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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.  Burden of frailty in the elderly population: perspectives for a public health challenge 
Archives of Public Health  2015;73(1):19.
Frailty is a major health condition associated with ageing. Although the concept is almost universally accepted, its operational definition remains controversial. Anyway, this geriatric condition represents a huge potential public health issue at both the patient and the societal levels because of its multiple clinical, societal consequences and its dynamic nature. Here, we review existing definitions and assessment tools for frailty, we highlight consequences of this geriatric condition and we discuss the importance of its screening and prevention to limit its public health burden.
doi:10.1186/s13690-015-0068-x
PMCID: PMC4392630  PMID: 25866625
Frailty; Elderly; Public health; Prevalence
5.  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
6.  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
7.  Assessment of knowledge and practice of health workers towards tuberculosis infection control and associated factors in public health facilities of Addis Ababa, Ethiopia: A cross-sectional study 
Archives of Public Health  2015;73(1):15.
Background
Tuberculosis is the leading causes of mortality among infectious diseases worldwide. The risk of transmission from patients to health workers is doubles that of the general population. The close contact to the infectious case before diagnosis is the major risk for tuberculosis infection. The aim of the study was to assess knowledge and practice of health professionals towards tuberculosis infection control and its associated factors in health facilities of Addis Ababa, Ethiopia.
Methods
A cross-sectional study was conducted from February 29 to April 15/2014 in selected health facilities in Addis Ababa. Five hundred ninety health workers were included in the study. The sample size was assigned to each health facility proportional to their number of health workers. Study subjects were selected from each stratum by simple random sampling technique. Interviewer administered structured questionnaire was used to collect information. Logistic regression was used to identify factors associated with knowledge and practice of health workers towards tuberculosis infection control.
Result
Five hundred eighty two participants with 98.6% response rate were involved in the study. Of these, 36.1% had poor knowledge and 51.7% unsatisfactory practice score towards tuberculosis infection control. Having more than six years working experience in health facility (AOR = 2.51; 95% CI: 1.5-4.1) and tuberculosis related training (AOR = 2.51 95% CI; 1.5, 4.1) were significantly associated with knowledge on tuberculosis infection control. Having experience in tuberculosis clinic (AOR =1.93; 95% CI: 1.12, 3.34) and tuberculosis related training (AOR = 1.48; 95% CI: 1.87, 2.51) were significantly associated with practice on tuberculosis infection control.
Conclusion
One third of health workers had relatively poor knowledge and nearly half of them had unsatisfactory practice on tuberculosis infection control. Tuberculosis training and work experiences in health facility are determinant factor to knowledge. Whereas tuberculosis related training and experience in tuberculosis clinic are predictor to practice. So, training of the health professionals, on job orientations of junior health workers, and farther study including private health workers are recommended.
doi:10.1186/s13690-015-0062-3
PMCID: PMC4377015  PMID: 25821581
Knowledge; Practices; Health worker; Tuberculosis infection control
8.  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
9.  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
10.  Implementing the European Core Health Indicators (ECHI) in the Netherlands: an overview of data availability 
Background
The European Commission, together with the European Union (EU) Member States, developed a core set of indicators for monitoring public health in the EU, the European Core Health Indicators (ECHI) shortlist. From 2009 to 2012 developmental work on the ECHI indicators continued within the framework of the Joint Action for European Community Health Indicators and Monitoring (ECHIM). In this article, we give the current state of affairs on the availability of data for the ECHI indicators in the Netherlands and show what progress has been made over the past 5 years. The information provided serves as an illustration of the challenges encountered in a European country when working on harmonising national data collections with international data delivery requirements.
Methods
To assess data availability, we consulted Dutch data experts and relevant websites and reports on health monitoring activities. We compared the available Dutch data with the definitions, preferred data sources and relevant dimensions as requested by ECHI.
