Studies with Secondary Data in Taiwan
Application in Life Course Epidemiology
Chung-Yi Li, Ph.D.
Professor
Department and Graduate Institute of Public Health
College of Medicine, National Cheng Kung University
Outlines
• Background: Life-course perspectives
• Some Examples
• Perspectives on life course epidemiological
studies in Taiwan
2
Background:
Life-course perspectives
3
(a): biological pathway
(b): social pathway
(c): socio-biological
(d): bio-social
Life Course Approach to Health
• Emphasizes a temporal and social
perspective
– looking back across an individual’s or a
cohort’s life experiences or across
generations for clues to current patterns of
health and disease
– recognizing that both past and present
experiences are shaped by the wider social,
economic and cultural context.
5
Life Course Approach (I)
• The “fetal origins hypothesis” (programming) which
links conditions in the intrauterine environment to the
later development of adult chronic disease (Barker,
1998).
– Critical periods of growth and development
– Sensitive developmental stages when social and cognitive
skills, habits, coping strategies, attitudes and values are more
easily acquired than at later ages.
– Biological and social experiences may act interactively, to
attenuate or exacerbate long term risks to health
6
Life Course Approach (II)
• Cumulative effects on later health may occur
not only across an individual’s life but also
across generations (Lumey 1998; Davey Smith
2000).
8
Three Models (hypotheses)
• Critical period
– Barker’s “Fetal Programming Theory”
– Sensitivity period
• Accumulation of risk
– Exposures or insults gradually accumulate to increase the
risk of chronic disease and mortality
• Social mobility
– Downward or upward inter-generational or intragenerational mobility
9
Key Concepts
• Health and risk of premature death are
determined by socioeconomic factors acting
throughout life
• Socioeconomic influences on particular causes
of death may have different critical times
10
Model Paper
Disentangle “accumulation”, “critical
point”, “social mobility”
11
12
Trajectory of Exposure
13
Trajectory in Detail
14
Effect of “risk accumulation”
15
Effect of “critical period”
16
Effect of “social mobility”
17
NSHD
• It began with interviews of more than 13,000
mothers who had given birth in the United
Kingdom during one week of March 1946.
NCDS
• Attempts to trace 17,000 members of the 1958
birth cohort to get information concerning their
physical, educational and social development.
• During the period 2002-2004, genetic information
on participants was also obtained to examine the
genetic effects on common traits and diseases.
19
BCS70
•Monitoring the development of 17,000 babies
born in the UK in one particular week in
April 1970
MCS
•Following the lives of 19,000 babies born in
the year 2000–2001.
•Collecting information on child development,
social stratification and family life in order to
identify possible advantages and disadvantages
that the children are facing.
20
Some Examples
21
Two Articles
on
Assessment of Risk Accumulation
22
23
LBW
Lower family SES
Lower learning
achievement
24
Study Design: A Cohort Study
• Between September 1, 1985 and August 31,
1989, a total of 1 623 038 live births were
registered in the Taiwan Birth Registry (TBR).
– TLBW: >=37 GW and BW <2500 g; N=37,925
– PNBW: <37 GW and BW >=2500 g; N=22,080
– PLBW: <37 GW and BW <2500 g; N= 30,594
– Reference group: A random sample of TNBW
births; N= 90,599
25
Outcome Measures
• Four study groups were linked to the first-time
BCT test scores of 3 different disciplines.
