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1.  Planning ahead in public health? A qualitative study of the time horizons used in public health decision-making 
BMC Public Health  2008;8:415.
Background
In order to better understand factors that influence decisions for public health, we undertook a qualitative study to explore issues relating to the time horizons used in decision-making.
Methods
Qualitative study using semi-structured interviews. 33 individuals involved in the decision making process around coronary heart disease were purposively sampled from the UK National Health Service (national, regional and local levels), academia and voluntary organizations. Analysis was based on the framework method using N-VIVO software. Interviews were transcribed, coded and emergent themes identified.
Results
Many participants suggested that the timescales for public health decision-making are too short. Commissioners and some practitioners working at the national level particularly felt constrained in terms of planning for the long-term. Furthermore respondents felt that longer term planning was needed to address the wider determinants of health and to achieve societal level changes. Three prominent 'systems' issues were identified as important drivers of short term thinking: the need to demonstrate impact within the 4 year political cycle; the requirement to 'balance the books' within the annual commissioning cycle and the disruption caused by frequent re-organisations within the health service. In addition respondents suggested that the tools and evidence base for longer term planning were not well established.
Conclusion
Many public health decision and policy makers feel that the timescales for decision-making are too short. Substantial systemic barriers to longer-term planning exist. Policy makers need to look beyond short-term targets and budget cycles to secure investment for long-term improvement in public health.
doi:10.1186/1471-2458-8-415
PMCID: PMC2649072  PMID: 19094194
2.  The perceived impact of location privacy: A web-based survey of public health perspectives and requirements in the UK and Canada 
BMC Public Health  2008;8:156.
Background
The "place-consciousness" of public health professionals is on the rise as spatial analyses and Geographic Information Systems (GIS) are rapidly becoming key components of their toolbox. However, "place" is most useful at its most precise, granular scale – which increases identification risks, thereby clashing with privacy issues. This paper describes the views and requirements of public health professionals in Canada and the UK on privacy issues and spatial data, as collected through a web-based survey.
Methods
Perceptions on the impact of privacy were collected through a web-based survey administered between November 2006 and January 2007. The survey targeted government, non-government and academic GIS labs and research groups involved in public health, as well as public health units (Canada), ministries, and observatories (UK). Potential participants were invited to participate through personally addressed, standardised emails.
Results
Of 112 invitees in Canada and 75 in the UK, 66 and 28 participated in the survey, respectively. The completion proportion for Canada was 91%, and 86% for the UK. No response differences were observed between the two countries. Ninety three percent of participants indicated a requirement for personally identifiable data (PID) in their public health activities, including geographic information. Privacy was identified as an obstacle to public health practice by 71% of respondents. The overall self-rated median score for knowledge of privacy legislation and policies was 7 out of 10. Those who rated their knowledge of privacy as high (at the median or above) also rated it significantly more severe as an obstacle to research (P < 0.001). The most critical cause cited by participants in both countries was bureaucracy.
Conclusion
The clash between PID requirements – including granular geography – and limitations imposed by privacy and its associated bureaucracy require immediate attention and solutions, particularly given the increasing utilisation of GIS in public health. Solutions include harmonization of privacy legislation with public health requirements, bureaucratic simplification, increased multidisciplinary discourse, education, and development of toolsets, algorithms and guidelines for using and reporting on disaggregate data.
doi:10.1186/1471-2458-8-156
PMCID: PMC2396622  PMID: 18471295
3.  Development and evaluation of a leadership training program for public health emergency response: results from a Chinese study 
BMC Public Health  2008;8:377.
Background
Since the 9/11 attack and severe acute respiratory syndrome (SARS), the development of qualified and able public health leaders has become a new urgency in building the infrastructure needed to address public health emergencies. Although previous studies have reported that the training of individual leaders is an important approach, the systemic and scientific training model need further improvement and development. The purpose of this study was to develop, deliver, and evaluate a participatory leadership training program for emergency response.
Methods
Forty-one public health leaders (N = 41) from five provinces completed the entire emergency preparedness training program in China. The program was evaluated by anonymous questionnaires and semi-structured interviews held prior to training, immediately post-training and 12-month after training (Follow-up).
Results
The emergency preparedness training resulted in positive shifts in knowledge, self-assessment of skills for public health leaders. More than ninety-five percent of participants reported that the training model was scientific and feasible. Moreover, the response of participants in the program to the avian influenza outbreak, as well as the planned evaluations for this leadership training program, further demonstrated both the successful approaches and methods and the positive impact of this integrated leadership training initiative.
Conclusion
The emergency preparedness training program met its aims and objectives satisfactorily, and improved the emergency capability of public health leaders. This suggests that the leadership training model was effective and feasible in improving the emergency preparedness capability.
doi:10.1186/1471-2458-8-377
PMCID: PMC2605461  PMID: 18973664
4.  Establishing a nationwide emergency department-based syndromic surveillance system for better public health responses in Taiwan 
BMC Public Health  2008;8:18.
