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1.  Public health indicators for the EU: the joint action for ECHIM (European Community Health Indicators & Monitoring) 
Archives of Public Health  2013;71(1):12.
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/0778-7367-71-12
PMCID: PMC3682857  PMID: 23721296
Public health indicators; Public health monitoring; Public health reporting
2.  Public health in the genomic era: will Public Health Genomics contribute to major changes in the prevention of common diseases? 
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.
doi:10.1186/0778-7367-69-8
PMCID: PMC3436652  PMID: 22958637
Epidemiology; Genomics; Epigenomics; Prevention; Public Health; Public Health Genomics; Translational Research; Policymaking; Personalised Healthcare
3.  Public health reasoning: much more than deduction 
Archives of Public Health  2013;71(1):25.
The deductive paradigm has produced notable successes in epidemiology and public health. But while deductive logic has made a substantial contribution to the public health field, it must be recognized that there are also limits to that contribution. This report examines one such limit: the need for non-deductive models in public health reasoning. The findings of a study of public health reasoning in 879 members of the public are reported. Four non-deductive strategies were chosen for their capacity to bridge gaps in one’s knowledge. It emerged that subjects were adept at using these strategies in the absence of knowledge to arrive at judgements about public health problems. The implications of this finding for public health communication are discussed.
doi:10.1186/0778-7367-71-25
PMCID: PMC4176304  PMID: 24047328
4.  Ethics, privacy and the legal framework governing medical data: opportunities or threats for biomedical and public health research? 
Archives of Public Health  2013;71(1):15.
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?
doi:10.1186/0778-7367-71-15
PMCID: PMC3691608  PMID: 23799934
Privacy; Medical data; Ethical considerations; Data analysis
5.  Web-based interventions to promote physical activity by older adults: promising perspectives for a public health challenge 
Archives of Public Health  2013;71(1):16.
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.
doi:10.1186/0778-7367-71-16
PMCID: PMC3723485  PMID: 23819885
Physical activity; Web-based intervention; Older adults; Exercise; Internet; Technology; Computer; Physical activity promotion
6.  Public, environmental, and occupational health research activity in Arab countries: bibliometric, citation, and collaboration analysis 
Background
The objective of this study was to analyze quantity, assess quality, and investigate international collaboration in research from Arab countries in the field of public, environmental and occupational health.
Methods
Original scientific articles and reviews published from the 22 Arab countries in the category "public, environmental & occupational health" during the study period (1900 – 2012) were screened using the ISI Web of Science database.
Results
The total number of original and review research articles published in the category of "public, environmental & occupational health" from Arab countries was 4673. Main area of research was tropical medicine (1862; 39.85%). Egypt with 1200 documents (25.86%) ranked first in quantity and ranked first in quality of publications (h-index = 51). The study identified 2036 (43.57%) documents with international collaboration. Arab countries actively collaborated with authors in Western Europe (22.91%) and North America (21.04%). Most of the documents (79.9%) were published in public health related journals while 21% of the documents were published in journals pertaining to prevention medicine, environmental, occupational health and epidemiology.
Conclusion
Research in public, environmental and occupational health in Arab countries is in the rise. Public health research was dominant while environmental and occupation health research was relatively low. International collaboration was a good tool for increasing research quantity and quality.
doi:10.1186/2049-3258-73-1
PMCID: PMC4322552  PMID: 25671116
Arab countries; Public health; Environmental and occupational health; Bibliometric analysis; ISI web of science
7.  Establishment and reinforcement of the national reference centers for human microbiology in Belgium 
Archives of Public Health  2012;70(1):16.
Background
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.
Methods
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.
Results
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.
Conclusions
These NRCs are important focal points of the national and international network in public health microbiology.
doi:10.1186/0778-7367-70-16
PMCID: PMC3436681  PMID: 22958353
National reference centers; Public health microbiology
8.  Joint Action European Partnership for Action Against Cancer 
Archives of Public Health  2012;70(1):24.
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.
doi:10.1186/0778-7367-70-24
PMCID: PMC3542586  PMID: 23095375
EPAAC; Cancer; Health policy; Public health; Joint Action
9.  Sharing knowledge to advance healthcare policies in Europe for people living with dementia and their carers: the ALCOVE project 
Archives of Public Health  2012;70(1):21.
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/0778-7367-70-21
PMCID: PMC3523028  PMID: 22958544
Alzheimer’s disease and related dementia; Dementia; Public health; BPSD; Antipsychotics; Risk reduction; Prevalence; Diagnosis; Advanced declaration of will; Health care system
10.  Enhancing capacity for risk factor surveillance at the regional/local level: a follow-up review of the findings of the Canadian Think Tank Forum after 4 years 
Background
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.
Methods
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
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.
Conclusions
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.
doi:10.1186/2049-3258-72-2
PMCID: PMC3916079  PMID: 24451555
Public health surveillance; Capacity building; Behavioural risk factors
11.  Interventions for physical activity promotion applied to the primary healthcare settings for people living in regions of low socioeconomic level: study protocol for a non-randomized controlled trial 
Background
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.
