Public health policies aim to improve and maintain the health of citizens. Relevant data and indicators are needed for a health policy that is based on factual information. After 14 years of work (1998–2012), the multi-phase action on European Community Health Indicators (ECHI) has created a health monitoring and reporting system. It has generated EU added value by defining the ECHI shortlist with 88 common and comparable key health indicators for Europe.
In the 2009-2012 Joint Action for ECHIM project the ECHI shortlist was updated through consultation with Member State representatives. Guidelines for implementation of the ECHI Indicators at national level were developed and a pilot data collection was carried out.
67 of the ECHI Indicators are already part of regular international data collections and thus available for a majority of Member States, 14 are close to ready and 13 still need development work. By mid-2012 half of the countries have incorporated ECHI indicators in their national health information systems and the process is ongoing in the majority of the countries. Twenty-five countries were able to provide data in a Pilot Data Collection for 20 ECHI Indicators that were not yet (fully) available in the international databases.
The EU needs a permanent health monitoring and reporting system. The Joint Action for ECHIM has set an example for the implementation of a system that can develop and maintain the ECHI indicators,, and promote and encourage the use of ECHI in health reporting and health policy making. The aim for sustainable public health monitoring is also supported by a Eurostat regulation on public health statistics requiring that health statistics shall be provided according to the ECHI methodology. Further efforts at DG SANCO and Eurostat are needed towards a permanent health monitoring system.
Public health indicators; Public health monitoring; Public health reporting
The completion of the Human Genome Project triggered a whole new field of genomic research which is likely to lead to new opportunities for the promotion of population health. As a result, the distinction between genetic and environmental diseases has faded. Presently, genomics and knowledge deriving from systems biology, epigenomics, integrative genomics or genome-environmental interactions give a better insight on the pathophysiology of common diseases. However, it is barely used in the prevention and management of diseases. Together with the boost in the amount of genetic association studies, this demands for appropriate public health actions. The field of Public Health Genomics analyses how genome-based knowledge and technologies can responsibly and effectively be integrated into health services and public policy for the benefit of population health. Environmental exposures interact with the genome to produce health information which may help explain inter-individual differences in health, or disease risk. However today, prospects for concrete applications remain distant. In addition, this information has not been translated into health practice yet. Therefore, evidence-based recommendations are few. The lack of population-based research hampers the evaluation of the impact of genomic applications. Public Health Genomics also evaluates the benefits and risks on a larger scale, including normative, legal, economic and social issues. These new developments are likely to affect all domains of public health and require rethinking the role of genomics in every condition of public health interest. This article aims at providing an introduction to the field of and the ideas behind Public Health Genomics.
Epidemiology; Genomics; Epigenomics; Prevention; Public Health; Public Health Genomics; Translational Research; Policymaking; Personalised Healthcare
Sarcopenia, operationally defined as the loss of muscle mass and muscle function, is a major health condition associated with ageing, and contributes to many components of public health at both the patient and the societal levels. Currently, no consensual definition of sarcopenia exists and therefore it is still a challenge to establish the actual prevalence of sarcopenia or to establish the direct and indirect impacts of sarcopenia on public health. Anyway, this geriatric syndrome represents a huge potential public health issue because of its multiple clinical and societal consequences. Moreover, all these aspects have an impact on healthcare costs both for the patient and the society. Therefore, the implementation of effective and broadly applicable preventive and therapeutic interventions has become a medical and societal challenge for the growing number of older persons affected by sarcopenia and its disabling complications.
Sarcopenia; Public health; Epidemiology; Consequences; Diagnosis
Frailty is a major health condition associated with ageing. Although the concept is almost universally accepted, its operational definition remains controversial. Anyway, this geriatric condition represents a huge potential public health issue at both the patient and the societal levels because of its multiple clinical, societal consequences and its dynamic nature. Here, we review existing definitions and assessment tools for frailty, we highlight consequences of this geriatric condition and we discuss the importance of its screening and prevention to limit its public health burden.
Frailty; Elderly; Public health; Prevalence
The deductive paradigm has produced notable successes in epidemiology and public health. But while deductive logic has made a substantial contribution to the public health field, it must be recognized that there are also limits to that contribution. This report examines one such limit: the need for non-deductive models in public health reasoning. The findings of a study of public health reasoning in 879 members of the public are reported. Four non-deductive strategies were chosen for their capacity to bridge gaps in one’s knowledge. It emerged that subjects were adept at using these strategies in the absence of knowledge to arrive at judgements about public health problems. The implications of this finding for public health communication are discussed.
