Research Papers In Public Health

Public Health is an international, multidisciplinary peer-reviewed journal. It publishes original papers, reviews and short reports on all aspects of the science, philosophy, and practice of public health.

It is aimed at all public health practitioners and researchers and those who manage and deliver public health services and systems. It will also be of interest to anyone involved in provision of public health programmes, the care of populations or communities and those who contribute to public health systems in any way.

Published twelve times a year, Public Health considers submissions on any aspect of public health across age groups and settings.

These include:
Public health practice and impact
Applied Epidemiology
• Need or impact assessments
Health service effectiveness, management and re-design
Health Protection including control of communicable diseases
Health promotion and disease prevention
• Evaluation of public health programmes or interventions
• Public health governance, audit and quality
• Public health law and ethics
• Public health policy and comparisons
• Capacity in public health systems and workforce

This is not an exhaustive list and the Editors will consider articles on any issue relating to public health.

Public Health also publishes invited articles, reviews and supplements from leading experts on topical issues.

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E. A. Richardson | J. Pearce | R. Mitchell | S. Kingham

Objectives: Local availability of green space has been associated with a wide range of health benefits. Possible causative mechanisms underpinning the green space and health relationship include the provision of physical activity opportunities, the stress-relieving effects of nature and the facilitation of social contacts. This study sought to investigate whether urban green space was related to individual-level health outcomes, and whether levels of physical activity were likely to be a mediating factor in any relationships found. Study design: Cross-sectional analysis of anonymized individual health survey responses. Methods: Neighbourhood-level green space availability was linked to 8157 respondents to the New Zealand Health Survey 2006/07 on the basis of their place of residence. Adjusted multilevel models were constructed for four health outcomes which are plausibly related to green space via physical activity: cardiovascular disease; overweight; poor general health; and poor mental health (Short Form 36). Results: The greenest neighbourhoods had the lowest risks of poor mental health [odds ratio (OR) 0.81, 95% confidence interval (CI) 0.66-1.00]. Cardiovascular disease risk was reduced in all neighbourhoods with > 15% green space availability (e.g. OR 0.80, 95% CI 0.64-0.99 for those with 33-70% green space), However, a dose-response relationship was not found. Green space availability was not related to overweight or poor general health. Overall, levels of physical activity were higher in greener neighbourhoods, but adjustment for this only slightly attenuated the green space and health relationships. Conclusions: Neighbourhood green space was related to better cardiovascular and mental health in a New Zealand Health Survey, independent of individual risk factors. Although physical activity was higher in greener neighbourhoods, it did not fully explain the green space and health relationship. © 2013 The Royal Society for Public Health.

B. C. Guinhouya | H. Samouda | C. De Beaufort

This study explored the proportion of European youth who are sufficiently active according to physical activity (PA) recommendations , based exclusively on objective assessment through accelerometers. A systematic electronic search of studies published up to March 2012 was conducted. PubMed was used to identify accelerometry-assessed PA studies that involved European youth. Within the 131 European studies, only 35 clearly reported the proportion of youth meeting the PA recommendations. Different thresholds lying between 1000 and 4000 counts/min (cpm) were used to define moderate-to-vigorous PA (MVPA). Overall, up to 100% of youth may be sufficiently active when using a threshold of approximately > 1000-1500 cpm. With the most cited cut-off point (i.e. > 2000 cpm), up to 87% of European youth might be considered physically active with reference to the current recommendations. Alternatively, with a cut-off point > 3000 cpm, no more than 3-5% of them appeared to achieve these recommendations. The large discrepancy in outcomes released by accelerometer data is mainly due to the variety of cut-off points for MVPA among youth, hindering the definition of a clear goal towards PA promotion in Europe. Standardization of methods is urgently required. © 2013 The Royal Society for Public Health.

