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26.  Premature mortality in Belgium in 1993-2009: leading causes, regional disparities and 15 years change 
Archives of Public Health  2014;72(1):34.
Background
Reducing premature mortality is a crucial public health objective. After a long gap in the publication of Belgian mortality statistics, this paper presents the leading causes and the regional disparities in premature mortality in 2008–2009 and the changes since 1993.
Methods
All deaths occurring in the periods 1993–1999 and 2003–2009, in people aged 1–74 residing in Belgium were included.
The cause of death and population data for Belgium were provided by Statistics Belgium , while data for international comparisons were extracted from the WHO mortality database.
Age-adjusted mortality rates and Person Year of Life Lost (PYLL) were calculated. The Rate Ratios were computed for regional and international comparisons, using the region or country with the lowest rate as reference; statistical significance was tested assuming a Poisson distribution of the number of deaths.
Results
The burden of premature mortality is much higher in men than in women (respectively 42% and 24% of the total number of deaths). The 2008–9 burden of premature mortality in Belgium reaches 6410 and 3440 PYLL per 100,000, respectively in males and females, ranking 4th and 3rd worst within the EU15. The disparities between Belgian regions are substantial: for overall premature mortality, respective excess of 40% and 20% among males, 30% and 20% among females are observed in Wallonia and Brussels as compared to Flanders. Also in cause specific mortality, Wallonia experiences a clear disadvantage compared to Flanders. Brussels shows an intermediate level for natural causes, but ranks differently for external causes, with less road accidents and suicide and more non-transport accidents than in the other regions.
Age-adjusted premature mortality rates decreased by 29% among men and by 22% among women over a period of 15 years. Among men, circulatory diseases death rates decreased the fastest (-43.4%), followed by the neoplasms (-26.6%), the other natural causes (-21.0%) and the external causes (-20.8%). The larger decrease in single cause is observed for stomach cancer (-48.4%), road accident (-44%), genital organs (-40.4%) and lung (-34.6%) cancers. On the opposite, liver cancer death rate increased by 16%.
Among female, the most remarkable feature is the 50.2% increase in the lung cancer death rate. For most other causes, the decline is slightly weaker than in men.
Conclusion
Despite a steady decrease over time, international comparisons of the premature mortality burden highlight the room for improvement in Belgium. The disadvantage in Wallonia and to some extent in Brussels suggest the role of socio-economic factors; well- designed health policies could contribute to reduce the regional disparities. The increase in female lung cancer mortality is worrying.
doi:10.1186/2049-3258-72-34
PMCID: PMC4200135  PMID: 25328677
Premature mortality; Mortality rates; Potential Years of Life Lost; Causes of death; Belgium
27.  Is the different time trend (1997–2008) of the obesity prevalence among adults in the three Belgian regions associated with lifestyle changes? 
Archives of Public Health  2014;72(1):18.
Background
Obesity is a major public health issue with increasing prevalence among adults. However, in Belgium the regional time trends (1997–2008) differed: the prevalence of obesity increased in the Flemish and Brussels Regions, but remained stable in the Walloon Region, the latter still showing the highest prevalence. The purpose of the present study is to explore if the different time trends of obesity prevalence in the three Belgian regions is associated with lifestyle changes.
Methods
We used data from four successive cross-sectional waves (1997, 2001, 2004 and 2008) of the Belgian Health Interview Survey. The study was restricted to the adult population, resulting in samples of respectively 8,071, 9,391, 10,319 and 8,831 individuals. In line with the WHO definition, obesity was defined as having a BMI ≥ 30. Differences in regional trends of obesity were investigated through stratified analyses. The association between obesity and survey year, adjusted for lifestyle factors (alcohol consumption, smoking, fruit and vegetables consumption and leisure time physical activity), was assessed via logistic regression models. Interactions were added to the models to explore if the association between lifestyle factors and obesity varied over time.
Results
Obesity was associated with daily alcohol use in the Brussels (OR 0.66, 95% CI 0.50-0.88) and Walloon Regions (OR 0.8, 95% CI 0.6-0.9), with lower tendencies of being obese for daily drinkers. The probability of being obese was lower among smokers in the Flemish (OR 0.7, 95% CI 0.6-0.8) and Walloon Regions (OR 0.7, 95% CI 0.6-0.9) than among non-smokers. A lack of leisure time physical activity was associated with the probability of being obese in all regions (Brussels Region: OR 1.6, 95% CI 1.3-1.8; Flemish Region: OR 1.6, 95% CI 1.4-1.9; Walloon Region: OR 1.8, 95% CT 1.6-2.1). This association decreased significantly between 1997 and 2008 only in the Walloon Region.
Conclusion
The decreasing association between obesity and a lack of leisure time physical activity in the Walloon Region between 1997 and 2008 could indicate that there is an increasing awareness of risk factors for obesity in the Walloon population, which may have resulted in a more favourable evolution of the obesity epidemic.
doi:10.1186/2049-3258-72-18
PMCID: PMC4063436  PMID: 24949198
Health Interview Survey; Obesity; Lifestyle; Physical activity; Eating habits; Smoking; Alcohol drinking; Time trend; Health promotion; Belgium
28.  Protocol of the PSYCHOTSH study: association between neonatal thyroid stimulating hormone concentration and intellectual, psychomotor and psychosocial development at 4–5 year of age: a retrospective cohort study 
Archives of Public Health  2014;72(1):27.
Background
Several European countries, including Belgium, still suffer from mild iodine deficiency. Thyroid stimulating hormone (TSH) concentration in whole blood measured at birth has been proposed as an indicator of maternal iodine status during the last trimester of pregnancy. It has been shown that mild iodine deficiency during pregnancy may affect the neurodevelopment of the offspring. In several studies, elevated TSH levels at birth were associated with suboptimal cognitive and psychomotor outcomes among young children. This paper describes the protocol of the PSYCHOTSH study aiming to assess the association between neonatal TSH levels and intellectual, psychomotor and psychosocial development of 4–5 year old children. The results could lead to a reassessment of the recommended cut-off levels of 5 > mU/L used for monitoring iodine status of the population.