Privacy is an important concern in any research programme that deals with personal medical data. In recent years, ethics and privacy have become key considerations when conducting any form of scientific research that involves personal data. These issues are now addressed in healthcare professional training programmes. Indeed, ethics, legal frameworks and privacy are often the subject of much confusion in discussions among healthcare professionals. They tend to group these different concepts under the same heading and delegate responsibility for “ethical” approval of their research programmes to ethics committees. Public health researchers therefore need to ask questions about how changes to legal frameworks and ethical codes governing privacy in the use of personal medical data are to be applied in practice. What types of data do these laws and codes cover? Who is involved? What restrictions and requirements apply to any research programme that involves medical data?
Privacy; Medical data; Ethical considerations; Data analysis
Regular physical activity is associated with a wide range of health benefits. As population age, promotion of physical activity should specifically target older adults, an expanding group involving potential higher health care costs in the near future. Innovative interventions focusing on physical activity behaviors of senior adults exposed promising results, most recently through the use of the Internet. If seniors and Internet are generally considered as two opposite concepts, arguments in favour of bringing them together in a public health perspective have been identified by the recent literature. Older adults are the fastest growing group of Internet users and are more prone than younger to use it for health-related subjects. Web-based interventions are effective in many health promotion sectors, including physical activity. This is particularly true when interventions target the environmental determinants of each senior citizen and are specifically designed for this population. Those early research findings must clearly be extended, particularly regarding to the long term effects of Web-based physical activity interventions. Solutions that will reduce the high dropout rate recorded in the existing literature must also be considered as a priority in order to ensure the development of this forward-looking field of research.
Physical activity; Web-based intervention; Older adults; Exercise; Internet; Technology; Computer; Physical activity promotion
Tuberculosis is the leading causes of mortality among infectious diseases worldwide. The risk of transmission from patients to health workers is doubles that of the general population. The close contact to the infectious case before diagnosis is the major risk for tuberculosis infection. The aim of the study was to assess knowledge and practice of health professionals towards tuberculosis infection control and its associated factors in health facilities of Addis Ababa, Ethiopia.
A cross-sectional study was conducted from February 29 to April 15/2014 in selected health facilities in Addis Ababa. Five hundred ninety health workers were included in the study. The sample size was assigned to each health facility proportional to their number of health workers. Study subjects were selected from each stratum by simple random sampling technique. Interviewer administered structured questionnaire was used to collect information. Logistic regression was used to identify factors associated with knowledge and practice of health workers towards tuberculosis infection control.
Five hundred eighty two participants with 98.6% response rate were involved in the study. Of these, 36.1% had poor knowledge and 51.7% unsatisfactory practice score towards tuberculosis infection control. Having more than six years working experience in health facility (AOR = 2.51; 95% CI: 1.5-4.1) and tuberculosis related training (AOR = 2.51 95% CI; 1.5, 4.1) were significantly associated with knowledge on tuberculosis infection control. Having experience in tuberculosis clinic (AOR =1.93; 95% CI: 1.12, 3.34) and tuberculosis related training (AOR = 1.48; 95% CI: 1.87, 2.51) were significantly associated with practice on tuberculosis infection control.
One third of health workers had relatively poor knowledge and nearly half of them had unsatisfactory practice on tuberculosis infection control. Tuberculosis training and work experiences in health facility are determinant factor to knowledge. Whereas tuberculosis related training and experience in tuberculosis clinic are predictor to practice. So, training of the health professionals, on job orientations of junior health workers, and farther study including private health workers are recommended.
Knowledge; Practices; Health worker; Tuberculosis infection control
Microbiology reference laboratories are critical in the development of high-quality clinical and public health services. In Belgium, the reference laboratories performed their activities on a voluntary basis and lacked a legal status.
Pathogens or groups of pathogens necessitating a national reference center (NRC) were prioritized based on diagnostic and epidemiologic relevance. Terms of reference for each of these pathogens were developed.
Recently, 40 NRCs for different pathogens or groups of pathogens have been installed in Belgium to fulfill the following core functions: offering reference diagnostics, collecting reference materials, sharing information and scientific advice, participating in national and international networks, collaborating with research workgroups, and contributing to surveillance activities.