D. Nutsford | A. L. Pearson | S. Kingham

Objectives: This study aims to find whether proximity to urban green spaces is associated with human mental health. Study design: A cross-sectional examination of the relationship between access to urban green spaces and counts of anxiety/mood disorder treatments amongst residents (aged 15 years and over) in Auckland City, New Zealand. Methods: Anxiety/mood disorder treatment counts by three age groups were aggregated to 3149 small area units in Auckland. Six measures of green space access were derived using GIS techniques involving total green spaces and useable green spaces. Negative binomial regression models have been fitted to test the relationship between access to green space and area-level anxiety/mood disorder treatment counts, adjusted for age and area-level deprivation. Results: Anxiety/mood disorder treatment counts were associated with three green space measures. The proportion of both total and useable green space within 3km and distance to nearest useable green space all indicated a protective effect of increased access to green space against anxiety/mood disorder treatment counts. Access to total and useable green space within 300m did not exhibit significant associations. Conclusion: This study found that decreased distance to useable green space and increased proportion of green space within the larger neighbourhood were associated with decreased anxiety/mood disorder treatment counts in an urban environment. This suggests the benefits of green space on mental health may relate both to active participation in useable green spaces near to the home and observable green space in the neighbourhood environment. © 2013 The Royal Society for Public Health.

S. B. Rasheed | R. K. Butlin | M. Boots

The presence of dengue virus has been detected using neutralization and haemagglutination inhibition antibodies in local populations in Pakistan since the 1960s. However, the first epidemic was not reported until 1994. This was followed by some cases in 1995, but the disease was confined to the port city of Karachi. Since 2006, dengue epidemics have occurred every year and the range has extended to most cities in Pakistan. Dengue now affects thousands of people and has caused hundreds of deaths. It has become a major health problem in Pakistan, and it is likely to become an even greater health problem in the coming years. This review gives an insight into the dengue situation from the early 1960s to the most recent epidemics in Pakistan, and also describes the primary vector of this disease (Aedes aegypti) in Pakistan. As such, it provides the first comprehensive review of the emergence of this important public health problem. © 2012 The Royal Institute of Public Health.

P. Kun | X. Tong | Y. Liu | X. Pei | H. Luo

Objective: To estimate the prevalence of post-traumatic stress disorder (PTSD) and assess determinants related to PTSD symptoms among adult earthquake survivors after the 2008 Wenchuan earthquake in China. Study design: Cross-sectional multicluster sample surveys with data collected from four counties. Methods: Surveys were conducted separately in four counties in Sichuan Province, with a total of 2004 respondents. Beichuan County and Dujiangyan City were damaged more severely than Yaan County and Langzhong County during the earthquake. In total, 1890 households were represented, with a mean of 2.2 respondents per household. Data were collected using structured interviews, and the Harvard Trauma Questionnaire and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria were used to diagnose PTSD. Results: The prevalence rates of suspected PTSD were 47.3% (n=436) in heavily damaged areas and 10.4% (n=93) in moderately damaged areas. The prevalence rates of PTSD symptoms among elderly, middle aged and young adults were 55.8%, 50.2% and 28.6% (P=0.001), respectively, in heavily damaged areas. Older age, female gender, unmarried/divorced/widowed, ethnic minority, death of family member, no household income and damaged household were independent risk factors for PTSD symptoms in heavily damaged areas. Conclusion: Interventions designed to reduce PTSD among populations affected by the 2008 earthquake should focus on people without household incomes, those with damaged households and those who experienced the death of a family member. Effective, sustainable and culturally sensitive psychosocial interventions and mental health services are required, and attention should be directed to survivors who experienced the death of a family member, women and older adults following the devastating natural disaster. Governments should support income-generating activi ties and improve living conditions. Trained field personnel can assist with PTSD assessments and referrals, and existing rural healthcare services can be used to provide treatment for common psychiatric disorders. © 2013 The Royal Society for Public Health.