Background
With international concern over emerging infectious diseases (EID) and bioterrorist attacks, public health is being required to have early outbreak detection systems. A disease surveillance team was organized to establish a hospital emergency department-based syndromic surveillance system (ED-SSS) capable of automatically transmitting patient data electronically from the hospitals responsible for emergency care throughout the country to the Centers for Disease Control in Taiwan (Taiwan-CDC) starting March, 2004. This report describes the challenges and steps involved in developing ED-SSS and the timely information it provides to improve in public health decision-making.
Methods
Between June 2003 and March 2004, after comparing various surveillance systems used around the world and consulting with ED physicians, pediatricians and internal medicine physicians involved in infectious disease control, the Syndromic Surveillance Research Team in Taiwan worked with the Real-time Outbreak and Disease Surveillance (RODS) Laboratory at the University of Pittsburgh to create Taiwan's ED-SSS. The system was evaluated by analyzing daily electronic ED data received in real-time from the 189 hospitals participating in this system between April 1, 2004 and March 31, 2005.
Results
Taiwan's ED-SSS identified winter and summer spikes in two syndrome groups: influenza-like illnesses and respiratory syndrome illnesses, while total numbers of ED visits were significantly higher on weekends, national holidays and the days of Chinese lunar new year than weekdays (p < 0.001). It also identified increases in the upper, lower, and total gastrointestinal (GI) syndrome groups starting in November 2004 and two clear spikes in enterovirus-like infections coinciding with the two school semesters. Using ED-SSS for surveillance of influenza-like illnesses and enteroviruses-related infections has improved Taiwan's pandemic flu preparedness and disease control capabilities.
Conclusion
Taiwan's ED-SSS represents the first nationwide real-time syndromic surveillance system ever established in Asia. The experiences reported herein can encourage other countries to develop their own surveillance systems. The system can be adapted to other cultural and language environments for better global surveillance of infectious diseases and international collaboration.
doi:10.1186/1471-2458-8-18
PMCID: PMC2249581  PMID: 18201388
5.  Institutional trust and alcohol consumption in Sweden: The Swedish National Public Health Survey 2006 
BMC Public Health  2008;8:283.
Background
Trust as a measure of social capital has been documented to be associated with health. Mediating factors for this association are not well investigated. Harmful alcohol consumption is believed to be one of the mediating factors. We hypothesized that low social capital defined as low institutional trust is associated with harmful alcohol consumption.
Methods
Data from the 2006 Swedish National Survey of Public Health were used for analyses. The total study population comprised a randomly selected representative sample of 26.305 men and 30.584 women aged 16–84 years. Harmful alcohol consumption was measured using a short version the Alcohol Use Disorders Identification Test (AUDIT), developed and recommended by the World Health Organisation. Low institutional trust was defined based on trust in ten main welfare institutions in Sweden.
Results
Independent of age, country of birth and socioeconomic circumstances, low institutional trust was associated with increased likelihood of harmful alcohol consumption (OR (men) = 1.52, 95% CI 1.34–1.70) and (OR (women) = 1.50, 95% CI 1.35–1.66). This association was marginally altered after adjustment for interpersonal trust.
Conclusion
Findings of the present study show that lack of trust in institutions is associated with increased likelihood of harmful alcohol consumption. We hope that findings in the present study will inspire similar studies in other contexts and contribute to more knowledge on the association between institutional trust and lifestyle patterns. This evidence may contribute to policies and strategies related to alcohol consumption.
doi:10.1186/1471-2458-8-283
PMCID: PMC2527331  PMID: 18700949
6.  Socio-economic factors explain differences in public health-related variables among women in Bangladesh: A cross-sectional study 
BMC Public Health  2008;8:254.
Background
Worldwide one billion people are living in slum communities and experts projected that this number would double by 2030. Slum populations, which are increasing at an alarming rate in Bangladesh mainly due to rural-urban migration, are often neglected and characterized by poverty, poor housing, overcrowding, poor environment, and high prevalence of communicable diseases. Unfortunately, comparisons between women living in slums and those not living in slums are very limited in Bangladesh. The objectives of the study were to examine the association of living in slums (dichotomized as slum versus non-slum) with selected public health-related variables among women, first without adjusting for the influence of other factors and then in the presence of socio-economic variables.
Methods
Secondary data was used in this study. 120 women living in slums (as cases) and 480 age-matched women living in other areas (as controls) were extracted from the Bangladesh Demographic and Health Survey 2004. Many socio-economic and demographic variables were analysed. SPSS was used to perform simple as well as multiple analyses. P-values based on t-test and Wald test were also reported to show the significance level.
Results
Unadjusted results indicated that a significantly higher percent of women living in slums came from country side, had a poorer status by household characteristics, had less access to mass media, and had less education than women not living in slums. Mean BMI, knowledge of AIDS indicated by ever heard about AIDS, knowledge of avoiding AIDS by condom use, receiving adequate antenatal visits (4 or more) during the last pregnancy, and safe delivery practices assisted by skilled sources were significantly lower among women living in slums than those women living in other areas. However, all the unadjusted significant associations with the variable slum were greatly attenuated and became insignificant (expect safe delivery practices) when some socio-economic variables namely childhood place of residence, a composite variable of household characteristics, a composite variable of mass media access, and education were inserted into the multiple regression models. Taken together, childhood place of residence, the composite variable of mass media access, and education were the strongest predictors for the health related outcomes.