Methods
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.
Result
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.
Conclusion
Both interventions are applicable in regions of low socioeconomic level, while respecting the social and economic characteristics of each region.
Trial registration
ClinicalTrials.gov NCT01852981
doi:10.1186/2049-3258-72-8
PMCID: PMC3977937  PMID: 24624930
Health promotion; Intervention study; Public health practice; Physical activity
12.  The joint action on healthy life years (JA: EHLEIS) 
Background
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.1186/0778-7367-71-2
PMCID: PMC3598905  PMID: 23379576
Health status indicators; Gender; Socioeconomic status; Public health; Health expectancy; Healthy life years; EU
13.  High human exposure to pyrene (polycyclic aromatic hydrocarbon) in Kinshasa, a capital of the Democratic Republic of Congo 
Archives of Public Health  2013;71(1):14.
Background
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.
Methods
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).
Results
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.
Conclusion
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.
doi:10.1186/0778-7367-71-14
PMCID: PMC3691609  PMID: 23782930
Biomonitoring; Environmental pollution; Organic compounds; Public health; Polycyclic aromatic hydrocarbons
14.  Belgian health-related data in three international databases 
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.
Methods
For the indicators present in the three databases, the availability of Belgian data and the source of these data were checked.
Main findings
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.
Discussion
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.
doi:10.1186/0778-7367-69-6
PMCID: PMC3436617  PMID: 22958554
Belgium; databases; health status indicators; public health
15.  Past and future corollaries of theories on causes of metabolic syndrome and obesity related co-morbidities part 2: a composite unifying theory review of human-specific co-adaptations to brain energy consumption 
Archives of Public Health  2014;72(1):31.
Forward
A composite unifying theory on causes of obesity related-MetS has been formulated and published in an accompanying article (1). In the current article, the historical and recent past, present and future corollaries of this theory are discussed. By presenting this composite theory and corollaries, it is hoped that human evolution and physiology will be viewed and studied from a new vantage point. The politics of management of ecological farming and nutrition will change, a profound reconfiguration of scientific theory generation and advancement in a ‘high-tech’ world can be made, and pathways for solutions recognised.
Metabolic syndrome (MetS) predicts type II diabetes mellitus (TIIDM), cardiovascular disease (CVD) and cancer, and their rates have escalated over the last few decades. Obesity related co-morbidities also overlap the concept of the metabolic syndrome (MetS). However, understanding of the syndrome’s underlying causes may have been misapprehended.
The current paper follows on from a theory review by McGill, A-T in Archives of Public Health, 72: 30. This accompanying paper utilises research on human evolution and new biochemistry to theorise on why MetS and obesity arise and how they affect the population. The basis of this composite unifying 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. In humans who consume a nutritious diet, the NRF2 system has become highly energy efficient. Other relevant human-specific co-adaptations are explored.
In order to ‘test’ this composite unifying theory it is important to show that the hypothesis and sub-theories pertain throughout the whole of human evolution and history up till the current era. Corollaries of the composite unifying theory of MetS are examined with respect to past under-nutrition and malnutrition since agriculture began 10,000 years ago. The effects of man-made pollutants on degenerative change are examined. Projections are then made from current to future patterns on the state of ‘insufficient micronutrient and/or unbalanced high energy malnutrition with central obesity and metabolic dysregulation’ or ‘malnubesity’.
Forecasts on human health are made on positive, proactive strategies using the composite unifying theory, and are extended to the wider human ecology of food production. A comparison is made with the outlook for humans if current assumptions and the status quo on causes and treatments are maintained. Areas of further research are outlined. A table of suggestions for possible public health action is included.
doi:10.1186/2049-3258-72-31
PMCID: PMC4335399
16.  Health literacy among university students in Greece: determinants and association with self-perceived health, health behaviours and health risks 
Archives of Public Health  2014;72(1):15.
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/2049-3258-72-15
PMCID: PMC4066308  PMID: 24987522
Health literacy; Health behaviour; Health risks; Greece; University student
17.  Implementation of joint health indicators in Europe - Joint Action for ECHIM. Arpo Aromaa on behalf of the ECHIM core group 
Archives of Public Health  2012;70(1):22.
The story of the implementation of the joint EU health indicators (ECHI indicators) began in the 1990s after the Amsterdam Treaty. The first concrete step in establishing a health monitoring capacity for EU was the Commission working group set up in 1997. Several consecutive and parallel projects, notably the health indicator projects ECHI-1 and ECHI-2 between the years 2000 and 2005 led to a preparedness to implement the jointly agreed health indicators (ECHI shortlist) in all European countries. ECHIM (2005 – 2008) and the Joint Action for ECHIM (2009 - ) laid the foundation for the implementation of health indicators, and initiated Europe wide implementation proper. After the European recession of 2008 the circumstances in different countries were not optimal. Also the collaboration with the Commission could have been better. Nevertheless, the implementation process of the ECHI indicators is now well underway in most countries. By June 2012 half of the Member States had incorporated the ECHI indicators into their national health information system, and, if work can continue, by 2014 most countries are likely to have done so. Unfortunately, a gap may occur between the current programme and the next public health programme. The current momentum must not be lost. Therefore, all those responsible need to urge that the Commission (DG SANCO) together with the Member States helps to bridge the gap from June 2012 to January 2014. The new Public Health Programme provides the necessary financial instruments for setting up a permanent EU health information and reporting system.
