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
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
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
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
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
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
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
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
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
The small but growing literature on socio-economic inequality in morbidity among older persons suggests that social inequalities in health persist into old age. A largely separate body of literature looks at the predictors of long-term care use, in particular of institutional care. Various measures of socio-economic status are often included as control variables in these studies. Review articles generally conclude that the evidence for such variables being a predictor for institutionalization is “inconclusive”. In this paper we look at the association among older persons in Belgium between one particular measure of socio-economic status – preferential status in public health care insurance – and first use of home long-term care and residential care. Preferential status entitles persons to higher reimbursement rates for health care from the public health care insurance system and is conditional on low income. We also study whether preferential status is related to the onset of five important chronic conditions and the time of death.
We use survival analysis; the source of the data is a large administrative panel of a sample representative for all older persons in Belgium (1,268,740 quarterly observations for 69,562 individuals).
We find a strong association between preferential status and the likelihood of home care use, but for residential care it is small for men and non-existent for women. We also find that preferential status is significantly related to the chance of getting two out five chronic conditions – COPD and diabetes, but not dementia, hip fracture and Parkinson’s disease – and to the probability of dying (not for women). For home care use and death, the association with preferential status declines with increasing age from age 65 onwards, such that it is near zero for those aged around 90 and older.
We find clear associations between an indicator of low income and home care use, some chronic conditions and death. The associations are stronger among men than among women. We also find that the association declines with age for home care use and death, which might be explained by selective survival.
Long-term care; Socio-economic status; Morbidity; Mortality; Preferential status
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.
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.
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.
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.
Health Interview Survey; Obesity; Lifestyle; Physical activity; Eating habits; Smoking; Alcohol drinking; Time trend; Health promotion; Belgium
Health literacy is widely considered as a key determinant of health and a priority in the public health policy agenda. Low health literacy has been associated with poorer health states, broader inequalities and higher health systems’ costs. In the present study we bring into focus the functional health literacy among university students in Greece, researching and assessing mainly their ability to apply basic knowledge in a health context.
The study was carried out during the period 15–30 April 2013, among a random sample of 1,526 students of 14 Higher Tertiary Public universities and Technological Educational Institutes in Greece. The objective of the study was to assess the functional health literacy among university students in Greece, adopting the short four-item comprehension test of Bostock and Steptoe. Summary statistics, correlations and regressions were used to assess the determinants of health literacy and the association with self-perceived health, health behaviours and health risks.
Economic factors, such as family income, demographic factors, such as gender, and health behaviours and risks, namely consumption of alcohol, smoking and physical workout are associated with the level of health literacy and health status of the participant. While the results of the study are consistent with previous work in this area, several findings worth further research.
Though, health promotion interventions in Greece include health literacy as one of the basic pillars of the public health policy agenda, it is clear, that health literacy needs to become a key policy issue in Greece, mainly focusing in young ages, where healthy (or unhealthy) behaviours are established affecting the health through the life span.
Health literacy; Health behaviour; Health risks; Greece; University student
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.
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.
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.
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.
Children; Obesity; Family intervention; School intervention; Frameworks; Treatment
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.
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.
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.
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.
Prevalence; Child obesity; Determinants; Urban; Children; Tanzania
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.
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.
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).
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.
Outbreak; Vaccine-preventable-disease; Measles; Immunization registry; Anti-vaccination
Many studies suggest that high salt intakes are related to high blood pressure and consequently cardiovascular diseases. In addition salt intake was found to be related with obesity, renal stones, osteoporosis and stomach cancer. Belgium, such as other European countries, is suffering from both salt intakes that are twice as high as the recommended intakes and mild iodine deficiency. No comprehensive strategy encompassing both public health problems has been developed. While specific salt reduction targets for processed foods are still under discussion using a consensus approach with industry, an agreement was signed between the bakery sector and the Ministry of Health in April 2009, to encourage and increase the use of iodised salt in the production of bread. Based on results of recent surveys on population iodine status it is advised not to currently revise iodine concentrations in salt in bread but to advocate for a higher percentage of bakers using iodised salt and to install a good monitoring system to control the percentage of bakers effectively using adequately iodised salt. With regard to salt reduction, it is of utmost importance that all companies contribute and harmonise the salt content of their products according to the lowest possible thresholds in a first step. In order to achieve this goal, it will be necessary, in addition to the consensus approach, to come up with at least some legislative tools such as a salt tax or mandatory labelling of foods exceeding a specific sodium concentration. Once salt reduction targets have been clearly defined in Belgium over the longer term, a legal framework should be set in place where iodine concentration in salt for the production of bread and household salt is strictly regulated by law, to avoid a large variability in the iodine content of salt brands consumed. In conclusion, it is possible to tackle salt reduction and iodine deficiency at the same time on the condition that the approach is coordinated and well monitored. All the interventions and measures taken should clearly include education and communication directed towards consumers, food producers, public health professionals, pharmacists, healthcare workers, and media representatives.
Sodium; Iodine; Belgium
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.
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.
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.
Capacity to consent; Substance use; Psychometric instruments; Vulnerable populations
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.
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)
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.
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.
Cigarette smoking; Smoking epidemic; Diffusion of innovations; Ghanaian men