Conclusion
Reporting unadjusted findings of public health variables in women from slums versus non-slums can be misleading due to confounding factors. Our findings suggest that an association of childhood place of residence, mass media access and public health education should be considered before making any inference based on slum versus non-slum comparisons.
doi:10.1186/1471-2458-8-254
PMCID: PMC2496908  PMID: 18651946
7.  An analysis of hospital preparedness capacity for public health emergency in four regions of China: Beijing, Shandong, Guangxi, and Hainan 
BMC Public Health  2008;8:319.
Background
Hospital preparedness is critical for the early detection and management of public health emergency (PHE). Understanding the current status of PHE preparedness is the first step in planning to enhance hospitals' capacities for emergency response. The objective of this study is to understand the current status of hospital PHE preparedness in China.
Methods
Four hundred hospitals in four city and provinces of China were surveyed using a standardized questionnaire. Data related to hospital demographic data; PHE preparation; response to PHE in community; stockpiles of drugs and materials; detection and identification of PHE; procedures for medical treatment; laboratory diagnosis and management; staff training; and risk communication were collected and analyzed.
Results
Valid responses were received from 318 (79.5%) of the 400 hospitals surveyed. Of the valid responses, 264 (85.2%) hospitals had emergency plans; 93.3% had command centres and personnel for PHE; 22.9% included community organisations during the training for PHE; 97.4% could transport needed medical staff to a PHE; 53.1% had evaluated stockpiles of drugs; 61.5% had evaluated their supply systems; 55.5% had developed surveillance systems; and 74.6% could monitor the abnormity(See in appendix). Physicians in 80.2% of the analyzed hospitals reported up-to-date knowledge of their institution's PHE protocol. Of the 318 respondents, 97.4% followed strict laboratory regulations, however, only about 33.5% had protocols for suspected samples. Furthermore, only 59.0% could isolate and identify salmonella and staphylococcus and less than 5% could isolate and identify human H5N1 avian flu and SARS. Staff training or drill programs were reported in 94.5% of the institutions; 50.3% periodically assessed the efficacy of staff training; 45% had experts to provide psychological counselling; 12.1% had provided training for their medical staff to assess PHE-related stress. All of the above capacities related to the demographic characteristics of hospitals and will be discussed in-depth in this paper.
Conclusion
Our survey suggested that, at the time of the survey, hospital preparedness for PHE in China was at an early stage of development. Comprehensive measures should be taken to enhance hospital capacity in the prevention and management of PHE.
doi:10.1186/1471-2458-8-319
PMCID: PMC2567325  PMID: 18803860
8.  'People pull the rug from under your feet': barriers to successful public health programmes 
BMC Public Health  2008;8:173.
Background
A community public health programme, 'Breathing Space', aimed to tackle smoking in a low income area in Scotland. This paper draws on the qualitative process evaluation of a community-based initiative 'Breathing Space', which set out to tackle smoking in a low income area of Scotland, in order to explore user perceptions of key factors affecting implementation, and in particular to explore the implications of participant knowledge and expertise for programme stability and continuity.
Methods
The overall evaluation of Breathing Space used a quasi-experimental design and incorporated a detailed process evaluation. The process evaluation aimed to document development and implementation of the programme using a range of qualitative methods, including observation, in-depth interviews, focus groups and documentary analysis. The paper draws upon 59 semi-structured in-depth interviews which were carried out as part of the process evaluation.
Findings
Staff numbers from the multi-agency partnership dwindled across the lifecouof the programme and respondents identified lack of continuity as a key issue. While staff changes are an anticipated problem in programme implementation, here we draw on concepts of technicality and indeterminacy to explore the different aspects of public health programmes which are forfeited when individuals leave. The paper argues that, while technical components of public health programmes (such as the importance of staff complement and continuity) are widely recognised, it is the more indeterminate aspects, including the loss of key theoretical understanding underpinning the programme, which most affect programme delivery. Indeed, the paper suggests that, where inadequate planning and resources threaten the continuity of indeterminate knowledge, the success of public health programmes may be especially jeopardised.
Conclusion
Community-based programmes which rely strongly on partnership processes would benefit from early consideration of the potential risks associated with both expected and unexpected stakeholder change. Building in appropriate contingency plans is necessary for sustaining the theory and culture of the programme. Evaluations of innovative community development initiatives may benefit from a formative approach.
doi:10.1186/1471-2458-8-173
PMCID: PMC2408582  PMID: 18498632
9.  Timing of therapy for latent tuberculosis infection among immigrants presenting to a U.S. public health clinic: a retrospective study 
BMC Public Health  2008;8:158.
Background
In the U.S. more than half of incident tuberculosis (TB) cases occur in immigrants. Current guidelines recommend screening and treatment for latent TB infection (LTBI) within 5 years of arrival to the U.S. This study evaluates the timing of LTBI therapy among immigrants presenting for care to a public health TB clinic.