Methods
In total, 380 Belgian 4–5 year old preschool children from Brussels and Wallonia with a neonatal blood spot TSH concentration between 0 and 15 mU/L are included in the study. For each sex and TSH-interval (0–1, 1–2, 2–3, 3–4, 4–5, 5–6, 6–7, 7–8, 8–9 and 9–15 mU/L), 19 newborns were randomly selected from all newborns screened by the neonatal screening centre in Brussels in 2008–2009. Infants with congenital hypothyroidism, low birth weight and prematurity were excluded from the study. Neonatal TSH concentration was measured by the Autodelphia method in dried blood spots, collected by heel stick on filter paper 3 to 5 days after birth. Cognitive abilities and psychomotor development are assessed using the Wechsler Preschool and Primary Scale of Intelligence - third edition - and the Charlop-Atwell Scale of Motor coordination. Psychosocial development is measured using the Child Behaviour Check List for age 1½ to 5 years old. In addition, several socioeconomic, parental and child confounding factors are assessed.
Conclusions
This study aims to clarify the effect of mild iodine deficiency during pregnancy on the neurodevelopment of the offspring. Therefore, the results may have important implications for future public health recommendations, policies and practices in food supplementation. In addition, the results may have implications for the use of neonatal TSH screening results for monitoring the population iodine status and may lead to the definition of new TSH cut-offs for determination of the severity of iodine status and for practical use in data reporting by neonatal screening centres.
doi:10.1186/2049-3258-72-27
PMCID: PMC4150557  PMID: 25180082
Iodine deficiency; Thyroid stimulating hormone; Child development; Cognitive development; Psychomotor development; Psychosocial development
29.  Causes of metabolic syndrome and obesity-related co-morbidities Part 1: A composite unifying theory review of human-specific co-adaptations to brain energy consumption 
Archives of Public Health  2014;72(1):30.
One line summary
Metabolic syndrome and obesity-related co-morbidities are largely explained by co-adaptations to the energy use of the large human brain in the cortico-limbic-striatal and NRF2 systems.
The medical, research and general community is unable to effect significantly decreased rates of central obesity and related type II diabetes mellitus (TIIDM), cardiovascular disease (CVD) and cancer. All conditions seem to be linked by the concept of the metabolic syndrome (MetS), but the underlying causes are not known. MetS markers may have been mistaken for causes, thus many treatments are destined to be suboptimal.
The current paper aims to critique current paradigms, give explanations for their persistence, and to return to first principles in an attempt to determine and clarify likely causes of MetS and obesity related comorbidities. A wide literature has been mined, study concepts analysed and the basics of human evolution and new biochemistry reviewed. A plausible, multifaceted composite unifying theory is formulated.
The basis of the theory is that the proportionately large, energy-demanding human brain may have driven co-adaptive mechanisms to provide, or conserve, energy for the brain. A ‘dual system’ is proposed. 1) The enlarged, complex cortico-limbic-striatal system increases dietary energy by developing strong neural self-reward/motivation pathways for the acquisition of energy dense food, and (2) the nuclear factor-erythroid 2-related factor 2 (NRF2) cellular protection system amplifies antioxidant, antitoxicant and repair activity by employing plant chemicals, becoming highly energy efficient in humans.
The still-evolving, complex human cortico-limbic-striatal system generates strong behavioural drives for energy dense food procurement, including motivating agricultural technologies and social system development. Addiction to such foods, leading to neglect of nutritious but less appetizing ‘common or garden’ food, appears to have occurred. Insufficient consumption of food micronutrients prevents optimal human NRF2 function. Inefficient oxidation of excess energy forces central and non-adipose cells to store excess toxic lipid. Oxidative stress and metabolic inflammation, or metaflammation, allow susceptibility to infectious, degenerative atherosclerotic cardiovascular, autoimmune, neurodegenerative and dysplastic diseases.
Other relevant human-specific co-adaptations are examined, and encompass the unusual ability to store fat, certain vitamin pathways, the generalised but flexible intestine and microbiota, and slow development and longevity.
This theory has significant past and future corollaries, which are explored in a separate article by McGill, A-T, in Archives of Public Health, 72: 31.
doi:10.1186/2049-3258-72-30
PMCID: PMC4335398
Metabolic syndrome; Obesity-related co-morbidities; Theory review; Evolution and nutrition; Food micronutrient; Malnutritive obesity (Malnubesity); Cortico-limbic-striatal; Food addiction; Nuclear factor-erythroid 2-related factor 2 (NRF2); Human brain metabolism; Oxidative stress; Metabolic inflammation
30.  A Centre for the Diagnosis and Treatment of Tuberculosis (CDT) in a resource-limited setting: a dragnet for patients with heart disease? 
Archives of Public Health  2014;72(1):26.
Background
Cardiovascular disease is a growing public health problem in sub-Saharan Africa. Cough and dyspnea are symptoms of both lung diseases and heart failure. This study aimed at determining the contribution of cardiac diseases versus pulmonary diseases in the etiological profile of patients presenting with cough and dyspnea in a Center for the Diagnosis and Treatment of Tuberculosis (CDT), in a semi-rural area in Cameroon.
Methods
This is a cross-sectional analysis of data from patients aged 18 years or more who consulted for cough and or dyspnea between December 2009 and December 2010 at the CDT of Lafe-Baleng, Bafoussam, Cameroon.
Results
A total of 1196 patients were received for various complaints during the study period; 348 (29.1%) of them presented with cough and or dyspnea, and were included in the study. 186 patients (53.4%; 95% CI: 48.2-58.6) had a pure cardiac disease, while 122 patients (35.1%; 95% CI: 30.2-40.2) had a pulmonary disease. The prevalence of hypertension was 50.9%, and hypertensive heart disease was the most frequent cardiac disease with a prevalence rate of 37.6%. Heart failure was diagnosed in 222 patients, representing 63.8% (95% CI: 58.9-68.9) of patients with cough and or dyspnea, and 18.6% (95% CI: 16.5-21.0) of all the patients received at the CDT of Lafe-Baleng during the study period. Compared to patients with a pulmonary disease, patients with cardiac disease were older (p < 0.001) and more likely to present with dyspnea (p < 0.001) and to have hypertension (p < 0.001).