These NRCs are important focal points of the national and international network in public health microbiology.
National reference centers; Public health microbiology
The objective of this study was to analyze quantity, assess quality, and investigate international collaboration in research from Arab countries in the field of public, environmental and occupational health.
Original scientific articles and reviews published from the 22 Arab countries in the category "public, environmental & occupational health" during the study period (1900 – 2012) were screened using the ISI Web of Science database.
The total number of original and review research articles published in the category of "public, environmental & occupational health" from Arab countries was 4673. Main area of research was tropical medicine (1862; 39.85%). Egypt with 1200 documents (25.86%) ranked first in quantity and ranked first in quality of publications (h-index = 51). The study identified 2036 (43.57%) documents with international collaboration. Arab countries actively collaborated with authors in Western Europe (22.91%) and North America (21.04%). Most of the documents (79.9%) were published in public health related journals while 21% of the documents were published in journals pertaining to prevention medicine, environmental, occupational health and epidemiology.
Research in public, environmental and occupational health in Arab countries is in the rise. Public health research was dominant while environmental and occupation health research was relatively low. International collaboration was a good tool for increasing research quantity and quality.
Arab countries; Public health; Environmental and occupational health; Bibliometric analysis; ISI web of science
The European Commission, together with the European Union (EU) Member States, developed a core set of indicators for monitoring public health in the EU, the European Core Health Indicators (ECHI) shortlist. From 2009 to 2012 developmental work on the ECHI indicators continued within the framework of the Joint Action for European Community Health Indicators and Monitoring (ECHIM). In this article, we give the current state of affairs on the availability of data for the ECHI indicators in the Netherlands and show what progress has been made over the past 5 years. The information provided serves as an illustration of the challenges encountered in a European country when working on harmonising national data collections with international data delivery requirements.
To assess data availability, we consulted Dutch data experts and relevant websites and reports on health monitoring activities. We compared the available Dutch data with the definitions, preferred data sources and relevant dimensions as requested by ECHI.
The Netherlands can provide data for 66 of the 75 ECHI indicators for which availability could be assessed: for all of the 48 ECHI indicators that can be extracted from international databases and for 18 of the 27 indicators not available from international databases. Breakdowns by socio-economic status and region are not possible for 23 (35%) of the total of 66 indicators for which data are available and for 21 (32%) of these 66 indicators the definition is not exactly the same as requested by ECHIM. Since 2009, better estimates have become available for low birth weight, practising physicians and practising nurses.
Moreover, several European initiatives to improve harmonised data collection are expected to have a positive effect on data availability for the Netherlands. Such initiatives should become sustainable in order to provide possibilities for monitoring trends. The scattered data ownership in the Netherlands complicates the coordination work for international data deliveries.
Data availability in the Netherlands is good. Since 2009, several Dutch and European developments in harmonising data collection have contributed or will significantly contribute to improvements in the data situation for the ECHI indicators in the Netherlands.
Electronic supplementary material
The online version of this article (doi:10.1186/s13690-014-0058-4) contains supplementary material, which is available to authorized users.
Public health; Monitoring; European Core Health Indicators; International comparisons; European Union; Netherlands
Health interview surveys are important data sources for empirical research in public health. However, the diversity of methods applied, such as in the mode of data collection, make it difficult to compare results across surveys, time, or countries. The aim of this study was to explore whether the prevalence rates of health-related indicators amongst adults differ when self-administered paper mail questionnaires (SAQ-Paper), self-administered web surveys (SAQ-Web), and computer-assisted telephone interviews (CATI) are used for data collection in a health survey.
Data were obtained from a population-based mixed-mode health interview survey of adults in Germany carried out within the ‘German Health Update’ (GEDA) study. Data were collected either by SAQ-Paper (n = 746), SAQ-Web (n = 414), or CATI (n = 411). Predictive margins from logistic regression models were used to estimate the prevalence rates of chronic conditions, subjective health, mental health, psychosocial factors, and health behaviours, adjusted for the socio-demographic characteristics of each mode group.