Results
The Netherlands can provide data for 66 of the 75 ECHI indicators for which availability could be assessed: for all of the 48 ECHI indicators that can be extracted from international databases and for 18 of the 27 indicators not available from international databases. Breakdowns by socio-economic status and region are not possible for 23 (35%) of the total of 66 indicators for which data are available and for 21 (32%) of these 66 indicators the definition is not exactly the same as requested by ECHIM. Since 2009, better estimates have become available for low birth weight, practising physicians and practising nurses.
Moreover, several European initiatives to improve harmonised data collection are expected to have a positive effect on data availability for the Netherlands. Such initiatives should become sustainable in order to provide possibilities for monitoring trends. The scattered data ownership in the Netherlands complicates the coordination work for international data deliveries.
Conclusion
Data availability in the Netherlands is good. Since 2009, several Dutch and European developments in harmonising data collection have contributed or will significantly contribute to improvements in the data situation for the ECHI indicators in the Netherlands.
Electronic supplementary material
The online version of this article (doi:10.1186/s13690-014-0058-4) contains supplementary material, which is available to authorized users.
doi:10.1186/s13690-014-0058-4
PMCID: PMC4349313  PMID: 25741441
Public health; Monitoring; European Core Health Indicators; International comparisons; European Union; Netherlands
11.  Mode differences in a mixed-mode health interview survey among adults 
Archives of Public Health  2014;72(1):46.
Background
Health interview surveys are important data sources for empirical research in public health. However, the diversity of methods applied, such as in the mode of data collection, make it difficult to compare results across surveys, time, or countries. The aim of this study was to explore whether the prevalence rates of health-related indicators amongst adults differ when self-administered paper mail questionnaires (SAQ-Paper), self-administered web surveys (SAQ-Web), and computer-assisted telephone interviews (CATI) are used for data collection in a health survey.
Methods
Data were obtained from a population-based mixed-mode health interview survey of adults in Germany carried out within the ‘German Health Update’ (GEDA) study. Data were collected either by SAQ-Paper (n = 746), SAQ-Web (n = 414), or CATI (n = 411). Predictive margins from logistic regression models were used to estimate the prevalence rates of chronic conditions, subjective health, mental health, psychosocial factors, and health behaviours, adjusted for the socio-demographic characteristics of each mode group.
Results
Socio-demographic characteristics were found to differ significantly between study participants who responded by SAQ-Paper, SAQ-Web, and CATI. Crude prevalence rates for health-related indicators also showed significant variation across all three survey modes. After adjusting for socio-demographic factors though, significant differences in prevalence rates between the two self-administered modes (SAQ-Paper and SAQ-Web) were found in only 2 out of the 19 health-related indicators studied. The differences between CATI and the two self-administered modes remained significant however, especially for indicators of mental and psychosocial health and self-reported sporting activity.
Conclusions
The findings of this study indicate that prevalence rates obtained from health interview surveys can vary with the mode of data collection, primarily between interviewer and self-administered modes. Hence, the type of survey mode used should be considered when comparing results from different health surveys. Mixing self-administered modes, such as paper-based questionnaires and web surveys, may be a combination to minimize mode differences in mixed-mode health interview surveys.
Electronic supplementary material
The online version of this article (doi:10.1186/2049-3258-72-46) contains supplementary material, which is available to authorized users.
doi:10.1186/2049-3258-72-46
PMCID: PMC4373057  PMID: 25810913
Health surveys; Data collection; Public health surveillance; Mixed-mode; Survey methods; Mode effects; Health indicators
12.  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
13.  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
14.  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
15.  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
16.  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
17.  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
18.  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
19.  Mapping the cause-specific premature mortality reveals large between-districts disparity in Belgium, 2003–2009 
Archives of Public Health  2015;73(1):13.
Background
Reducing premature mortality is a crucial public health objective. The goal of this paper, beside updating previous mortality atlases with recent data, is to explore the relative between-districts disparity using a relative-scale map design.
Methods
Causes of deaths and population data were provided by Statistics Belgium. All deaths occurring in the periods 1993–1999 and 2003–2009, in people aged 1–74 residing in Belgium were included. Age-adjusted rates by cause of death were computed for both periods; the 2003-2009 rates were classified using a relative scale with a 10% change between each level and represented on chloropleths maps with a green-to-red divergent colour scheme centred on the national mean. This particular design allows the comparability across all the maps since a same meaning is given to a specific colour. The variation coefficient and the decile ratio were calculated and compared between the 2 periods.