Conclusion
We found a high prevalence of heart failure in this Centre for the Diagnosis and Treatment of Tuberculosis thus, a veritable dragnet for patients with heart disease. Our findings emphasize the urgent need to increase the access to cardiovascular care and to continuously raise the awareness of the communities on cardiovascular diseases in Cameroon.
doi:10.1186/2049-3258-72-26
PMCID: PMC4132523  PMID: 25126419
Cardiac disease; Center for the diagnosis and treatment of tuberculosis; Sub-Saharan Africa; Cameroon
31.  Is low health literacy associated with overweight and obesity in adolescents: an epidemiology study in a 12–16 years old population, Nanning, China, 2012 
Archives of Public Health  2014;72(1):11.
Background
The problem of overweight and obesity in children and adolescents is considered an epidemic in both developed and developing world by the WHO. There has been little study on the relationship between health literacy and body weight among adolescents.
This epidemiological study aims to investigate the association between low health literacy and overweight and obesity among a population of Chinese adolescents aged 12–16 years in the city of Nanning, China in 2012.
Methods
This study was a population-based cross-sectional health survey utilising a two-stage random cluster sampling design. The sample consisted of high school students aged between 12–16 years with the total student population attending high schools in a large city as the sample frame. Health literacy was measured by the Chinese version of the short form of the Test of Functional Health Literacy translated for and validated among Taiwanese adolescents. Overweight and obesity were assessed in accordance to the recommendation of the World Health Organization (WHO) Global Database of Body Mass Index classification methods. Data were analysed using logistic regression modelling techniques with adjustment to the cluster sampling effect.
Results
A total of 1035 students responded to the survey providing usable information with 628 (48.1%) respondents classified as high, 558 (42.8%) moderate, and 119 (9.1%) low levels of health literacy. After adjusting for potential confounding factors and the cluster sampling effect, low health literacy was significantly associated with overweight and obesity (OR = 1.84, 95% C.I. = 1.13-2.99).
Conclusion
Results suggested that low health literacy level was associated with many aspects of adolescence health including their body weight. These results have public health implications on an important global problem of adolescence body weight. Enhancing the health literacy should be considered as part of the strategies in combating adolescence weight problem.
doi:10.1186/2049-3258-72-11
PMCID: PMC3994214  PMID: 24685203
Health literacy; Overweight; Obesity; Adolescents; Epidemiology study
32.  School based interventions versus family based interventions in the treatment of childhood obesity- a systematic review 
Background
The prevalence of childhood obesity, which has seen a rapid increase over the last decade, is now considered a major public health problem. Current treatment options are based on the two important frameworks of school- and family-based interventions; however, most research has yet to compare the two frameworks in the treatment of childhood obesity.
The objective of this review is to compare the effectiveness of school-based intervention with family-based intervention in the treatment of childhood obesity.
Methods
Databases such as Medline, Pub med, CINAHL, and Science Direct were used to execute the search for primary research papers according to inclusion criteria. The review included a randomised controlled trial and quasi-randomised controlled trials based on family- and school-based intervention frameworks on the treatment of childhood obesity.
Results
The review identified 1231 articles of which 13 met the criteria. Out of the thirteen studies, eight were family-based interventions (n = 8) and five were school-based interventions (n = 5) with total participants (n = 2067). The participants were aged between 6 and 17 with the study duration ranging between one month and three years. Family-based interventions demonstrated effectiveness for children under the age of twelve and school-based intervention was most effective for those aged between 12 and 17 with differences for both long-term and short-term results.
Conclusions
The evidence shows that family- and school-based interventions have a considerable effect on treating childhood obesity. However, the effectiveness of the interventional frameworks depends on factors such as age, short- or long-term outcome, and methodological quality of the trials. Further research studies are required to determine the effectiveness of family- and school-based interventions using primary outcomes such as weight, BMI, percentage overweight and waist circumference in addition to the aforementioned factors.
doi:10.1186/2049-3258-72-3
PMCID: PMC3974185  PMID: 24472187
Children; Obesity; Family intervention; School intervention; Frameworks; Treatment
33.  A brief tool to assess capacity to consent for medical care among homeless individuals with problematic substance use: study protocol 
Archives of Public Health  2013;71(1):11.
Background
Public health care increasingly uses outreach models to engage individuals who are marginalized, many of whom misuse substances. Problematic substance use, together with marginalization from the health care system, among homeless adults makes it difficult to assess their capacity to consent to medical care. Tools have been developed to assess capacity to consent; however, these tools are lengthy and unsuitable for outreach settings. The primary objective of this study is to develop, validate, and pilot a brief but sensitive screening instrument which can be used to guide clinicians in assessing capacity to consent in outreach settings. The goal of this paper is to outline the protocol for the development of such a tool.
Methods/Design
A brief assessment tool will be developed and compared to the MacArthur Competency Assessment Tool for Treatment (MacCAT-T). As list of 36 possible questions will be created by using qualitative data from clinician interviews, as well as concepts from the literature. This list will be rated by content experts according to the extent that it corresponds to the test objectives. The instrument will be validated with 300 homeless adult volunteers who self-report problematic substance use. Participants will be assessed for capacity using the MacCAT-T and the new instrument. A combination of Classical Test Theory and advanced psychometric methods will be used for the psychometric analysis. Corrected Item-Total correlation will be examined to identify items that discriminate poorly. Guided exploratory factor analysis will be conducted on the final selection of items to confirm the assumptions for a unidimensional polytomous Rasch model. If unidimensionality is confirmed, an unstandardized Cronbach Alpha will be calculated. If multi-dimensionality is detected, a multidimensional Rasch analysis will be conducted. Results from the new instrument will be compared to the total score from the MacCAT-T by using Pearson’s correlation test. The new instrument will then be piloted in real-time by street outreach clinicians to determine the acceptability and usefulness of the new instrument.
Discussion
This research will build on the existing knowledge about assessing capacity to consent and will contribute new knowledge about assessing individuals whose judgment is impaired by substance use.
doi:10.1186/0778-7367-71-11
PMCID: PMC3651044  PMID: 23651056
Capacity to consent; Substance use; Psychometric instruments; Vulnerable populations
34.  Prevalence and determinants of obesity among primary school children in Dar es Salaam, Tanzania 
Archives of Public Health  2013;71(1):26.