Socio-demographic characteristics were found to differ significantly between study participants who responded by SAQ-Paper, SAQ-Web, and CATI. Crude prevalence rates for health-related indicators also showed significant variation across all three survey modes. After adjusting for socio-demographic factors though, significant differences in prevalence rates between the two self-administered modes (SAQ-Paper and SAQ-Web) were found in only 2 out of the 19 health-related indicators studied. The differences between CATI and the two self-administered modes remained significant however, especially for indicators of mental and psychosocial health and self-reported sporting activity.
The findings of this study indicate that prevalence rates obtained from health interview surveys can vary with the mode of data collection, primarily between interviewer and self-administered modes. Hence, the type of survey mode used should be considered when comparing results from different health surveys. Mixing self-administered modes, such as paper-based questionnaires and web surveys, may be a combination to minimize mode differences in mixed-mode health interview surveys.
Electronic supplementary material
The online version of this article (doi:10.1186/2049-3258-72-46) contains supplementary material, which is available to authorized users.
Health surveys; Data collection; Public health surveillance; Mixed-mode; Survey methods; Mode effects; Health indicators
Cancer is a major European public health issue and represents the second most important cause of death and morbidity in Europe. Moreover, as a result of constant advances in medicine, medical technology and other sciences, and due to improvements in economic circumstances, cancer survival rates are increasing in Europe and prevalent cases (i.e. number of subjects who have experienced cancer) represent a growing proportion of the population. In order to tackle cancer efficiently throughout the European Member states, the European Commission launched the Joint Action (JA) ‘European Partnership for Action Against Cancer’ (EPAAC) facilitated by the Community Health Programme, in September 2009. EPAAC is designed to fill a gap in cooperation, collaboration and shared experiences for countries with similar needs and diverse experience in the area of their national cancer control policies. Activities and studies are tackling the main challenges of cancer control in Europe as a whole and in the Member states, including the provision of services and health system responses, human resources and research. In contrast with previous European actions in the field of cancer, EPAAC joins different partners and stakeholders at various levels ranging from Member states (including Iceland and Norway) and Regions to patient representatives.
EPAAC; Cancer; Health policy; Public health; Joint Action
Alzheimer’s disease and other related dementias are public health priorities in the European Union due to their prevalence, cost and profound impact on society. Because of these pressing implications, the European Union decided to create a Joint Action to share knowledge about dementia and health policy in order to preserve the health, quality of life, autonomy and dignity of people living with dementia and their carers in Europe.
ALCOVE is a European Community-funded Joint Action coordinated by the HAS (French National Authority for Health) with a 24-month duration. The project’s life cycle has been divided into the following four steps: (1) collection of existing information, (2) analysis of existing information and making comparisons across Member States, (3) identifying Evidence, Needs, and Priorities, (4) drafting recommendations and disseminating them.
19 countries are participating in the ALCOVE initiative. The project will publish its final findings in 2013. The project’s objectives, participants, method, on-going procedures and work plans are already available on the ALCOVE website:
http://www.alcove-project.eu/. Preliminary results show that recommendations will need to focus on clinical and epidemiological data collection, diagnostic system assessment, outstanding approaches for treating behavioural disorders, limiting antipsychotic use, and competence assessment in this vulnerable population.
The European Member States involved are mobilized to share best health policy practices in order to tackle the challenge of dementia’s threat on European health and social systems and to improve the quality of life and care for individuals and their family carers.
Alzheimer’s disease and related dementia; Dementia; Public health; BPSD; Antipsychotics; Risk reduction; Prevalence; Diagnosis; Advanced declaration of will; Health care system
National health surveys are sometimes used to provide estimates on risk factors for policy and program development at the regional/local level. However, as regional/local needs may differ from national ones, an important question is how to also enhance capacity for risk factor surveillance regionally/locally.
A Think Tank Forum was convened in Canada to discuss the needs, characteristics, coordination, tools and next steps to build capacity for regional/local risk factor surveillance. A series of follow up activities to review the relevant issues pertaining to needs, characteristics and capacity of risk factor surveillance were conducted.
Results confirmed the need for a regional/local risk factor surveillance system that is flexible, timely, of good quality, having a communication plan, and responsive to local needs. It is important to conduct an environmental scan and a gap analysis, to develop a common vision, to build central and local coordination and leadership, to build on existing tools and resources, and to use innovation.
Findings of the Think Tank Forum are important for building surveillance capacity at the local/county level, both in Canada and globally. This paper provides a follow-up review of the findings based on progress over the last 4 years.