P. Virtanen | U. Janlert | A. Hammarström

Objectives: Earlier research on health-related selection into unemployment has been based on relatively severe health problems, leaves questions unanswered about particular problems, follow-up times have been short and the measurement of unemployment utilised has been crude. The present study explores the effects of suboptimal health on employment in the long term, with statistics that enable assessment of the occurrence and extent of unemployment. Study design: Employment status of a population cohort (n = 1083) was measured half-yearly from 18 to 42 years of age with four follow-up surveys. Methods: Health status at 30 years of age was assessed with nine indicators. Their associations with the occurrence of a period of unemployment during the subsequent 12 years were analysed with Cox proportional hazard models, and generalized linear models were applied in assessing their associations with prolonged unemployment. Results: Suboptimal self-rated health and suboptimal mood were the most robust predictors of both occurrence of unemployment {hazard rates 1.48 [95% confidence interval (CI) 1.13-1.94] and 1.59 (95% CI 1.19-2.12), respectively} and prolonged unemployment [risk ratios 1.95 (95% CI 1.66-2.29) and 1.44 (95% CI 1.24-1.67), respectively] . Significant associations, particularly with prolonged unemployment, were also seen for musculoskeletal pain, suboptimal sense functions and sleep quality, and smoking and risky alcohol intake. Conclusions: There is health-related selection into unemployment in early middle age, irrespective of unemployment earlier in the life course. High risk ratios for prolonged unemployment suggest that selection takes place, in particular, at re-employment. The findings indicate the need for policies to prevent those with a history of health problems being at a disadvantage in terms of future employment. © 2012 The Royal Society for Public Health.

M. J. Platt

Preterm birth is defined as birth before 37 completed weeks gestation, and it is estimated that each day, across the world over 41,000 infants are born before this gestational age. The risk of adverse consequences declines with increasing gestational age. While this paper focuses on the consequences of preterm birth, the adverse consequences for infants born at 38 and 39 weeks gestation are also of a higher risk than those for infants born at 40 weeks gestation, with the neonatal mortality risk increasing again in infants born beyond the 42nd week of gestation. © 2014 The Royal Society for Public Health.

A. Pringle | S. Zwolinsky | J. McKenna | A. Daly-Smith | S. Robertson | A. White

Objectives: To investigate the impact of a national programme of men's health delivered in/by English Premier League (EPL) football clubs on health profiles. Study design: Health promotion interventions were delivered to male supporters with heightened health risks, and hard-to-engage men who were not using primary care and health information services. Interventions included educational activities on match days and weekly lifestyle classes at the football stadia/training venues. Activities were led by the health trainers in 16 EPL football clubs. Methods: Pre- and post-intervention, men completed validated self-report measures for demographics and health behaviours. Intention-to-treat (ITT) analysis was performed alongside a standard per-protocol (PP) analysis based on pre- vs post-intervention differences over 3 months. Descriptive statistics were used to show demographics pre-intervention and changes in the health profiles of participants. Results: Predominantly, recruits were White British men aged 18-44 years. Most men (78%, 909/1159) did not see themselves as having health problems. Around 35% (364/1044) never consulted a general practitioner (GP), while 57% (591/1040) reported that they never used health advice services. In men providing pre-intervention responses, the proportions who failed to meet the recommendations for healthy behaviours were as follows: physical activity, 85% (1106/1301); sitting time, 68% (623/907); consumption of fruit/vegetables, 88% (948/1072); smoking, 33% (422/1262); alcohol consumption, 30% (203/679); and body mass index (BMI), 63.8% (570/893). ITT and PP analyses demonstrated the significant increases in weekly physical activity (P < 0.001) and daily consumption of fruit and vegetables (P < 0.001), and significant decreases in daily sitting time (P < 0.001), weekly alcohol consumption (P < 0.001) and BMI (P < 0.05). Conclusion: A national programme of men's health delivered in EPL football clubs reached men failing to meet health guidelines. Interventions engaged men who neither consulted a GP nor used health information services. Positive changes were found for an array of activity-related and other health behaviours on PP analysis and the more stringent evaluation con dition of ITT analysis. © 2012 The Royal Society for Public Health.

H. L. Lin | Q. Z. An | Q. Z. Wang | C. X. Liu

Objective: Inconsistent findings of association between supplemental folate consumption and pancreatic cancer risk have been observed in the literature. This study aims to summarize the relationship between folate intake and risk of pancreatic cancer. Study design: Pertinent studies published before November 2011 were identified by searching PubMed and Embase and by reviewing the reference lists of retrieved articles. The summary relative risks were estimated by the random effects model. A linear regression analysis of the natural logarithm of the relative risk (RR) was carried out to assess a possible dose-response relationship between folate intake and pancreatic cancer risk. Results: Ten studies on dietary and supplemental folate intake and pancreatic cancer (4 case-control and 6 cohort studies) were included in the meta-analysis. The pooled RRs of pancreatic cancer for the highest vs lowest categories of dietary folate intake and supplemental folate intake were 0.66 (95% CI: 0.49-0.88) and 1.08 (95% CI, 0.82-1.41), respectively. The dose-response meta-analysis indicated that a 100μg/day increment in dietary folate intake conferred a RR of 0.93 (95% CI: 0.90-0.97). These findings support the hypothesis that dietary folate may play a protective role in carcinogenesis of pancreatic cancer. © 2013 The Royal Society for Public Health.