Background
Childhood obesity has increased dramatically and has become a public health concern worldwide. Childhood obesity is likely to persist through adulthood and may lead to early onset of NCDs. However, there is paucity of data on obesity among primary school children in Tanzania. This study assessed the prevalence and determinants of obesity among primary school children in Dar es Salaam.
Methods
A cross sectional study was conducted among school age children in randomly selected schools in Dar es Salaam. Anthropometric and blood pressure measurements were taken using standard procedures. Body Mass Index (BMI) was calculated as weight in kilograms divided by the square of height in meters (kg/m2). Child obesity was defined as BMI at or above 95th percentile for age and sex. Socio-demographic characteristics of children were determined using a structured questionnaire. Logistic regression was used to determine association between independent variables with obesity among primary school children in Dar es Salaam.
Results
A total of 446 children were included in the analysis. The mean age of the participants was 11.1±2.0 years and 53.1% were girls. The mean BMI, SBP and DBP were 16.6±4.0 kg/m2, 103.9±10.3mmHg and 65.6±8.2mmHg respectively. The overall prevalence of child obesity was 5.2% and was higher among girls (6.3%) compared to boys (3.8%). Obese children had significantly higher mean values for age (p=0.042), systolic and diastolic blood pressures (all p<0.001). Most obese children were from households with fewer children (p=0.019) and residing in urban areas (p=0.002). Controlling for other variables, age above 10 years (AOR=3.3, 95% CI=1.5-7.2), female sex (AOR=2.6, 95% CI=1.4-4.9), urban residence (AOR=2.5, 95% CI=1.2-5.3) and having money to spend at school (AOR=2.6, 95% CI=1.4-4.8) were significantly associated with child obesity.
Conclusions
The prevalence of childhood obesity in this population was found to be low. However, children from urban schools and girls were proportionately more obese compared to their counterparts. Primary preventive measures for childhood obesity should start early in childhood and address socioeconomic factors of parents contributing to childhood obesity.
doi:10.1186/0778-7367-71-26
PMCID: PMC3844852  PMID: 24094276
Prevalence; Child obesity; Determinants; Urban; Children; Tanzania
35.  Obstacles in measles elimination: an in-depth description of a measles outbreak in Ghent, Belgium, spring 2011 
Archives of Public Health  2013;71(1):17.
Background
From Mid-February to April 2011 one of the largest measles-outbreak in Flanders, since the start of the 2-dose vaccination scheme in 1995, took place in Ghent, Belgium. The outbreak started in a day care center, infecting children too young to be vaccinated, after which it spread to anthroposophic schools with a low measles, mumps and rubella vaccination coverage. This report describes the outbreak and evaluates the control measures and interventions.
Methods
Data collection was done through the system of mandatory notification of the public health authority. Vaccination coverage in the schools was assessed by a questionnaire and the electronic immunization database ‘Vaccinnet’. A case was defined as anyone with laboratory confirmed measles or with clinical symptoms and an epidemiological link to a laboratory confirmed case. Towards the end of the outbreak we only sought laboratory confirmation for persons with an atypical clinical presentation or without an epidemiological link. In search for an index patient we determined the measles IgG level of infants from the day care center.
Results
A total of 65 cases were reported of which 31 were laboratory confirmed. Twenty-five were confirmed by PCR and/or IgM. In 6 infants, too young to be vaccinated, only elevated measles IgG levels were found. Most cases (72%) were young children (0–9 years old). All but two cases were completely unimmunized. In the day care center all the infants who were too young to be vaccinated (N=14) were included as cases. Thirteen of them were laboratory confirmed. Eight of these infants were hospitalized with symptoms suspicious for measles. Vaccination coverage in the affected anthroposophic schools was low, 45-49% of the pupils were unvaccinated. We organized vaccination campaigns in the schools and vaccinated 79 persons (25% of those unvaccinated or incompletely vaccinated).
Conclusions
Clustering of unvaccinated persons, in a day care center and in anthroposophic schools, allows for measles outbreaks and is an important obstacle for the elimination of measles. Isolation measures, a vacation period and an immunization campaign limited the spread of measles within the schools but could not prevent further spread among unvaccinated family members. It was necessary to raise clinicians' awareness of measles since it had become a rare, less known disease and went undiagnosed.
doi:10.1186/0778-7367-71-17
PMCID: PMC3716678  PMID: 23834074
Outbreak; Vaccine-preventable-disease; Measles; Immunization registry; Anti-vaccination
36.  Assessment of pattern for consumption and awareness regarding energy drinks among medical students 
Archives of Public Health  2013;71(1):31.
Background
Energy drink is a type of beverage which contains stimulant drugs chiefly caffeine and marketed as mental and physical stimulator. Coffee, tea, soft drinks and other caffeinated beverages are not considered as energy drinks. Purpose of our study was to evaluate the awareness of medical students regarding energy drinks and their pattern and reason of energy drinks consumption.
Methods
This was a cross sectional and observational study conducted during the period of January – December 2012 at four Medical Colleges (Dow Medical College, Sindh Medical College, Jinnah Medical College and Liaquat National Medical College) of Karachi, Pakistan. Over all 900 M.B.B.S students were invited to participate after taking written consent but viable questionnaire was submitted by 866 students, estimated response rate of 96%. All data was entered and analyzed through SPSS version 19.
Result
Out of 866 participants, majority were females 614 (70.9%) and only 252 (28.5%) were males, with a mean age of 21.43 ± 1.51 years. Energy drinks users were 350 (42.89%) and non users were 516 (59.58%). Only 102 (29.3%) users and 159 (30.7%) non users know the correct definition of Energy drinks. Regarding awareness, mostly user and non users thought that usage of energy drinks had been on rise due to its usefulness in reducing sleep hours [users193 (43.9%), nonusers 247 (56.1%) (p < 0.05)], for studying or completing major projects [users184 (45.0%), nonusers 225 (55.0%) (p < 0.05)] and for refreshment purposes [users179 (44.9%), nonusers 220 (55.1%) (p < 0.05)]. Two main reasons of not using energy drinks by non-users were “awareness from its side effects” 247 (47.8%) and “have no specific reason” 265 (51.3%). Most common side effects reported by users were fatigue 111 (31.7%) and weight gain 102 (29.4%).