Methods
Retrospective chart review of patients prescribed LTBI treatment based on medical records from Prince Georges County Health Department.
Results
1882 immigrants received LTBI therapy at Prince Georges County Health Department between 1999 and 2004. 417 of these patients were diagnosed with LTBI through contact investigations and were excluded from the analysis. Among the remaining 1465 individuals, median time from arrival to the U.S. until initiation of LTBI therapy was 5 months (range 0–42.4 years). 16% of all immigrants initiated therapy more than 5 years after arrival to the U.S. A logistic regression model using risks identified on univariate analysis revealed that referral for therapy by non-immigration proceedings was the strongest predictor of initiation of therapy more than 5 years after arrival to the U.S. Other factors associated with > 5 year U.S. residence prior to initiation of LTBI therapy included female gender (adjusted odds ratio (AOR) 1.8, 95% CI 1.2–2.6), age ≥ 35 (AOR = 4.1, 95% 2.5–6.6), and originating from Latin American and the Caribbean (AOR = 1.9, 95% CI 1.3–3.0).
Conclusion
Foreign-born individuals who are not referred for LTBI therapy through immigration proceedings are less likely to receive LTBI therapy within 5 years of arrival to the U.S. These data highlight the need to explore other mechanisms for timely LTBI screening beyond services provided by immigration.
doi:10.1186/1471-2458-8-158
PMCID: PMC2394528  PMID: 18474110
10.  Are hygiene and public health interventions likely to improve outcomes for Australian Aboriginal children living in remote communities? A systematic review of the literature 
BMC Public Health  2008;8:153.
Background
Australian Aboriginal children living in remote communities still experience a high burden of common infectious diseases which are generally attributed to poor hygiene and unsanitary living conditions. The objective of this systematic literature review was to examine the epidemiological evidence for a relationship between various hygiene and public health intervention strategies, separately or in combination, and the occurrence of common preventable childhood infectious diseases. The purpose was to determine what intervention/s might most effectively reduce the incidence of skin, diarrhoeal and infectious diseases experienced by children living in remote Indigenous communities.
Methods
Studies were identified through systematically searching electronic databases and hand searching. Study types were restricted to those included in Cochrane Collaboration Effective Practice and Organisation of Care Review Group (EPOC) guidelines and reviewers assessed the quality of studies and extracted data using the same guidelines. The types of participants eligible were Indigenous populations and populations of developing countries. The types of intervention eligible for inclusion were restricted to those likely to prevent conditions caused by poor personal hygiene and poor living environments.
Results
The evidence showed that there is clear and strong evidence of effect of education and handwashing with soap in preventing diarrhoeal disease among children (consistent effect in four studies). In the largest well-designed study, children living in households that received plain soap and encouragement to wash their hands had a 53% lower incidence of diarrhoea (95% CI, 0.35, 0.59). There is some evidence of an effect of education and other hygiene behaviour change interventions (six studies), as well as the provision of water supply, sanitation and hygiene education (two studies) on reducing rates of diarrhoeal disease. The size of these effects is small and the quality of the studies generally poor.
Conclusion
Research which measures the effectiveness of hygiene interventions is complex and difficult to implement. Multifaceted interventions (which target handwashing with soap and include water, sanitation and hygiene promotion) are likely to provide the greatest opportunity to improve child health outcomes in remote Indigenous communities.
doi:10.1186/1471-2458-8-153
PMCID: PMC2397399  PMID: 18462504
11.  Impact of methodological "shortcuts" in conducting public health surveys: Results from a vaccination coverage survey 
BMC Public Health  2008;8:99.
Background
Lack of methodological rigor can cause survey error, leading to biased results and suboptimal public health response. This study focused on the potential impact of 3 methodological "shortcuts" pertaining to field surveys: relying on a single source for critical data, failing to repeatedly visit households to improve response rates, and excluding remote areas.
Methods
In a vaccination coverage survey of young children conducted in the Commonwealth of the Northern Mariana Islands in July 2005, 3 sources of vaccination information were used, multiple follow-up visits were made, and all inhabited areas were included in the sampling frame. Results are calculated with and without these strategies.
Results
Most children had at least 2 sources of data; vaccination coverage estimated from any single source was substantially lower than from all sources combined. Eligibility was ascertained for 79% of households after the initial visit and for 94% of households after follow-up visits; vaccination coverage rates were similar with and without follow-up. Coverage among children on remote islands differed substantially from that of their counterparts on the main island indicating a programmatic need for locality-specific information; excluding remote islands from the survey would have had little effect on overall estimates due to small populations and divergent results.
Conclusion
Strategies to reduce sources of survey error should be maximized in public health surveys. The impact of the 3 strategies illustrated here will vary depending on the primary outcomes of interest and local situations. Survey limitations such as potential for error should be well-documented, and the likely direction and magnitude of bias should be considered.
doi:10.1186/1471-2458-8-99
PMCID: PMC2346471  PMID: 18371195
12.  Cigarette and waterpipe smoking among adolescents in Estonia: HBSC survey results, 1994–2006 
BMC Public Health  2008;8:392.