D. A. Cohen | S. Lapham | K. R. Evenson | S. Williamson | D. Golinelli | P. Ward | A. Hillier | T. L. McKenzie

Objectives: To determine if neighbourhood socio-economic status (SES) is associated with park use and park-based physical activity. Study design: Cross-sectional study. Methods: The use and characteristics of 24 neighbourhood parks in Albuquerque, Chapel Hill/Durham, Columbus and Philadelphia were observed systematically in three seasons (spring, summer and autumn), with nearly 36,000 park users observed. Twelve parks were in high-poverty neighbourhoods and 12 parks were in low-poverty neighbourhoods. In total, 3559 park users and 3815 local residents were surveyed. Park incivilities were assessed and park administrators were interviewed about management practices. Results: The size and number of facilities in parks in high-poverty neighbourhoods were similar to those in parks in low-poverty neighbourhoods, but the former had more hours of programming. Neighbourhood poverty level, perception of safety and the presence of incivilities were not associated with the number of park users observed. However, programmed activities and the number of activity facilities were strongly correlated with park use and energy expended in the park. Conclusions: The finding that park programming is the most important correlate of park use and park-based physical activity suggests that there are considerable opportunities for facilitating physical activity among populations of both high- and low-poverty areas. © 2013 The Royal Society for Public Health.

N. Katsiki | S. K. Papadopoulou | A. I. Fachantidou | D. P. Mikhailidis

Smoking, both active and passive, is an established vascular risk factor. The present narrative review considers the effects of different forms of smoking (i.e. cannabis, cigar, pipe, smokeless tobacco and cigarette) on cardiovascular risk. Furthermore, the impact of smoking on several vascular risk factors [e.g. hypertension, diabetes mellitus (DM), dyslipidaemia and haemostasis] and on vascular diseases such as coronary heart disease (CHD), peripheral arterial disease (PAD), abdominal aortic aneurysms (AAA) and carotid arterial disease, is discussed. The adverse effects of all forms of smoking and the interactions between smoking and established vascular risk factors highlight the importance of smoking cessation in high-risk patients in terms of both primary and secondary vascular disease prevention. Healthcare providers should discourage people (especially the young) from becoming smokers, strongly encourage all vascular patients to stop smoking and support those who decide to quit by pharmaceutical and psychological interventions. In high-risk populations such as patients with CHD, DM and/or PAD, smoking cessation should always be a part of a multifactorial treatment to reduce vascular risk. © 2013 The Royal Society for Public Health.

S. K. Mistry | S. Puthussery

© 2014 The Royal Society for Public Health. Objective: To assess and synthesize the published evidence on risk factors of overweight and obesity in childhood and adolescence in South Asia. Study design: A systematically conducted narrative review. Methods: A systematic review was conducted of all primary studies published between January 1990 and June 2013 from India, Pakistan, Nepal, Bangladesh, Sri Lanka, Bhutan, and Maldives located through the following data bases: PubMed, PubMed central, EMBASE, MEDLINE, BioMed central, Directory of Open Access Journals (DOAJ) and electronic libraries of the authors' institutions. Data extraction and quality appraisal of included studies was done independently by two authors and findings were synthesized in a narrative manner as meta-analysis was found to be inappropriate due to heterogeneity of the included studies. Results: Eleven primary studies were included in the final review, all of which were conducted in school settings in India, Pakistan and Bangladesh. Prevalence of overweight and obesity showed wide variations in the included studies. The key individual risk factors with statistically significant associations to overweight and obesity included: lack of physical activities reported in six studies; prolonged TV watching/playing computer games reported in four studies; frequent consumption of fast food/junk food reported in four studies; and frequent consumption of calorie dense food items reported in two studies. Family level risk factors included higher socioeconomic status reported in four studies and family history of obesity reported in three studies. Conclusion: This review provides evidence of key contributors to the increasing burden of obesity and overweight among children and adolescents in South Asia, and demonstrates the nutritional transition that characterizes other developing countries and regions around the world. The findings have implications for policy, practice and the development of interventions at various levels to promote healthy eating and physical activity among children and adolescents in the region as well as more globally.