Conclusion
In sum, the fact that despite serious side effects of weight gaining and fatigue, practice of consuming energy drinks is highly prevalent among medical students, particularly because they are ever ready to boost their energy level and reduce sleep hours due to stress of exams and projects. This warrants the creation of continued public health awareness about the appropriate use of caffeinated beverages, their potential benefits, side effects and correction of wrong perceptions.
doi:10.1186/2049-3258-71-31
PMCID: PMC3976099  PMID: 24351105
Palpitation; Energy drinks; Behavior
37.  Socioeconomic inequalities in cigarette smoking among men: evidence from the 2003 and 2008 Ghana demographic and health surveys 
Background
Tobacco use is a public health burden in both developed and developing countries. However, there is still a dearth of nationally representative studies from Sub-Saharan Africa to inform interventions in the region. Socioeconomic trends and disparities in cigarette smoking were explored among Ghanaian men.
Method
A nationally representative sample of Ghanaian men 15–59 years was surveyed in the 2003 (N = 5015) and 2008 (N = 4568) Ghana Demographic and Health Surveys (N = 9583). Logistic regression analyses were conducted to investigate cigarette smoking by socioeconomic status (SES) and the changes over the two study periods. The results are presented as adjusted odds ratios (AOR) at 95% confidence intervals (CI)
Results
The prevalence decreased by 1.7% from 9% (95% CI 0.09–0.11) in 2003 to 7.3% (95% CI 0.07–0.09) in 2008. The prevalence of cigarette smoking was higher in the older age groups (25–34 year-olds and 35–59 year-olds) compared to 15–24 year-olds. Education (AOR = 2.2, 95% CI 1.4–3.4; no education vs higher education) and occupation (AOR = 4.2, 95% CI 2.3–7.6; not working vs managerial position) and being in labour force (AOR = 2.6, 95% CI 1.7–4.0) were related to cigarette smoking. Furthermore, religion, wealth (AOR = 3.1 95% CI 2.1–4.5; poorest compared to richest) and rural residence (AOR = 1.8, 95% CI 1.5–2.1) were associated with cigarette smoking. Over the period, cigarette smoking seems to have decreased among Ghanaian male at the population level but not among all groups by age, education, wealth and place of residence.
Conclusion
Cigarette smoking interventions should be structured to reduce the menace among men. Such interventions must also particularly target lower socioeconomic groups in order to avert an increase in the inequalities in the behaviour and prervent a consequent increase in the socioeconomic gradient in tobacco-related diseases and deaths.
doi:10.1186/0778-7367-71-9
PMCID: PMC3686574  PMID: 23621799
Cigarette smoking; Smoking epidemic; Diffusion of innovations; Ghanaian men
38.  Socio-economic, clinical and biological risk factors for mother - to – child transmission of HIV-1 in Muhima health centre (Rwanda): a prospective cohort study 
Background
Three decades since the first HIV-1 infected patients in Rwanda were identified in 1983; the Acquired Immunodeficiency Syndrome epidemic has had a devastating history and is still a major public health challenge in the country. This study was aimed at assessing socioeconomic, clinical and biological risk factors for mother – to – child transmission of HIV- in Muhima health centre (Kigali/Rwanda).
Methods
The prospective cohort study was conducted at Muhima Health centre (Kigali/Rwanda).
During the study period (May 2007 – April 2010), of 8,669 pregnant women who attended antenatal visits and screened for HIV-1, 736 tested HIV-1 positive and among them 700 were eligible study participants. Hemoglobin, CD4 count and viral load tests were performed for participant mothers and HIV-1 testing using DNA PCR technique for infants.
Follow up data for eligible mother-infant pairs were obtained from women themselves and log books in Muhima health centre and maternity, using a structured questionnaire.
Predictors of mother-to-child transmission of HIV-1 were assessed by multivariable logistic regression analysis.
Results
Among the 679 exposed and followed-up infants, HIV-1 status was significantly associated with disclosure of HIV status to partner both at 6 weeks of age (non-disclosure of HIV status, adjusted odds ratio [AOR] 4.68, CI 1.39 to 15.77, p < 0.05; compared to disclosure) and at 6 months of age (non-disclosure of HIV status, AOR, 3.41, CI 1.09 to 10.65, p < 0.05, compared to disclosure).
A significant association between mother’s viral load (HIV-1 RNA) and infant HIV-1 status was found both at 6 weeks of age (> = 1000 copies/ml, AOR 7.30, CI 2.65 to 20.08, p < 0.01, compared to <1000 copies/ml) and at 6 months of age (> = 1000 copies/ml, AOR 4.60, CI 1.84 to 11.49, p < 0.01, compared to <1000 copies/ml).
Conclusion
In this study, the most relevant factors independently associated with increased risk of mother – to – child transmission of HIV-1 included non-disclosure of HIV status to partner and high HIV-1 RNA. Members of this cohort also showed socioeconomic inequalities, with unmarried status carrying higher risk of undisclosed HIV status. The monitoring of maternal HIV-1 RNA level might be considered as a routinely used test to assess the risk of transmission with the goal of achieving viral suppression as critical for elimination of pediatric HIV, particularly in breastfeeding populations.
doi:10.1186/0778-7367-71-4
PMCID: PMC3598904  PMID: 23448752
Socioeconomic, Clinical and biological risk factors; HIV-1; Mother - to – child transmission; Cohort; Muhima/Rwanda
39.  Translation validation of a new back pain screening questionnaire (the STarT Back Screening Tool) in French 
Archives of Public Health  2012;70(1):12.
Background
Low back pain (LBP) is a major public health problem and the identification of individuals at risk of persistent LBP poses substantial challenges to clinical management. The STarT Back questionnaire is a validated nine-item patient self-report questionnaire that classifies patients with LBP at low, medium or high-risk of poor prognosis for persistent non-specific LBP. The objective of this study was to translate and cross-culturally adapt the English version of the STarT Back questionnaire into French.