Background
Smoking is a major single cause of preventable morbidity and premature mortality. Tobacco use among adolescents is a significant public health problem as smoking behaviour is undeniably established in adolescence. While cigarette smoking among adolescents has been a significant public health problem for years, waterpipe smoking is considered to be a new global public health threat. The objectives of this study were to describe trends of cigarette smoking and the prevalence of waterpipe smoking and to study the association between cigarette and waterpipe smoking among adolescents in Estonia.
Methods
This study was based on a four-yearly HBSC survey of health behaviour among school-aged children conducted in 1994–2006 in Estonia. It was a school-based survey of a nationally representative sample using standardized methodology. The target group of the survey were 11-, 13-, and 15-year-old schoolchildren (N = 13826), 6656 boys and 7170 girls. Cigarette and waterpipe smoking was determined on a 4-stage scale: every day, at least once a week, less than once a week, not smoking. Logistic regression analysis was applied to examine gender- and age-specific smoking trends and to study the association between cigarette and waterpipe smoking.
Results
Prevalence of smoking was higher among boys than girls in all age groups during the whole study period. The prevalence of cigarette smoking increased in 1994–2002 and then slightly decreased in both genders. The increase in smoking was larger among girls. Among girls, daily smoking increased during the whole study period. Among 15-year-old schoolchildren one-third of the boys and one quarter of the girls were cigarette smokers, 21% of the boys and 12% of the girls were daily smokers in 2006. One fourth of the boys and one sixth of the girls were waterpipe smokers. A logistic regression analysis revealed a strong association between cigarette and waterpipe smoking among schoolchildren.
Conclusion
The results of this study can significantly enhance the capacity to develop and implement tobacco prevention and control programmes among the youth in Estonia.
doi:10.1186/1471-2458-8-392
PMCID: PMC2613150  PMID: 19032756
13.  Ultra-brief intervention for problem drinkers: research protocol 
BMC Public Health  2008;8:298.
Background
Helping the large number of problem drinkers who will never seek treatment is a challenging issue. Public health initiatives employing educational materials or mass media campaigns have met with mixed success. However, clinical research has developed effective brief interventions to help problem drinkers. This project will employ an intervention that has been validated in clinical settings and then modified into an ultra-brief format suitable for use as a public health intervention. The major objective of this study is to conduct a randomized controlled trial to establish the effectiveness of an ultra-brief, personalized feedback intervention for problem drinkers.
Methods/design
Problem drinkers recruited on a baseline population telephone survey conducted in a major metropolitan city in Canada will be randomized to one of three conditions – a personalized feedback pamphlet condition, a control pamphlet condition, or a no intervention control condition. In the week after the baseline survey, households in the two pamphlet conditions will be sent their respective pamphlets. Changes in drinking will be assessed post intervention at three-month and six-month follow-ups. Drinking outcomes will be compared between experimental conditions using Structural Equation Modeling. The primary hypothesis is that problem drinkers from households who receive the personalized feedback pamphlet intervention will display significantly improved drinking outcomes at three and six-month follow-ups as compared to problem drinkers from households in the no intervention control condition. Secondary hypotheses will test the impact of the intervention on help seeking, and explore the mediating or moderating role of perceived drinking norms, perceived alcohol risks and the problem drinker's social reasons for drinking.
Discussion
This trial will provide information on the effectiveness of a pamphlet-based personalized feedback intervention for problem drinkers in a community setting.
Trial registration
ClinicalTrials.gov registration #NCT00688584.
doi:10.1186/1471-2458-8-298
PMCID: PMC2528012  PMID: 18727823
14.  Vouchers for scaling up insecticide-treated nets in Tanzania: Methods for monitoring and evaluation of a national health system intervention 
BMC Public Health  2008;8:205.
Background
The Tanzania National Voucher Scheme (TNVS) uses the public health system and the commercial sector to deliver subsidised insecticide-treated nets (ITNs) to pregnant women. The system began operation in October 2004 and by May 2006 was operating in all districts in the country. Evaluating complex public health interventions which operate at national level requires a multidisciplinary approach, novel methods, and collaboration with implementers to support the timely translation of findings into programme changes. This paper describes this novel approach to delivering ITNs and the design of the monitoring and evaluation (M&E).
Methods
A comprehensive and multidisciplinary M&E design was developed collaboratively between researchers and the National Malaria Control Programme. Five main domains of investigation were identified: (1) ITN coverage among target groups, (2) provision and use of reproductive and child health services, (3) "leakage" of vouchers, (4) the commercial ITN market, and (5) cost and cost-effectiveness of the scheme.
Results
The evaluation plan combined quantitative (household and facility surveys, voucher tracking, retail census and cost analysis) and qualitative (focus groups and in-depth interviews) methods. This plan was defined in collaboration with implementing partners but undertaken independently. Findings were reported regularly to the national malaria control programme and partners, and used to modify the implementation strategy over time.
