variables predominating for long-term outcome.

Adult↗

PubMed2005

Maternal anthropometry and pregnancy outcomes: a proposal for the monitoring of pregnancy weight gain in outpatient clinics in South Africa.

The aim of this review was to develop a framework for the monitoring of pregnancy weight gain in South African outpatient clinics. Studies showed that intrauterine malnutrition have more serious consequences for children than postnatal malnutrition. Undernutrition, as well as overnutrition during pregnancy, was associated with adverse pregnancy outcomes. The IOM published recommended weight gains by pre-pregnancy body mass index (BMI). Wasting in pregnant women can be defined as a mid-upperarm circumference (MUAC) < 22cm. Low prepregnancy BMI is considered a risk factor for preterm birth and intra-uterine growth retardation. Pregnant women in developing countries start to attend antenatal clinics late in pregnancy, so that prepregnancy BMI may be unknown and antenatal care can be based on pregnancy weight gain only. A framework is proposed that identifies the critical points for action during pregnancy to improve birth outcomes. Health care providers should measure height, weight and MUAC and try to classify pregnant women according to weight status, set weight gain goals and monitor gestational weight gain between follow-up visits. Women with short stature (< 145cm), low body weight (< 45kg), and/or MUAC < 22cm are considered to be at risk of adverse pregnancy outcomes. Weekly weight gains should range from 0.3kg for overweight women to 0.5kg or more for underweight women from the second trimester. Genetic background, age, general health, HIV and educational status, cigarette smoking, past nutritional status of the mother, parity, multiple pregnancies, climate, socioeconomic conditions and the availability of health services should be adjusted for in statistical analyses.

Anthropometry↗

PubMed2005

Improving attitude towards elderly people: Evaluation of an intervention programme for caregivers.

There is yet no specific Government policy on care of the elderly in Nigeria despite increase in its awareness as well as the number of people reaching old age. This study was carried out to assess the attitude of caregivers in seven out of the eleven wards in Ilorin metropolis. The caregivers consisted of daughters (44.4%), sons (18.3%), family-relation (24.6%), employees (1.4%), neighbors (4.5%) and community members (6.8%). The data collection toll was a structured questionnaire consisting of three parts designed to determine the socio-demographic characteristics, general and specific attitude to the care of the elderly. Effect of Health Education on attitude of caregivers concerning the care of the elderly was also evaluated. Based on the scoring system, the attitude of the caregivers was found to be fairly positive and after the Health Education intervention, a significant improvement in the attitude of caregivers was recorded. The Mean (SD) score increased significantly from 78.4 +/- (14.6) pre-intervention to 96.8 +/-(15.2), post-intervention, p-value < 0.05. Religious teaching (35.9%), traditional/customary obligation (28.7%) and personal feeling (21.1%) were the most influencing factors of attitude of caregivers towards the care of the elderly. The influence of educational status of caregivers on where the elderly should be taken care of was found to be non statistically significant (p > 0.05). Gender had overall positive effect on attitudinal measurement. The deduction from this study is that care of the elderly is still being valued despite lack of specific government policy and support. The negative attitude of caregivers to institutional care may be difficult to change through health education intervention because care of the elderly at home is still being greatly valued in this country as it is seen as a responsibility of children and other family members. Institutional care is also considered as an abomination and irresponsibility by some caregivers Keywords: attitude, caregivers, elderly, intervention and health education.

Adult↗

PubMed2006

Socioeconomic differentials in nutritional status of children in the states of West Bengal and Assam, India.

Malnutrition among children is prevalent in almost all the states in India. This study assesses the extent and causes of malnutrition in two eastern Indian states with similar climates, namely West Bengal and Assam, using data from the National Family Health Survey 1998-99 (NFHS-2). The three indices of malnutrition taken for analysis are weight-for-height (WHZ), height-for-age (HAZ) and weight-for-age (WAZ). These are assumed to depend on birth order, preceding birth interval, parent's educational status, working status of the mother, mother's age at delivery of the children, source of drinking water, toilet facilities and standard of living of the household. Logistic regression was carried out separately for each of the three indices on the explanatory variables for both the states. It was found that not all variables are equally important in determining whether a baby is underweight, or suffering from acute or chronic malnutrition. Also, the importance of variables is not the same in the two states. It was observed that the coefficients associated with the variables in determining weight-for-height are not significant compared with those for weight-for-age and height-for-age.