• The rate of successful linkage was
– TLBW:
– PNBW:
– PLBW: 84.5% (lowest)
– Reference group: 92.5% (highest)
26
27
28
LBW
No apparent risk accumulation risk was found
for two risk factors for lower learning
achievement of Taiwanese adolescents
Lower family SES
Lower learning
achievement
29
30
Study design
• Study cohort
– 312,335 live singletons registered in the Taiwan
Birth Registry between Sep. 1st 1989 and Aug. 31st
1990. 42.9% are first births
• Linkage to 2005 BCT score dataset
– Successful linkage rate was the highest (92.3%) and
lowest (88.3%) for the second and the >=fifth births,
respectively
31
32
33
34
35
Higher birth
order
A risk compromise was found for the
two risk factors for lower learning
achievement of Taiwanese adolescents
Lower family SES
Lower learning
achievement
36
Two Papers
on
Assessment of Critical Periods
37
Deliver a LBW infant
LBW at birth
for mothers
Consequences of
mal-adaptation
to pregnancy
cigarette smoking and
hypertension
Barker’s fetal origins hypothesis
CVD
The LBW-Cardiovascular Disease Model
38
Deliver a LBW infant
CVD
The LBW-Cardiovascular Disease Model
39
40
Study Design
• Retrospective cohort study (nearly 30 years)
• Study cohorts
– 1,400,383 singletons from primigravida were
registered in TBR, 1978-1987
– 85,285 mothers delivered LBW infants
– 1,315,098 gave birth to NBW infants
• Study cohorts were linked to mortality registry
(up to 2007)
41
42
43
Deliver a LBW infant
Consequences of
mal-adaptation to
pregnancy ???
cigarette smoking and
hypertension ???
CVD
44
45
46
47
Study Cohort & Nested Case-control Design
All 5,654,833 live births
registered in Taiwan between
1978 and 1993, followed to the
end of 2008
3,984 suicides
aged 15-30
during 1993–
2008
For each case, 30
controls with the same
sex and birth year, who
were alive at the date of
suicide were selected
A total of
119,520
controls
48
49
50
Incomplete Consideration of Potential
Confounders
Live Birth
Registry
•Perinatal risk
factors
•
•
•
•
NHI Data
Death Registry
•Psychological
disease
•Major
illnesses
•Causes of
death
Psychological comorbidity prior to suicide
Major illnesses
Familial clustering of psychological illness
Behaviors disorders
51
Some Other Examples
52
53
Perspectives on life course
epidemiological studies in Taiwan
54
Population-based Health Data in Taiwan
Inf. Dis.
registry
Vaccination
registry
Birth
registry
National
Health
Insurance
claims data
Catatrophic
illnesses
registry
Cancer
registry
Cause of
death
55
Life Course Approach
Since 1978/1994
Since 1979
Since 1996
Since 1982
56
衛生署健康資料加值應用協作中心成大分中心
The Collaboration Center of Health Information
Application(CCHIA) at NCKU
一般民眾
學術研究人員
為讓民眾瞭解健康
新知、提供即時及
正確就醫資訊(就
醫地、就醫科別、
醫院及醫師服務品
質等資訊）、疾病
及健康管理……，
進入網站
為提供全球學術研
究人員對醫藥衛生
研究領域之卓越成
果的初探，成大團
隊提供台灣學者過
去十幾年採全人口
之全民健康保
險……，進入網站
成大團隊使命
醫藥產業人員
為促進醫療及衛生
工作者即時準確的
獲得醫學知識的及
擬定衛生政策，成
大團隊提供臨床、
公衛、藥學、醫管
等專業領域知
識……，進入網站
提供正確(求真)、可信(求
善)、可用(求美)的醫藥衛
生知識及數據分析，讓實
務工作者獲得實證資訊後，
採取具體行動。成大團隊
擁有不同醫療專科(風濕免
疫科、腎臟科、腫瘤科、
精神科、小兒科、家醫科、
外科、感染科)的醫師及學
術領域(醫學、公衛、環衛、
醫管、統計、資訊)的老師，
以及不同性質的全人口資
料…… ，進入網站
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互動論壇
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病例對照研究
台灣「全民健康保險學術研究資料庫」大型追蹤-證明抗病毒藥物可有效降低B型肝炎相關肝癌復發率
及死亡率刊登世界頂尖的「美國醫學會雜誌(JAMA)」
成果深具臨床意義
為一種流行病學研究設計，
即選擇有某疾病的病人群
與一群類似但未罹患該疾
病的人，然後研究者回溯
確定兩組暴露的頻率，可
估計所要研究特徵對疾病
的相對危險性。
58
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網站更新日期：2013-01-23
59
Hypothesis
Parental mental
illnesses
1. Adverse
birth outcome
2. Inadequate
care &
attention
1. Natural
causes of death
in childhood
2. Unnatural
causes of death
60
5-Year Follow-up, Up to 2008
61