Conclusion
The M&E of the TNVS is a potential model for generating information to guide national and international programmers about options for delivering priority interventions. It is independent, comprehensive, provides timely results, includes information on intermediate processes to allow implementation to be modified, measures leakage as well as coverage, and measures progress over time.
doi:10.1186/1471-2458-8-205
PMCID: PMC2442068  PMID: 18544162
15.  Prevalence and social environment of cigarette smoking in Cyprus youth 
BMC Public Health  2008;8:190.
Background
Tobacco use is the single most preventable cause of morbidity and mortality in humans. Limited data exist regarding the extent of the problem among Cyprus youth. We use the Global Youth Tobacco Survey to assess the prevalence of cigarette smoking among middle and high school students as well as the social environment in which this is taking place.
Methods
The survey was conducted by the Cyprus International Institute for the Environment and Public Health in association with Harvard School of Public Health. A two-stage cluster sample design was used to select a representative sample of students from middle and high schools registered with the Republic of Cyprus in 2005–2006. The study questionnaire consisted of 99 questions and participation in the survey was voluntary. Statistical analyses were performed taking into consideration the specific design of the study and the sample weights associated with each completed questionnaire.
Results
The prevalence of current smoking, defined as having smoked cigarettes on one or more days of the past 30 days, is 13% among boys and 7% among girls in middle schools, and 36% among boys and 23% among girls in high schools. Furthermore, 16% of middle school students and more than 24% of high school students that had never smoked indicated that they are likely to initiate smoking within the next year. Exposure to environmental tobacco smoke is also very high with 91% of students reporting being exposed to smoke in places outside home. In addition, more than 95% of current smokers reported that they had bought cigarettes in a store during the past month and were not refused cigarettes because of their age.
Conclusion
Smoking prevalence among Cyprus middle and high school students is high and there are indications of an increase in the prevalence of smoking among girls over the last few years. Susceptibility rates, exposure to second-hand smoke, and access to and availability of cigarettes to youth are also high and concerning. The present survey indicates that the problem of cigarette smoking among youth in Cyprus is significant and requires collective action immediately.
doi:10.1186/1471-2458-8-190
PMCID: PMC2435118  PMID: 18518947
16.  Systematic screening for unsafe driving due to medical conditions: Still debatable 
BMC Public Health  2008;8:27.
Background
Assessing people's ability to drive has become a public health concern in most industrialized countries. Although age itself is not a predictive factor of an increased risk for dangerous driving, the prevalence of medical conditions that may impair driving increases with age. Because the implementation of a screening for unsafe driving due to medical conditions is a public health issue, its usefulness should be judged using standardised criteria already proposed for screening for chronic disease. The aim of this paper is to propose standardised criteria suitable to assess the scientific validity of screening for unsafe driving due to medical conditions, and identify potential issues to be clarified before screening can be implemented and effective.
Discussion
Using criteria developed for screening for chronic diseases and published studies on driving with medical conditions, we specify six criteria to judge the opportunity of screening for unsafe driving due to medical conditions. This adaptation was needed because of the complexity of the natural history of medical conditions and their potential consequences on driving and road safety. We then illustrate that published studies pleading for or against screening for unsafe driving due to medical conditions fail to provide the needed documentation. Individual criteria were mentioned in 3 to 72% of 36 papers pleading for or against screening. Quantitative estimates of relevant indicators were provided in at most 42% of papers, and some data, such as the definition of an appropriate unsafe driving period were never provided.
Summary
The standardised framework described in this paper provides a template for assessing the effectiveness (or lack of effectiveness) of proposed measures for screening for unsafe driving due to medical conditions. Even if most criteria were mentioned in the published literature pleading for or against such a screening, the failure to find quantitative and evidence-based estimates of relevant indicators provides useful insight for further research.
doi:10.1186/1471-2458-8-27
PMCID: PMC2259338  PMID: 18215269
17.  Delayed Treatment of Diagnosed Pulmonary Tuberculosis in Taiwan 
BMC Public Health  2008;8:236.
Background
Mycobacterium tuberculosis infection is an ongoing public health problem in Taiwan. The National Tuberculosis Registry Campaign, a case management system, was implemented in 1997. This study examined this monitoring system to identify and characterize delayed treatment of TB patients.
Methods
Records of all tuberculosis cases treated in Taiwan from 2002 through 2005 were obtained from the National Tuberculosis Registry Campaign. Initiation of treatment more than 7 days after diagnosis was considered a long treatment delay.
Results
The study included 31,937 patients. The mean day of delayed treatment was 3.6 days. Most patients were treated immediately after diagnosis. The relationship between number of TB patients and days of delayed treatment after diagnosis exhibited a Power-law distribution. The long tail of the power-law distribution indicated that an extreme number occur cannot be neglected. Tuberculosis patients treated after an unusually long delay require close observation and follow up.