Public health surveillance; Capacity building; Behavioural risk factors
Life expectancy has been increasing during the last century within the European Union (EU). To measure progress in population health it is no longer sufficient to focus on the duration of life but quality of life should be considered. Healthy Life Years (HLY) allow estimating the quality of the remaining years that a person is expected to live, in terms of being free of long-standing activity limitation. The Joint Action on Healthy Life Years (JA: EHLEIS) is a joint action of European Member States (MS) and the European Union aiming at analysing trends, patterns and differences in HLY, as well as in other Summary Measures of Population Health (SMPH) indicators, across the European member states.
The JA: EHLEIS consolidates existing information on life and health expectancy by maximising the European comparability; by analysing trends in HLY within the EU; by analysing the evolution of the differences in HLY between Member States; and by identifying both macro-level as micro-level determinants of the inequalities in HLY. The JA: EHLEIS works in collaboration with the USA, Japan and OECD on the development of new SMPHs to be used globally. To strengthen the utility of the HLY for policy-making, annual meetings with policy-makers are planned.
The information system allows the estimation of a set of health indicators (morbidity and disability prevalence, life and health expectancies) for Europe, Member States and shortly their regional levels. An annual country report on HLY in the national languages is available. The JA: EHLEIS is developing statistical attribution and decomposition tools which will be helpful to determine the impact of specific diseases, life styles or other determinants on differences in HLY. Through a set of international workshops the JA: EHLEIS aims to develop a blueprint for an international harmonized Summary Measure of Population Health.
The JA: EHLEIS objectives are to monitor progress towards the headline target of the Europe 2020 strategy of increasing HLY by 2 years by 2020 and to support policy development by identifying the main determinants of active and healthy ageing in Europe.
Health status indicators; Gender; Socioeconomic status; Public health; Health expectancy; Healthy life years; EU
Regular physical activity practice has been widely recommended for promoting health, but the physical activity levels remain low in the population. Therefore, the study of interventions to promote physical activity is essential. Objective: To present the methodology of two physical activity interventions from the “Ambiente Ativo” (“Active Environment”) project.
12-month non-randomized controlled intervention trial. 157 healthy and physically inactive individuals were selected: health education (n = 54) supervised exercise (n = 54) and control (n = 49). Intervention based on health education: a multidisciplinary team of health professionals organized the intervention in group discussions, phone calls, SMS and educational material. Intervention based on supervised exercise program: consisted of offering an exercise program in groups supervised by physical education professionals involving strength, endurance and flexibility exercises. The physical activity level was assessed by the International Physical Activity Questionnaire (long version), physical activities recalls, pedometers and accelerometers over a seven-day period.
This study described two different proposals for promoting physical activity that were applied to adults attended through the public healthcare settings. The participants were living in a region of low socioeconomic level, while respecting the characteristics and organization of the system and its professionals, and also adapting the interventions to the realities of the individuals attended.
Both interventions are applicable in regions of low socioeconomic level, while respecting the social and economic characteristics of each region.
Health promotion; Intervention study; Public health practice; Physical activity
Aims of the study
This study wants to examine the availability of Belgian healthcare data in the three main international health databases: the World Health Organization European Health for All Database (WHO-HFA), the Organisation for Economic Co-operation and Development Health Data 2009 and EUROSTAT.
For the indicators present in the three databases, the availability of Belgian data and the source of these data were checked.
The most important problem concerning the availability of Belgian health-related data in the three major international databases is the lack of recent data. Recent data are available for 27% of the indicators of the WHO-HFA database, 73% of the OECD Health Data, and for half of the Eurostat indicators. Especially recent data about health status (including mortality-based indicators) are lacking.
Only the availability of the health-related data is studied in this article. The quality of the Belgian data is however also important to examine.
The main problem concerning the availability of health data is the timeliness. One of the causes of this lack of (especially mortality) data is the reform of the Belgian State. Nowadays mortality data are provided by the communities. This results in a delay in the delivery of national mortality data. However several efforts are made to catch up.
Belgium; databases; health status indicators; public health
Data on human exposure to chemicals in Africa are scarce. A biomonitoring study was conducted in a representative sample of the population in Kinshasa (Democratic Republic of Congo) to document exposure to polycyclic aromatics hydrocarbons.