Adolescent↗

PubMedDate not supplied

Personality as a mediator of demographic risk factors for suicide attempts in a community sample.

The aim of this study was to determine whether personality might partially explain associations between sociodemographic factors and self-reported suicide attempts. This analysis was motivated by reports that certain personality traits are logical targets for intervention, whereas sociodemographic characteristics are not generally modifiable. Data were from a postal survey sent to community residents who were previously selected at random (N = 912). Age, gender, health-insurance status, education, self-reported health, and marital history were identified as relevant sociodemographic predictors of having made one or more lifetime suicide attempts. Risk associated with each of these variables was mediated by the personality traits of self-directedness (SD) and harm avoidance (HA). In a multiple logistic-regression analysis constrained to sociodemographic predictors, only young age, female sex, poor self-reported health, and Medicaid status remained as predictors of suicide attempts. When personality factors were added to the model, all of the sociodemographic predictors except Medicaid status were rendered nonsignificant or marginally significant. Risk associated with gender was primarily related to HA, risk associated with poor self-reported health was mediated by both HA and SD, and the risk associated with young age was primarily mediated by SD; the last was the largest mediation effect observed. In contrast, risk associated with receipt of Medicaid, presumed to indicate low socioeconomic status, was not mediated by personality. We conclude that risk associated with certain nonmodifiable demographic factors is often mediated by potentially modifiable intrapersonal factors, such as SD.

Adolescent↗

PubMedDate not supplied

The rating form of IBD patient concerns: a new measure of health status.

Health status assessment for persons with chronic illness includes not only symptoms, but also an appraisal of the psychosocial concomitants of illness. In this national study of persons with inflammatory bowel disease (IBD), we standardized a disease-specific 25-item measure of perceived health status: the Rating Form of IBD Patient Concerns (RFIPC). Factor analysis yielded four indices: a) impact of disease (e.g., being a burden, loss of energy, loss of bowel control); b) sexual intimacy; c) complications of disease (e.g., developing cancer, having surgery, dying early); and d) body stigma (e.g., feeling dirty or smelly). A higher level of IBD concerns was associated with greater disease severity, female gender, and lower educational status. When controlling for these factors, as well as disease type and age, we found that concerns about: a) impact of disease was positively associated with poorer perception of health and well-being, greater psychological distress (SCL-90), and poorer daily function (Sickness Impact Profile) (p less than 0.0001); b) sexual intimacy was related to poorer psychologic function (p less than 0.01); and c) complications of disease was related to several measures of poorer daily function (p less than 0.0001 to 0.01). This standardized measure of the worries and concerns of persons with IBD may be used in clinical care and research to evaluate the effects of interventions on IBD patient outcomes.

Activities of Daily Living↗

PubMed2006

Relationship between household wealth inequality and chronic childhood under-nutrition in Bangladesh.

BACKGROUND: Household food insecurity and under-nutrition remain critically important in developing countries struggling to emerge from the scourge of poverty, where historically, improvements in economic conditions have benefited only certain privileged groups, causing growing inequality in health and healthcare among the population. METHODS: Utilizing information from 5,977 children aged 0-59 months included in the 2004 Bangladesh Demographic and Health Survey , this study examined the relationship between household wealth inequality and chronic childhood under-nutrition. A child is defined as being chronically undernourished or whose growth rate is adversely stunted, if his or her z-score of height-for-age is more than two standard deviations below the median of international reference. Household wealth status is measured by an established index based on household ownership of durable assets. This study utilized multivariate logistic regressions to estimate the effect of household wealth status on adverse childhood growth rate. RESULTS: The results indicate that children in the poorest 20% of households are more than three time as likely to suffer from adverse growth rate stunting as children from the wealthiest 20% of households (OR=3.6; 95% CI: 3.0, 4.3). The effect of household wealth status remain significantly large when the analysis was adjusted for a child's multiple birth status, age, gender, antenatal care, delivery assistance, birth order, and duration that the child was breastfed; mother's age at childbirth, nutritional status, education; household access to safe drinking water, arsenic in drinking water, access to a hygienic toilet facility, cooking fuel cleanliness, residence, and geographic location (OR=2.4; 95% CI: 1.8, 3.2). CONCLUSION: This study concludes that household wealth inequality is strongly associated with childhood adverse growth rate stunting. Reducing poverty and making services more available and accessible to the poor are essential to improving overall childhood health and nutritional status in Bangladesh.