Conclusion
This study found that TB control is generally acceptabl in Taiwan; however, delayed treatment increases the risk of transmission. Improving the protocol for managing confirmed TB cases can minimize disease transmission.
doi:10.1186/1471-2458-8-236
PMCID: PMC2483710  PMID: 18620595
18.  Problem drinking and exceeding guidelines for 'sensible' alcohol consumption in Scottish men: associations with life course socioeconomic disadvantage in a population-based cohort study 
BMC Public Health  2008;8:302.
Background
With surveys suggesting that exceeding guidelines for 'sensible' alcohol intake is commonplace, the health and social impact of modifying intake on a population level is potentially considerable. If public health interventions are to be successfully implemented, it is first important to identify correlates of such behaviours, including socioeconomic disadvantage. This was the aim of the present study.
Methods
Population-representative cohort study of 576 men from the West of Scotland. Data on life course socioeconomic position were collected in 1988 (at around 55 years of age). Alcohol consumption patterns (detailed seven day recall) and problem drinking (CAGE questionnaire) were ascertained in 1990/2 (at around 59 years of age). A relative index of inequality was computed to explore the comparative strength of different indicators of social circumstances from different periods of the life course.
Results
Socioeconomic adversity in both early life and in adulthood was related to an increased risk of exceeding the weekly and daily alcohol guidelines, with adult indicators of socioeconomic position revealing the strongest associations. Of these, material indicators of socioeconomic deprivation in adulthood – car ownership, housing tenure – were marginally more strongly related to heavy alcohol intake and problem drinking than education, income and occupational social class. A substantial proportion of the influence of early life deprivation on alcohol intake was mediated via adult socioeconomic position. Similar results were apparent when problem drinking was the outcome of interest.
Conclusion
In men in this cohort, exposure to disadvantaged social circumstances across the lifecourse, but particularly in adulthood, is associated with detrimental patterns of alcohol consumption and problem drinking in late middle age.
doi:10.1186/1471-2458-8-302
PMCID: PMC2538536  PMID: 18761741
19.  Psychosocial risk factors in home and community settings and their associations with population health and health inequalities: A systematic meta-review 
BMC Public Health  2008;8:239.
Background
The effects of psychosocial risk factors on population health and health inequalities has featured prominently in epidemiological research literature as well as public health policy strategies. We have conducted a meta-review (a review of reviews) exploring how psychosocial factors may relate to population health in home and community settings.
Methods
Systematic review (QUORUM) of literature reviews (published in any language or country) on the health associations of psychosocial risk factors in community settings. The literature search included electronic and manual searches. Two reviewers appraised included reviews using criteria for assessing systematic reviews. Data from the more robust reviews were extracted, tabulated and synthesised.
Results
Thirty-one reviews met our inclusion criteria. These explored a variety of psychosocial factors including social support and networks, social capital, social cohesion, collective efficacy, participation in local organisations – and less favourable psychosocial risk factors such as demands, exposure to community violence or anti-social behaviour, exposure to discrimination, and stress related to acculturation to western society. Most of the reviews focused on associations between social networks/support and physical or mental health. We identified some evidence of favourable psychosocial environments associated with better health. Reviews also found evidence of unfavourable psychosocial risk factors linked to poorer health, particularly among socially disadvantaged groups. However, the more robust reviews each identified studies with inconclusive findings, as well as studies finding evidence of associations. We also identified some evidence of apparently favourable psychosocial risk factors associated with poorer health.
Conclusion
From the review literature we have synthesised, where associations have been identified, they generally support the view that favourable psychosocial environments go hand in hand with better health. Poor psychosocial environments may be health damaging and contribute to health inequalities. The evidence that underpins our understanding of these associations is of variable quality and consistency. Future research should seek to improve this evidence base, with more longitudinal analysis (and intervention evaluations) of the effects of apparently under-researched psychosocial factors such as control and participation within communities. Future policy interventions relevant to this field should be developed in partnership with researchers to enable a better understanding of psychosocial mechanisms and the effects of psychosocial interventions.
doi:10.1186/1471-2458-8-239
PMCID: PMC2503975  PMID: 18631374
20.  Opinions of married women about potential causes and triggers of intimate partner violence against women. A cross-sectional investigation in an Iranian city 
BMC Public Health  2008;8:209.
Background
Population-based perception studies on potential causes and triggers of intimate partner violence against women (IPVAW) may enlighten context-relevant primary preventive actions in settings where data are limited. This study, conducted in one specific city, deals with married women's opinions concerning potential causes and triggers of IPVAW and seeks to highlight areas of consensus and divergence in the views.
Methods
A convenient sample of women aged 25–45 years and married for at least 5 years was consecutively recruited in the 48 public health centres of Kermanshah city, where free health services are provided to mothers and children under 6 years old. Respondents were individually interviewed on site by trained and experienced female interviewers (response rate 94.3%). A structured pilot-tested questionnaire was used that consisted mainly of closed questions about individual assessment of the extent to which various items could be regarded as a potential cause, a potential trigger or a potential consequence of IPVAW. Individual item frequencies were compiled and the association between socio-demographic attributes of the spouses and also respondents' prior exposure to violence and women answers was explored.