Methods
The translation was performed using best practice translation guidelines. The following phases were performed: contact with the STarT Back questionnaire developers, initial translations (English into French), synthesis, back translations, expert committee review, test of the pre-final version on 44 individuals with LBP, final version.
Results
The linguistic translation required minor semantic alterations. The participants interviewed indicated that all items of the questionnaire were globally clear and comprehensible. However, 6 subjects (14%) wondered if two questions were related to back pain or general health. After discussion within the expert committee and with the developer of the STarT Back tool, it was decided to modify the questionnaire and to add a reference to back pain in these two questions.
Conclusions
The French version of the STarT Back questionnaire has been shown to be comprehensible and adapted to the French speaking general population. Investigations are now required to test the psychometric properties (reliability, internal and external validity, responsiveness) of this translated version of the questionnaire.
doi:10.1186/0778-7367-70-12
PMCID: PMC3436683  PMID: 22958224
Low back pain; Questionnaire; Translation
40.  Severe acute respiratory infections during the influenza A(H1N1)2009 pandemic in Belgium: first experience of hospital-based flu surveillance 
Archives of Public Health  2010;68(3):87-93.
Introduction
In September 2009, as part of the surveillance during the Influenza A(2009) pandemic, Bel-gium introduced a web-based surveillance system aimed at recording hospitalisations and deaths attributable to Influenza in real time.
Methods
We present the web-based application developed for the pandemic as well as a descriptive analysis of Severe Acute Respiratory Infection (SARI) cases reported through this system.
Results
From 1 September to 31 December 2009, 1723 SARI-related hospitalisations potentially due to influenza were reported in Belgium. The median age of the patients was 29 years (range: < 1 year-99 years). Among SARI-hospitalised patients 68% were aged less than 45 years, 10.6% were vaccinated with the seasonal influenza vaccine and 7.5% with the pandemic influenza vaccine. No deaths were recorded.
Conclusions
This first experience showed the feasibility of getting real-time information from hospitals during a public health crisis. However, the absence of death detected through the system highlighted the importance of better defining the severity of the hospital cases.
doi:10.1186/0778-7367-68-3-87
PMCID: PMC3463031
SARI; hospitalisation; surveillance; influenza A(H1N1)2009; epidemiology
41.  Trends of violence among 7th, 8th and 9th grade students in the state of Lara, Venezuela: The Global School Health Survey 2004 and 2008 
Background
Violence by young people is one of the most visible forms of violence and contributes greatly to the global burden of premature death, injury and disability.
Methods
The Global School-based Student Health Survey (GSHS), State of Lara, Venezuela (GSHS-Lara) is a school-based surveillance system. It comprises a repeated, cross-sectional, self-administered survey drawn from a representative sample of 7th to 9th grade students, performed in the school years 2003-2004 (GSHS-Lara 2004) and 2007-2008 (GSHS-Lara 2008). It explores, among other things, a general violence indicator such as school absenteeism due to feeling unsafe at school or on the way to or from school for any reason; and more specific indicators of violence such as robbery, bullying, physical fights and use of weapons, as well as exposure to lectures on how to prevent violence. Results are given in terms of prevalence percentage.
Results
Absenteeism doubled between the two study periods (10.8% to 20.8%). The number of students that were a victim of robbery remained high and without change both outside (14.2% and 14.8%) and inside school (21.7% and 22.0%). The number of victims of bullying was high and increasing (33.4% and 43.6%). Bullying associated with being physically attacked decreased (18.5% to 14.3%). Physical attacks without active participation and not associated with bullying were frequent (21.5%). Physical fighting with active participation prevalence remained high and without change (27.5% and 28.2%). Carrying a weapon almost doubled (4.3% to 7.1%). Less than 65% reported classes for violence prevention.
Conclusions
The GSHS-Lara shows that violence is an important public health problem that needs to be addressed by the community and its authorities.
doi:10.1186/0778-7367-69-7
PMCID: PMC3436614  PMID: 22958602
Adolescents; Behavior; Bullying; Health Education; Physical Fight; Robbery; Unsafe School; Venezuela; Violence; Weapon
42.  Blood lead levels in the Kinshasa population: a pilot study 
Archives of Public Health  2010;68(1):30-41.
Objective
Leaded gasoline and lead paints are still in use in the Democratic Republic of Congo but data on blood lead levels in the general population are not available. We evaluated the Pb impregnation in children and adults (0 - 70 years old) in Kinshasa.
Methods
Blood lead was measured by atomic absorption in a sample of 485 healthy people (268 men and 217 women) living in Kinshasa between May 2003 and June 2004.
Results
Geometric mean blood lead was 120 µg/L (95% CI: 115-125), with a higher concentration in men than in women (127 vs 114 µg/L, p = 0.01). Sixty-three percent of children aged less than 6 years old presented blood lead levels above the 100 µg threshold. In the adult population, occupations with a potential risk of exposure to gasoline (car mechanics or garage owners, taxi drivers, conveyors and gas pump attendants) were associated with an extra blood lead of about 65µg/L.
Conclusion
This study indicates a relatively important Pb impregnation of the Kinshasa population. It demonstrates the existence of a major public health issue requiring corrective actions and the implementation of an appropriate regulation.
doi:10.1186/0778-7367-68-1-30
PMCID: PMC3436702
Leaded gasoline; Kinshasa; human exposure; saturnism; blood lead
43.  Factors associated with data quality in the routine health information system of Benin 
Archives of Public Health  2014;72(1):25.
Background
Routine health information systems (RHIS) are crucial to the acquisition of data for health sector planning. In developing countries, the insufficient quality of the data produced by these systems limits their usefulness in regards to decision-making. The aim of this study was to identify the factors associated with poor data quality in the RHIS in Benin.
Methods
This cross-sectional descriptive and analytical study included health workers who were responsible for data collection in public and private health centers. The technique and tools used were an interview with a self-administered questionnaire. The dependent variable was the quality of the data. The independent variables were socio-demographic and work-related characteristics, personal and work-related resources, and the perception of the technical factors. The quality of the data was assessed using the Lot Quality Assurance Sampling method. We used survival analysis with univariate proportional hazards (PH) Cox models to derive hazards ratios (HR) and their 95% confidence intervals (95% CI). Focus group data were evaluated with a content analysis.