1-hydroxypyrene (1-OHP) was measured by HPLC fluorescence in spot urine samples from 220 individuals (50.5% women), aged 6–70 years living in the urban area and from 50 additional subjects from the sub-rural area of Kinshasa. Data were compiled as geometric means and selected percentiles, expressed without (μg/L) or with creatinine adjustment (μg/g cr). Multiple regression analyses were applied to factors (creatinine, grilled meat habits and smoking habits) influencing 1-OHP (stepwise procedure, criteria: probability F to enter ≤ 0.05 and probability F to remove ≥ 0.10).
According to the regression models, creatinine, grilled meat habits and smoking habits contribute to explain 45% of the variation in population’s urinary 1-OHP by the environmental exposure. Overall, living in urban area of Kinshasa was associated with increased levels of 1-OHP in urine as compared to a population living in the sub-rural area [GM: 1.8 μg/L (n = 220) versus 1.4 μg/L (n = 50), p < 0.01] as well as compared to the reference values from databases involving American or German populations.
This study reveals the high pyrene (PAH) exposure of the Kinshasa population. However, more work, with a rigorous design in the exposed population (monitoring of air concentrations and identifying other sources of pyrene –PAH exposure), is needed to establish further documentation.
Biomonitoring; Environmental pollution; Organic compounds; Public health; Polycyclic aromatic hydrocarbons
To examine the incidence and reverse of obesity among young low-income children and variations across population subgroups.
We included 1.2 million participants in federally funded child health and nutrition programs who were 0 to 23 months old in 2008 and were followed up 24 to 35 months later in 2010–2011. Weight and height were measured. Obesity at baseline was defined as gender-specific weight-for-length ≥95th percentile on the 2000 Centers for Disease Control and Prevention growth charts. Obesity at follow-up was defined as gender-specific BMI-for-age ≥95th percentile. We used a multivariable log-binomial model to estimate relative risk of obesity adjusting for gender, baseline age, race/ethnicity, duration of follow-up, and baseline weight-for-length percentile.
The incidence of obesity was 11.0% after the follow-up period. The incidence was significantly higher among boys versus girls and higher among children aged 0 to 11 months at baseline versus those older. Compared with non-Hispanic whites, the risk of obesity was 35% higher among Hispanics and 49% higher among American Indians (AIs)/Alaska Natives (ANs), but 8% lower among non-Hispanic African Americans. Among children who were obese at baseline, 36.5% remained obese and 63.5% were nonobese at follow-up. The proportion of reversing of obesity was significantly lower among Hispanics and AIs/ANs than that among other racial/ethnic groups.
The high incidence underscores the importance of early-life obesity prevention in multiple settings for low-income children and their families. The variations within population subgroups suggest that culturally appropriate intervention efforts should be focused on Hispanics and AIs/ANs.
childhood obesity; incidence; preschool age; infancy; population-based studies; public health
Driving a taxicab remains one of the most dangerous occupations in the United States, with leading homicide rates. Although safety equipment designed to reduce robberies exists, it is not clear what effect it has on reducing taxicab driver homicides.
Taxicab driver homicide crime reports for 1996 through 2010 were collected from 20 of the largest cities (>200,000) in the United States: 7 cities with cameras installed in cabs, 6 cities with partitions installed, and 7 cities with neither cameras nor partitions. Poisson regression modeling using generalized estimating equations provided city taxicab driver homicide rates while accounting for serial correlation and clustering of data within cities. Two separate models were constructed to compare (1) cities with cameras installed in taxicabs versus cities with neither cameras nor partitions and (2) cities with partitions installed in taxicabs versus cities with neither cameras nor partitions. Cities with cameras installed in cabs experienced a significant reduction in homicides after cameras were installed (adjRR = 0.11, CL 0.06-0.24) and compared to cities with neither cameras nor partitions (adjRR = 0.32, CL 0.15-0.67). Cities with partitions installed in taxicabs experienced a reduction in homicides (adjRR = 0.78, CL 0.41-1.47) compared to cities with neither cameras nor partitions, but it was not statistically significant.
The findings suggest cameras installed in taxicabs are highly effective in reducing homicides among taxicab drivers. Although not statistically significant, the findings suggest partitions installed in taxicabs may be effective.
Taxicab driver homicides; Workplace violence; Public health; Robberies; Safety equipment; Intervention; Ecological study; Generalized estimating equations; Retrospective time series