Journal Article↗

PubMed1995

Pediatric office-based smoking intervention: impact on maternal smoking and relapse.

OBJECTIVE: To determine the impact of a brief smoking intervention delivered by pediatricians in the context of usual well baby office visits on postnatal maternal smoking and relapse. SETTING: Forty-nine private pediatric practices including 128 practitioners. DESIGN: Randomization of pediatric practices into minimal and extended intervention sites with all enrolled mothers of newborns within a practice receiving the same level of intervention. INTERVENTION: Smoking mothers in minimal condition received a hospital packet containing written information about passive smoking and a letter advising them to quit. Those in extended condition received the hospital packet plus oral and written advice at usual well baby visits: 2 weeks, 2, 4, and 6 months. MEASUREMENTS: Smoking and relapse rates at 6 months postpartum, demographics associated with smoking status, attitudes, and knowledge in regard to passive smoking, and recall surveys of mothers in regard to receiving advice or written materials. RESULTS: Two-thousand nine-hundred-one mothers of newborns were enrolled in the study. Those in the extended condition had higher quit rates (5.9% vs 2.7%, P < .01) and lower relapse rates (45% vs 55%, P < .01) than those in the minimal condition. Mothers' educational status and the presence of a smoking partner in the home were the major demographic variables associated with smoking status at enrollment and at follow-up. Compared with smokers in the minimal condition, those in extended at 6 months postpartum had significantly better attitudes and knowledge regarding passive smoking and allowed less smoking in the home. Mothers attending extended practices reported much higher rates of receiving oral advice and written materials than those in the minimal condition. CONCLUSIONS: A brief program can lead to major increases in the willingness of pediatricians to deliver smoking advice. A 1- to 2-minute intervention delivered in the context of usual well baby care can have a positive impact on maternal smoking and especially upon relapse prevention. A recent smoking history should be obtained from all mothers of newborns so that interventions can be aimed at both cessation and relapse prevention.

Female↗

PubMed1997

Long-term illness among indigenous and foreign-born people in Sweden.

This study shows the influence on self-reported health of ethnicity, operationalised as Swedes and foreign-born people from Finland, Western countries (Western Europe-except for Finland and South Europe-the United States, Canada, Australia, New Zealand and Japan), South Europe and all other countries (East Europe and non-European, non-Western countries). A simple random sample of 23.864 Swedes and foreign-born people were interviewed in 1980-1981 and 1988-1989 by Statistics Sweden. In successive models starting with only ethnicity and age, one variable at a time was included in the two main models, one with material and economic factors and another with lifestyle factors as independent variables, in order to study how the importance of ethnicity changed. The age-adjusted relations between male and female Finns and severe long-term illness were reduced from an odds ratio of 2.37 and 1.86, respectively, to 1.90 and 1.70 after including educational status, marital status, exercise, smoking, and body mass index in the final model. The high odds ratios for males and females born in South Europe or born in non-Western countries decreased with the inclusion of lifestyle factors but were still high 2.26 and 2.50 in South Europeans and 1.94 and 1.81 in non-Westerners. Males and females born in Finland, South Europe or in non-Western countries had high odds ratios for severe long-term illness when education, material standard, economic resources, leisure opportunities and social network were simultaneously controlled for. People born in Western countries showed no association to limiting long-term illness. The conclusion of the present study is that ethnicity, defined as foreign-born people, was strongly associated with limiting long-term illness when controlling for social, material and lifestyle factors.

Adolescent↗

PubMed1985

Demographic and educational characteristics of inner city middle school problem absence students.