Results
A significant link was found between data quality and level of responsibility (p = 0.011), sector of employment (p = 0.007), RHIS training (p = 0.026), level of work engagement (p < 0.001), and the level of perceived self-efficacy (p = 0.03). The focus groups confirmed a positive relationship with organizational factors such as the availability of resources, supervision, and the perceived complexity of the technical factors.
Conclusion
This exploratory study identified several factors associated with the quality of the data in the RHIS in Benin. The results could provide strategic decision support in improving the system’s performance.
doi:10.1186/2049-3258-72-25
PMCID: PMC4128530  PMID: 25114792
Data quality; Related factors; Health information systems
44.  Words, words, words 
doi:10.1186/0778-7367-69-1
PMCID: PMC3436648  PMID: 22958413
45.  Reliability and Validity of the Dutch Physical Activity Questionnaires for Children (PAQ-C) and Adolescents (PAQ-A) 
Archives of Public Health  2014;72(1):47.
Background
This study was designed to validate the Dutch Physical Activity Questionnaires for Children (PAQ-C) and Adolescents (PAQ-A).
Methods
After adjustment of the original Canadian PAQ-C and PAQ-A (i.e. translation/back-translation and evaluation by expert committee), content validity of both PAQs was assessed and calculated using item-level (I-CVI) and scale-level (S-CVI) content validity indexes. Inter-item and inter-rater reliability of 196 PAQ-C and 95 PAQ-A filled in by both children or adolescents and their parent, were evaluated. Inter-item reliability was calculated by Cronbach’s alpha (α) and inter-rater reliability was examined by percent observed agreement and weighted kappa (κ). Concurrent validity of PAQ-A was examined in a subsample of 28 obese and 16 normal-weight children by comparing it with concurrently measured physical activity using a maximal cardiopulmonary exercise test for the assessment of peak oxygen uptake (VO2 peak).
Results
For both PAQs, I-CVI ranged 0.67-1.00. S-CVI was 0.89 for PAQ-C and 0.90 for PAQ-A. A total of 192 PAQ-C and 94 PAQ-A were fully completed by both child and parent. Cronbach’s α was 0.777 for PAQ-C and 0.758 for PAQ-A. Percent agreement ranged 59.9-74.0% for PAQ-C and 51.1-77.7% for PAQ-A, and weighted κ ranged 0.48-0.69 for PAQ-C and 0.51-0.68 for PAQ-A. The correlation between total PAQ-A score and VO2 peak – corrected for age, gender, height and weight – was 0.516 (p = 0.001).
Conclusions
Both PAQs have an excellent content validity, an acceptable inter-item reliability and a moderate to good strength of inter-rater agreement. In addition, total PAQ-A score showed a moderate positive correlation with VO2 peak. Both PAQs have an acceptable to good reliability and validity, however, further validity testing is recommended to provide a more complete assessment of both PAQs.
Electronic supplementary material
The online version of this article (doi:10.1186/2049-3258-72-47) contains supplementary material, which is available to authorized users.
doi:10.1186/2049-3258-72-47
PMCID: PMC4323128  PMID: 25671114
Pediatrics; Physical activity; Reliability; Validation
46.  Why children are not vaccinated against measles: a cross-sectional study in two Nigerian States 
Archives of Public Health  2014;72(1):48.
Background
Childhood vaccination rates in Nigeria are among the lowest in the world and this affects morbidity and mortality rates. A 2011 mixed methods study in two states in Nigeria examined coverage of measles vaccination and reasons for not vaccinating children.
Methods
A household survey covered a stratified random cluster sample of 180 enumeration areas in Bauchi and Cross River States. Cluster-adjusted bivariate and then multivariate analysis examined associations between measles vaccination and potential determinants among children aged 12-23 months, including household socio-economic status, parental knowledge and attitudes about vaccination, and access to vaccination services. Focus groups of parents in the same sites subsequently discussed the survey findings and gave reasons for non-vaccination. A knowledge to action strategy shared findings with stakeholders, including state government, local governments and communities, to stimulate evidence-based actions to increase vaccination rates.
Results
Interviewers collected data on 2,836 children aged 12-23 months in Cross River and 2,421 children in Bauchi. Mothers reported 81.8% of children in Cross River and 42.0% in Bauchi had received measles vaccine. In both states, children were more likely to receive measles vaccine if their mothers thought immunisation worthwhile, if immunisation was discussed in the home, if their mothers had more education, and if they had a birth certificate. In Bauchi, maternal awareness about immunization, mothers’ involvement in deciding about immunization, and fathers’ education increased the chances of vaccination. In Cross River, children from communities with a government immunisation facility were more likely to have received measles vaccine. Focus groups revealed lack of knowledge and negative attitudes about vaccination, and complaints about having to pay for vaccination. Health planners in both states used the findings to support efforts to increase vaccination rates.
Conclusion
Measles vaccination remains sub-optimal, particularly in Bauchi. Efforts to counter negative perceptions about vaccination and to ensure vaccinations are actually provided free may help to increase vaccination rates. Parents need to be made aware that vaccination should be free, including for children without a birth certificate, and vaccination could be an opportunity for issuing birth certificates. The study provides pointers for state level planning to increase vaccination rates.
doi:10.1186/2049-3258-72-48
PMCID: PMC4322649  PMID: 25671115
Vaccination; Measles; Immunisation; Children; MDG4; Nigeria
47.  What determines health-related quality of life among people living with HIV: an updated review of the literature 
Archives of Public Health  2014;72(1):40.
Background
As infection with the Human Immunodeficiency Virus (HIV) has evolved to a chronic disease, perceived health-related quality of life (HRQoL) is becoming a prominent and important patient-reported outcome measure in HIV care. Literature discusses different factors influencing HRQoL in this population, however, currently no consensus exists about the main determinants. In this review a clear, up-to-date overview of the determinants influencing HRQOL among people living with HIV is provided.