J. Xu | L. Ou

Objectives: To examine the extent social support mediates resilience and quality of life in Wenchuan earthquake survivors. Study design: Originals. Methods: Self-report psychological questionnaires, the standard Chinese 12-item Short Form (SF-12v2), the Resilience Scale for Adults (RSA), and the Social Support Rating Scale (SSRS) were used to interview a total of 2080 survivors from 19 counties in the 2008 Wenchuan Earthquake area. A regression analysis was conducted to evaluate the mediating effect of social support on quality of life. Results: Males and individuals with a higher level of education were found to have a better quality of life. The association between resilience and quality of life improved after social support was included, suggesting that at least a part of this association was mediated by the level of social support provided. Conclusions: This analysis highlighted that the level of resilience and quality of life after an earthquake was associated with the level of social support. This result has clear policy implications, and indicates that more focus needs to be placed on policies that aim for the provision of early mental health intervention and social support to improve the quality of life of earthquake survivors. © 2014 The Royal Society for Public Health.

C. Okoli | L. Greaves | V. Fagyas

Objective: To understand differences in the context of, and reasons for, smoking initiation among boys and girls. Study design: Sex- and gender-based analysis of published literature. Methods: A comprehensive search of the PUBMED database was conducted for studies (published in the English language) between January 1980 and October 2010 that assessed smoking initiation among children and adolescents (aged 8-19 years). Information on demographics and study design were extracted by two authors from each eligible article. A sex- and gender-based analysis was employed. Results: Of 40 publications initially obtained, studies in adult or college-age populations (n = 9) and studies that did not examine the specific context of smoking initiation (n = 19) were excluded. Thus, this review is based on 12 eligible studies. Eligible studies represented data from 10,831 children and adolescents in nine countries. In most studies, boys had a lower age of smoking initiation than girls, with the exception of two studies from Yemen and China. In some countries, girls reported obtaining and smoking their first cigarette from family members at home. In most studies, the school was the main setting for initiation for boys, whereas the home setting was the main setting for girls. Conclusions: This study highlights gender and cultural differences in smoking initiation among children and adolescents. Smoking prevention programmes should thus include gender- and culture-specific content related to smoking initiation. Future studies may further examine gender- and culture-specific messaging to inform policies and enhance tailored programmes aimed at preventing smoking initiation. © 2012 The Royal Society for Public Health.

S. T. Heydari | A. Hoseinzadeh | F. Ghaffarpasand | A. Hedjazi | M. Zarenezhad | G. Moafian | M. R. Aghabeigi | A. Foroutan | Y. Sarikhani | P. Peymani | S. M. Ahmadi | H. Joulaei | M. Dehghankhalili | K. B. Lankarani

Objectives: To determine the epidemiological characteristics of fatal traffic accidents in Fars province, Iran. Study design: This cross-sectional study included 3642 traffic accident deaths in Fars province, Iran between November 200 9 and November 2011. The data source was the Fars Forensic Medicine Registry, which covers the entire province. According to Iranian law, all deaths resulting from injuries or accidents must be investigated to determine the exact cause of death by autopsy. All such deaths are referred to forensic medicine centres in each city, and all data are sent to the main centre in Shiraz, the capital city of Fars province. Results: Males accounted for 78.3% of the decedents (sex ratio of almost 3.6:1), and the mean±standard deviation age of all decedents was 32.2±20.3 years. Autopsy reports indicated that head trauma was the most common cause of death. Most collisions were vehicle-vehicle crashes (52.3%), with cars and motorcycles being the most prevalent modes of transport (39.6% and 24.6%, respectively). Fatal accidents were most common during the summer. Most fatal injuries (61.4%) occurred on outer-city roads and 27.4% occurred on inner-city roads. Significant associations were found between decedent's status (car driver, motorcycle driver or passenger, pedestrian or passenger) and interval between injury and death, light conditions at the scene of the accident, place of death, site of injury and cause of death. Conclusion: Although the clinical management of trauma patients has improved in Iran, coordination between trauma system organizations is required to decrease the burden of injuries. © 2013 The Royal Society for Public Health.