doi:10.1186/0778-7367-70-22
PMCID: PMC3523025  PMID: 23043717
Health indicators; Health information; European Community Health Indicators (ECHI); EU Joint Action
18.  Blood lead levels in children after phase-out of leaded gasoline in Kinshasa, the capital of Democratic Republic of Congo (DRC) 
Background
The phasing out of lead from gasoline has resulted in a significant decrease in blood lead levels (BLLs) in children during the last two decades. Tetraethyl lead was phased out in DRC in 2009. The objective of this study was to test for reduction in pediatric BLLs in Kinshasa, by comparing BLLs collected in 2011 (2 years after use of leaded gasoline was phased out) to those collected in surveys conducted in 2004 and 2008 by Tuakuila et al. (when leaded gasoline was still used).
Methods
We analyzed BLLs in a total of 100 children under 6 years of age (Mean ± SD: 2.9 ± 1.6 age, 64% boys) using inductively coupled argon plasma mass spectrometry (ICP – MS).
Results
The prevalence of elevated BLLs (≥ 10 μg/dL) in children tested was 63% in 2004 [n = 100, GM (95% CI) = 12.4 μg/dL (11.4 – 13.3)] and 71% in 2008 [(n = 55, GM (95% CI) = 11.2 μg/dL (10.3 – 14.4)]. In the present study, this prevalence was 41%. The average BLLs for the current study population [GM (95% CI) = 8.7 μg/dL (8.0 – 9.5)] was lower than those found by Tuakuila et al. (F = 10.38, p <0.001) as well as the CDC level of concern (10 μ/dL), with 3% of children diagnosed with BLLs ≥ 20 μg/dL.
Conclusion
These results demonstrate a significant success of the public health system in Kinshasa, DRC-achieved by the removal of lead from gasoline. However, with increasing evidence that adverse health effects occur at BLLs < 10 μg/dL and no safe BLLs in children has been identified, the BLLs measured in this study continue to constitute a major public health concern for Kinshasa. The emphasis should shift to examine the contributions of non-gasoline sources to children’s BLLs: car batteries recycling in certain residences, the traditional use of fired clay for the treatment of gastritis by pregnant women and leaded paint.
doi:10.1186/0778-7367-71-5
PMCID: PMC3620025  PMID: 23556999
Blood lead levels; Leaded gasoline; Children health; Phase out; Kinshasa
19.  Sodium reduction and the correction of iodine intake in Belgium: Policy options 
Archives of Public Health  2012;70(1):10.
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.
doi:10.1186/0778-7367-70-10
PMCID: PMC3461451  PMID: 22958752
Sodium; Iodine; Belgium
20.  Joint action on monitoring injuries in Europe (JAMIE) 
Archives of Public Health  2012;70(1):19.
Background
Injuries due to accidents or violence constitute a major public health problem globally and also within the 27 member states of the European Union (EU-MSs). In spite of the magnitude and the severity of the problem, injury surveillance systems are not yet sufficiently well developed to accurately quantify the burden of injuries on individuals, health services and society in the EU-region. Much of the injury information generated up until now is not comparable between countries, and not between registers, due to the lack of harmonised methodology and classification.
The hospital sector provides the best setting for collecting information as this information relates to the most severe cases (while less severe cases are treated by family doctors of school nurses for instance) and information can be obtained easily on a large number of cases at low cost (while surveys are expensive and suffering serious deficiencies as regards the specificity of data obtained). The WHO-International Classification of Diseases and its derivative classification on external causes of injuries provide the proper tools for standardised data collection on injuries treated within the health sector.
Project Objectives
JAMIE project aims at having by 2015 a common emergency departmental-based surveillance system for injury prevention in operation in all MS. Such a system should report on external causes of injuries due to accidents and violence as part of the Community Statistics on Public Health. The project will build on previous work on injury data exchange initiated by the European Commission (EC) and a number of EU-member states, which resulted to the so called Injury Data Base hosted by the EC.
In order to make injury data collection affordable for countries to collect and to have a greater number of countries joining the data exchange efforts, JAMIE envisages to have a relatively limited set data elements being collected in a representative sample of emergency departments in countries, while collecting in a few departments deeper information on the circumstances of the injury event.
doi:10.1186/0778-7367-70-19
PMCID: PMC3733502  PMID: 22958448
21.  Long-term care use and socio-economic status in Belgium: a survival analysis using health care insurance data 
Background
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.
Methods
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).
Results
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.
Conclusion
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.
doi:10.1186/0778-7367-71-1
PMCID: PMC3552700  PMID: 23286530
Long-term care; Socio-economic status; Morbidity; Mortality; Preferential status
22.  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
23.  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
24.  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
25.  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

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