Results of a study of characteristics of middle school students revealed highly significant differences between problem absence students and non-problem absence students on all study variables except sex. Characteristics such as increasing grade, being behind appropriate grade, busing and special education status, and the particular school attended were highly correlated with this behavior, as were race and increasing age.

Absenteeism↗

PubMed2006

Prevalence of diabetes and cardiovascular comorbidity in the Canadian Community Health Survey 2002-2003.

Diabetes mellitus is a major risk factor for heart disease (heart attack, angina, and heart failure), stroke, and hypertension, which shorten the average life expectancy. The main objective of this study was to describe the prevalence of heart disease, hypertension, and stroke among Canadians with diabetes compared to those without diabetes in the Canadian general population aged 12 years and over. It also estimated the strength of association between diabetes, heart disease, hypertension, and other factors such as age, gender, cigarette smoking, alcohol drinking, education status, body mass index (BMI), and other socioeconomic factors. Descriptive statistics were used initially to estimate the prevalence of related comorbidities by age and gender. Logistic regression was then employed to determine the potential strength of association between various effects. Data included 127,610 individuals who participated in the 2.1 cycles of the Canadian Community Health Survey (CCHS) in 2002-2003. The prevalence of self-reported hypertension, heart disease, and stroke among individuals with diabetes were 51.9, 21.7, and 4.8%, respectively. By comparison, prevalence among those without diabetes was 12.7, 4.2, and 0.9%. Adjusted Odds Ratios (OR) were 4.15, 5.04, and 6.75 for males', and 4.10, 5.29, and 4.56 for females' hypertension, heart disease, and stroke, respectively. Lower income (OR from 1.27-1.94) and lower education (OR from 1.23-1.86) were independently associated with a high prevalence of hypertension, heart disease, and stroke among diabetics. Alcohol consumption (OR from 1.06-1.38), high BMI (OR from 1.17-1.40), physical inactivity (OR from 1.21-2.45), ethnicity, and immigration status were also strongly associated with hypertension, heart disease, and stroke. The adjusted prevalence of hypertension, heart disease, and stroke in the CCHS-2003 health survey in Canada was significantly higher among those with diabetes compared to those without. Other factors such as age, gender, BMI, lifestyle, family incomes, physical activity levels, and socioeconomic status also affected the strength of association between diabetes and resulting comorbidities.

Adolescent↗

PubMed2001

Correlates of substance misuse in patients with first-episode schizophrenia and schizoaffective disorder.

OBJECTIVE: To identify factors associated with substance misuse in first-episode patients with schizophrenia or schizoaffective disorder. METHOD: Twenty-seven patients with a past or current history of substance misuse were compared with 91 patients with no history of misuse on demographic and psychopathological measures before being treated for their first episode of psychosis, and on cognitive measures after 6 months of treatment. RESULTS: There were no statistically significant differences between groups for sex, schizophrenia subtype, marital status, education, family history of schizophrenia, course of illness, age of onset, baseline symptoms, time to treatment response, medication side effects, attention span, memory and executive functioning. However, dual diagnosis patients were found to have a higher parental social class, better premorbid cognitive functioning, higher IQ and better language skills. CONCLUSION: First-episode patients with a history of substance misuse have higher intellectual functioning, which may be associated with higher premorbid socioeconomic status and cognitive functioning.

Adolescent↗

PubMed1996

Patients with traumatic brain injury referred to a rehabilitation and re-employment programme: social and professional outcome for 508 Finnish patients 5 or more years after injury.