Results
A clear-cut regional divide at the disadvantage of Wallonia, and to some extent, of Brussels, was seen for all-cause, cardiovascular, cerebrovascular, diabetes, alcohol-related, mental and neurological diseases and non-transport accidents premature mortality. A NE-SW pattern parallel to the French border was observed for Lip, Oral Cavity, Pharynx, Larynx and oesophageal cancers, while various patterns are observed for the other cancers. The highest rates of road accident mortality are observed in the Southern districts. Many of those patterns are in continuity with earlier observations. However, the pattern of diabetes and mental and neurological diseases are new features. The variation coefficient and the decile ratios increased by 10% between the 1993-1997 and 2003-2009 periods.
Conclusions
The use of a relative scale in the maps highlights the importance of the between-districts disparity in premature mortality, with for most causes, a clear-cut regional divide at the disadvantage of Wallonia; this health gap results of complex interactions between various factors, including the socioeconomic context, cultural habits and environmental influences, as well as public health policies. It should be considered as a warning signal, warranting the attention of the policy makers. Meanwhile, these results also highlight the potential for improvement in the more disadvantaged regions.
Electronic supplementary material
The online version of this article (doi:10.1186/s13690-015-0060-5) contains supplementary material, which is available to authorized users.
doi:10.1186/s13690-015-0060-5
PMCID: PMC4412101  PMID: 25922667
20.  Biological, psychological and social processes that explain celebrities’ influence on patients’ health-related behaviors 
Background
Celebrities can have substantial influence as medical advisors. However, their impact on public health is equivocal: depending on the advice’s validity and applicability, celebrity engagements can benefit or hinder efforts to educate patients on evidence-based practices and improve their health literacy. This meta-narrative analysis synthesizes multiple disciplinary insights explaining the influence celebrities have on people’s health-related behaviors.
Methods
Systematic searches of electronic databases BusinessSource Complete, Communication & Mass Media Complete, Humanities Abstracts, ProQuest Political Science, PsycINFO, PubMed, and Sociology Abstracts were conducted. Retrieved articles were used to inform a conceptual analysis of the possible processes accounting for the substantial influence celebrities may have as medical advisors.
Results
Fourteen mechanisms of celebrity influence were identified. According to the economics literature, celebrities distinguish endorsed items from competitors and can catalyze herd behavior. Marketing studies tell us that celebrities’ characteristics are transferred to endorsed products, and that the most successful celebrity advisors are those viewed as credible, a perception they can create with their success. Neuroscience research supports these explanations, finding that celebrity endorsements activate brain regions involved in making positive associations, building trust and encoding memories. The psychology literature tells us that celebrity advice conditions people to react positively toward it. People are also inclined to follow celebrities if the advice matches their self-conceptions or if not following it would generate cognitive dissonance. Sociology explains how celebrities’ advice spreads through social networks, how their influence is a manifestation of people’s desire to acquire celebrities’ social capital, and how they affect the ways people acquire and interpret health information.
Conclusion
There are clear and deeply rooted biological, psychological and social processes that explain how celebrities influence people’s health behaviors. With a better understanding of this phenomenon, medical professionals can work to ensure that it is harnessed for good rather than abused for harm. Physicians can discuss with their patients the validity of celebrity advice and share more credible sources of health information. Public health practitioners can debunk celebrities offering unsubstantiated advice or receiving inappropriate financial compensation, and should collaborate with well-meaning celebrities, leveraging their influence to disseminate medical practices of demonstrated benefit.
Electronic supplementary material
The online version of this article (doi:10.1186/2049-3258-73-3) contains supplementary material, which is available to authorized users.
doi:10.1186/2049-3258-73-3
PMCID: PMC4429495  PMID: 25973193
Medical advice; Celebrities; Health literacy; Evidence-based medicine
21.  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
22.  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
23.  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  PMID: 25708599
24.  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
25.  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

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