Methods
All studies published before July 2013 that identified determinants of HRQoL among people living with HIV in high-income countries, were considered in this narrative review. PubMed, Web of Science and The Cochrane Library were consulted using the keywords ‘determinants’, ‘quality of life’, ‘HIV’ and ‘AIDS’. To be included, studies should have reported overall health and/or physical/mental health scores on a validated instrument and performed multivariable regression analyses to identify determinants that independently influence perceived HRQoL.
Results
In total, 49 studies were included for further analysis and they used a variety of HRQoL instruments: Medical Outcomes Study Short Form-36 or variants, Medical Outcomes Study-HIV, HIV Cost and Services Utilization Study measure, Multidimensional Quality of Life Questionnaire, HIV targeted quality of life instrument, Functional Assessment of Human Immunodeficiency Virus Infection, HIV Overview of Problems Evaluation System, EuroQol, Fanning Quality of Life scale, Health Index and PROQOL-HIV. In this review, the discussed determinants were thematically divided into socio-demographic, clinical, psychological and behavioural factors. Employment, immunological status, presence of symptoms, depression, social support and adherence to antiretroviral therapy were most frequently and consistently reported to be associated with HRQoL among people living with HIV.
Conclusions
HRQoL among people living with HIV is influenced by several determinants. These determinants independently, but simultaneously impact perceived HRQoL. Most HRQoL instruments do not capture all key determinants. We recommend that the choice for an instrument should depend on the purpose of the HRQoL assessment.
Electronic supplementary material
The online version of this article (doi:10.1186/2049-3258-72-40) contains supplementary material, which is available to authorized users.
doi:10.1186/2049-3258-72-40
PMCID: PMC4323115  PMID: 25671112
HIV; Acquired immunodeficiency syndrome; Quality of life; Epidemiologic factors; Review
48.  Creating healthy food environments through global benchmarking of government nutrition policies and food industry practices 
Unhealthy processed food products are increasingly dominating over healthy foods, making food and nutrition environments unhealthier. Development and implementation of strong government healthy food policies is currently being circumvented in many countries by powerful food industry lobbying. In order to increase accountability of both governments and the private sector for their actions, and improve the healthiness of food environments, INFORMAS (the International Network for Food and Obesity/non-communicable diseases (NCDs) Research, Monitoring and Action Support) has recently been founded to systematically and comprehensively monitor food environments and policies in countries of varying size and income. This will enable INFORMAS to rank both governments and private sector companies globally according to their actions on food environments. Identification of those countries which have the healthiest food and nutrition policies and using them as international benchmarks against which national progress towards best practice can be assessed, should support reductions in global obesity and diet-related NCDs.
doi:10.1186/2049-3258-72-7
PMCID: PMC3974193  PMID: 24594359
49.  A review of the use of health examination data from the Health Survey for England in government policy development and implementation 
Archives of Public Health  2014;72(1):24.
Background
Information is needed at all stages of the policy making process. The Health Survey for England (HSE) is an annual cross-sectional health examination survey of the non-institutionalised general population in England. It was originally set up to inform national policy making and monitoring by the Department of Health. This paper examines how the nurse collected physical and biological measurement data from the HSE have been essential or useful for identification of a health issue amenable to policy intervention; initiation, development or implementation of a strategy; choice and monitoring of targets; or assessment and evaluation of policies.
Methods
Specific examples of use of HSE data were identified through interviews with senior members of staff at the Department of Health and the Health and Social Care Information Centre. Policy documents mentioned by interviewees were retrieved for review, and reference lists of associated policy documents checked. Systematic searches of Chief Medical Officer Reports, Government ‘Command Papers’, and clinical guidance documents were also undertaken.
Results
HSE examination data have been used at all stages of the policy making process. Data have been used to identify an issue amenable to policy-intervention (e.g. quantifying prevalence of undiagnosed chronic kidney disease), in strategy development (in models to inform chronic respiratory disease policy), for target setting and monitoring (the 1992 blood pressure target) and in evaluation of health policy (the effect of the smoking ban on second hand smoke exposure).
Conclusions
A health examination survey is a useful part of a national health information system.
doi:10.1186/2049-3258-72-24
PMCID: PMC4128608  PMID: 25114791
Policy; Evidence; Surveillance; Health examination survey
50.  Access to social capital and risk of HIV infection in Bukoba urban district, Kagera region, Tanzania 
Archives of Public Health  2014;72(1):38.
Background
Kagera is one of the 22 regions of Tanzania mainland, which has witnessed a decline in HIV prevalence during the past two decades; decreasing from 24% in 1987 to 4.7 in 2009 in the urban district of Bukoba. Access to social capital, both structural and cognitive, might have played a role in this development. The aim was to examine the association between individual structural and cognitive social capital and socio-economic characteristics and the likelihood of being HIV infected.
Methods
We conducted a population-based cross-sectional study of 3586 participants, of which 3423 (95%) agreed to test for HIV following pre-test counseling. The HIV testing was performed using enzyme-linked immunosorbent assay (ELISA) antibody detection tests. Multiple logistic regression analysis was applied to estimate the impact of socio-economic factors, individual structural and cognitive social capital and HIV sero-status.
Results
Individuals who had access to low levels of both structural and cognitive individual social capital were four and three times more likely to be HIV positive compared to individuals who had access to high levels. The associations remained statistically significant for both individual structural and cognitive social capital after adjusting for potential confounding factors such as age, sex, marital status, occupation, level of education and wealth index (OR =8.6, CI: 5.7-13.0 and OR =2.4, CI: 1.6-3.5 for individual structural and cognitive social capital respectively). For both women and men access to high levels of individual structural and cognitive social capital decreased the risk of being HIV infected. This study confirms previous qualitative studies indicating that access to structural and cognitive social capital is protective to HIV infection.
Conclusions
We suggest that policy makers and programme managers of HIV interventions may consider strengthening and facilitating access to social capital as a way of promoting HIV preventive information and interventions in order to reduce new HIV infections in Tanzania.
doi:10.1186/2049-3258-72-38
PMCID: PMC4322460  PMID: 25671111
Structural; Cognitive social capital; HIV prevalence; Tanzania

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