We studied influence of age and educational level before injury on the social and vocational outcome among a group of traumatic brain injury (TBI) patients with post-injury problems in their education and employment. Patients with TBI, followed up for at least 5 years, and who were admitted to a rehabilitation and re-employment programme, were selected for evaluation of long-term outcome. We used the Glasgow Coma Scale (GCS) scores at the time of emergency admission to the hospital to measure brain injury severity. Age at the time of TBI and educational status before TBI were correlated with the outcome measures at the end of follow-up separately in each category of brain injury severity. The study was carried out at the Kauniala outpatient neurological clinic, which specializes in brain injuries in Finland; it works closely with the Departments of Neurology and Neurosurgery at the Helsinki University Central Hospital. Main outcome measures were functional outcome measured by the Glasgow Outcome Scale (GOS), the educational level reached, and post-injury occupation, as well as the incapacity for work at the end of follow-up. In the severe category of brain injuries, children 7 years or younger at the time of injury suffered severe disability as measured by the GOS scores more often than did the older age groups (p = 0.010, chi 2). They were less often capable of independent employment (p = 0.011, chi 2) than the children injured at the age of 8-16. Patients with a higher education usually had a better outcome. In the category of mild brain injuries the majority of the patients, regardless of age, recovered well according to the GOS, and were capable of independent employment at the end of follow-up. Our patients were selected from the TBI population as survivors with problems in education and re-employment. Those with severe injury sustained early in life (childhood and early teens) coupled with poor educational attainment had relatively worse social and vocational outcome; better outcomes were enjoyed by those severely injured individuals whose injuries were sustained later (late teens or early adulthood). In the groups of patients with moderate and mild brain injuries such a relationship was not found between age or pre-injury education and outcome.

Adolescent↗

PubMed1996

Determinants of compliance with antiretroviral therapy in patients with human immunodeficiency virus: prospective assessment with implications for enhancing compliance.

Non-compliance with therapy is a significant problem, particularly when the disease process is chronic and therapeutic regimens are employed for prolonged periods. We assessed the prevalence and variables associated with compliance with antiretroviral therapy in patients with human immunodeficiency virus infection, by means of a longitudinal observational study of 46 patients aged 23 to 68 years, with human immunodeficiency virus infection, followed at the Pittsburgh VA Medical Center. Data on demographics, medical status, physical functioning (Karnofsky performance scores), CD4 lymphocyte count, depression (Beck depression inventory), coping (inventory of coping with illness scale scores), and psychological and emotional stress (profile of mood states scale scores), were prospectively assessed on all patients at baseline and every 6 months. Compliance was assessed at 6 and 12 months: patients taking > or = 80% of antiretroviral therapy were considered compliant. Overall, 63% of patients were compliant with antiretroviral therapy. Age, education, employment, religious support, and perceived quality of life did not correlate with compliance. By univariate analysis, lack of prior intravenous drug use was significantly associated with compliance (p = 0.01). Compliant patients had significantly better adaptive coping (p = 0.03), and less depression (p = 0.04). By multivariate analysis, black race was significantly associated with non-compliance independent of intravenous drug use and educational status. History of prior opportunistic infection (which presumably heightens the perceived severity of illness) (p = 0.02), and lesser psychological disturbance scores (p = 0.02) were associated with compliance. Compliance was observed despite the greater number of prescription medications taken by compliant patients (p = 0.04). At 12 months, Karnofsky scores were better in compliant patients (p = 0.02), although mortality was not different. Besides identifying predictors of compliance, our data suggest that symptoms of depression and psychological stress be sought in patients with non-adherence.

Activities of Daily Living↗

PubMed1999

Neighborhood environment and self-reported health status: a multilevel analysis.

OBJECTIVES: This study examined whether neighborhood socioeconomic environment helps to explain the proportion of community members with self-reported poor health status. METHODS: A random sample of 9240 persons aged 25 to 74 years were interviewed during 1988 and 1989. The socioeconomic environment of each respondent's neighborhood was measured with the Care Need Index (CNI) and the Townsend score. The data were analyzed with a multilevel model adjusted for the independent variables. The second-level variables were the 2 neighborhood scores. RESULTS: There was a clear gradient for poor health and education within every CNI interval so that with an increasing CNI (indicating more deprivation), the prevalence of poor health increased in all 3 education groups (P = .001). In the full model, decreasing educational level, obesity, length and frequency of smoking, physical inactivity, and increasing CNI were associated with poor health. Persons living in the most deprived neighborhoods had a prevalence ratio of 1.69 (95% confidence interval = 1.44, 1.98) for poor health compared with those living in the most affluent areas. CONCLUSIONS: Both neighborhood socioeconomic environment and individual educational status are associated with self-reported poor health.

Adult↗