B. Eastwood | M. J. Dockrell | D. Arnott | J. Britton | H. Cheeseman | M. J. Jarvis | A. McNeill

© 2015. Objectives: The recent growth in the market for electronic cigarettes (e-cigarettes) has led to concerns over their use by young people. It is therefore important to examine trends in the perception and use of e-cigarettes and conventional cigarettes in this group. Study design: Two-wave cross-sectional survey design. Methods: Young people aged 11-18 in Great Britain were surveyed online by YouGov in 2013 and 2014. Use of e-cigarettes, together with perceived health harms and intention to use were assessed and compared in relation to cigarette smoking history, age and gender. Results: Ever-use of e-cigarettes increased significantly from 4.6% (95% CI 3.8-5.7) in 2013 to 8.2% (95% CI 7.0-9.6) in 2014. Monthly or more use of e-cigarettes increased from 0.9% (95% CI 0.5-1.5) to 1.7 (1.2-2.4), but remained rare in never-smokers at under 0.2%. The proportion of young people who perceived e-cigarettes to be less harmful to users than cigarettes fell from 73.4% (95% CI 71.0-75.8) to 66.9% (95% CI 64.5-69.2), while the proportion who considered e-cigarettes to cause similar levels of harm increased from 11.8% (95% CI 10.0-13.5) to 18.2% (95% CI 16.3-20.1). Of the 8.2% of e-cigarette ever-users in 2014, 69.8% (95% CI 62.2%-77.3%) had smoked a cigarette prior to using an e-cigarette, while 8.2% (95% CI 4.1%-12.2%) first smoked a cigarette after e-cigarette use. Conclusions: A growing proportion of young people in Great Britain believe e-cigarettes are as harmful as smoking tobacco. Use of e-cigarettes by young people is increasing, but is largely confined to those who smoke.

M. L. Finkel | J. Hays

Unconventional drilling for natural gas by means of high volume horizontal hydraulic fracturing (fracking) is an important global public health issue. Given that no sound epidemiologic study has been done to assess the extent of exposure-related adverse health effects among populations living in areas where natural gas extraction is going on, it is imperative that research be conducted to quantify the potential risks to the environment and to human health not just in the short-term, but over a longer time period since many diseases (i.e., cancers) appear years after exposure. It should not be concluded that an absence of data implies that no harm is being done. © 2013 The Royal Society for Public Health.

B. R. Loomis | A. E. Kim | J. L. Goetz | H. R. Juster

Objective: To examine the association of community median income, race/ethnicity and age with the availability of tobacco products in New York State and six subareas. Study design: Spatial regression analysis applied to licensed tobacco retailer and sociodemographic data in 2009 in New York. Methods: This study assessed the association between tobacco retailer density and four demographic correlates (percentage African American, percentage Hispanic, percentage aged < 18 years and median household income) at the census tract level in New York in 2009. Associations were modelled for New York State and six subareas: Greater New York City/Long Island, New York minus Greater New York City/Long Island (rest of State), the Capital region (containing the city of Albany and surrounding areas), Erie County (containing the city of Buffalo), Monroe County (containing the city of Rochester) and Onondaga County (containing the city of Syracuse). In total, 19,420 licensed tobacco retailers were linked to 4795 residential census tracts. Results: In New York State, residential census tracts with higher proportions of African Americans and Hispanics generally had a significantly higher density of tobacco retailers. Census tracts with a higher percentage of residents aged < 18 years and higher median household income generally had a significantly lower density of tobacco retailers. However, these associations were not statistically significant in all areas studied. Conclusions: Tobacco retailers tend to be more densely distributed in areas characterized by high minority or low-income populations, but these associations were not found in all areas. This may suggest that policy measures to reduce the density of tobacco retailers may be more effective at reducing disparities in tobacco availability and exposure to point-of-sale advertising in some areas than in others. © 2013 The Royal Society for Public Health.

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