Results
For most factors covered, women mainly "agreed" or "agreed very much" about their potential as a trigger or a cause of IPVAW; agreements were stronger for individual-related potential causes. Generally, women's socio-demographic characteristics and prior victimisation did not much affect the opinions they expressed. For some triggers however, women's own occupation and their husband's educational level affected how much in agreement they were.
Conclusion
The women interviewed consider that most potential causes and triggers proposed may, at some point in a relationship, engender IPVAW. In the main, their views are not much altered by their own and their husbands' socioeconomic position or their prior victimisation. It remains to be seen whether married men and, for that matter, even women married for a shorter duration or from other settings will answer in a similar manner.
doi:10.1186/1471-2458-8-209
PMCID: PMC2443141  PMID: 18549484
21.  Relationship between parental locus of control and caries experience in preschool children – cross-sectional survey 
BMC Public Health  2008;8:208.
Background
Due to high prevalence and serious impacts, childhood caries represents a public health issue. Behavioural risk factors such as locus of health control have been implicated in the development of the disease; however their association with childhood caries has not been thoroughly studied. The aim of this cross-sectional survey was to assess the relationship between parental locus of health control and caries experience and untreated caries of their preschool children in a representative sample in Czech Republic, adjusting for relevant sociodemographic characteristics.
Methods
A representative sample of 285 preschool children and their parents was recruited. Study data included children's dental status recorded in nurseries and parental questionnaires with 13 attitudinal items regarding locus of control (LoC) in caries prevention. The association between parental locus of control and children's caries experience and level of untreated caries was analysed using logistic regression, adjusting for the effect of key sociodemographic variables.
Results
There was a statistically highly significant linear trend between increased parental LoC and higher probability of the children to be free from untreated caries, independent from the effect of sociodemographic variables of children and parents. A similar highly statistically significant trend, although not entirely linear, and independent from sociodemographic variables was observed with respect to the chance of the children to be free from caries experience with increasing strength of parental LoC. After full adjustment, children in the strongest parental LoC quintile were 2.81 (1.23–6.42, p< 0.05) times more likely to be free from untreated caries in comparison to the weakest parental LoC quintile and 2.32 (1.02–5.25, p< 0.05) times more likely to be free from caries experience in comparison to the weakest parental LoC quintile.
Conclusion
The findings support the hypothesis that higher internal parental LoC is associated with better control of both untreated caries and caries experience in their preschool children and highlight that a more internal LoC within the family is advantageous in the prevention of dental caries.
doi:10.1186/1471-2458-8-208
PMCID: PMC2442069  PMID: 18547444
22.  Chinese version of the Global Youth Tobacco Survey: cross-cultural instrument adaptation 
BMC Public Health  2008;8:144.
Background
Tobacco smoking poses public health concerns because of its high risk for many chronic diseases. Most smokers begin using tobacco in their teens and recent reports indicate that smoking prevalence is climbing among youth. The Global Youth Tobacco Survey (GYTS) is a worldwide, school-based, tobacco-specific survey, but cross-cultural differences limit its effectiveness in international studies. Specifically, the GYTS assesses not only the prevalence of smoking, but also tobacco-related attitudes, school curricula, and advertisements, which are culturally influenced. Therefore, we conducted this study to develop a Chinese version of the GYTS for both national surveillance and international comparison.
Methods
The original English GYTS was translated and back translated using a cross-cultural adaptation process. The comprehensiveness and feasibility of using the Chinese-version GYTS were reviewed by a panel of 6 tobacco-control experts. The understandability and cultural relevance of the Chinese-version GYTS were discussed in a focus group of 5 schoolteachers and 8 students. The expert and focus group feedback was incorporated into a final Chinese version of the GYTS, which was administered to 382 students throughout Taiwan by multi-stage sampling from 10 randomly selected schools.
Results
The internal consistency (Cronbach's alpha) for the GYTS subscales (smoking susceptibility, attitude toward smoking, and media messages about smoking) ranged from 0.70 to 0.94. The internal logical agreement of responses ranged from 85.3 to 99.2%.
Conclusion
The Chinese version of the GYTS has good reliability and validity and can serve as the foundation for international comparison and tobacco control in Chinese-speaking communities.
doi:10.1186/1471-2458-8-144
PMCID: PMC2390538  PMID: 18447909
23.  Self-management of type 2 diabetes mellitus: a qualitative investigation from the perspective of participants in a nurse-led, shared-care programme in the Netherlands 
BMC Public Health  2008;8:91.
Background
Diabetes mellitus is a major public health problem. Little is known about how people with type 2 diabetes experience self-management in a nurse-led, shared-care programme. The purpose of this article is to report an empirically grounded conceptualization of self-management in the context of autonomy of people with type 2 diabetes.
Methods
This study has a qualitative descriptive, and exploratory design with an inductive approach. Data were collected by means of in-depth interviews. The sample consisted of older adults with type 2 diabetes in a nurse-led, shared-care setting. The data analysis was completed by applying the constant comparative analysis as recommended in grounded theory.
Results
People with type 2 diabetes use three kinds of self-management processes: daily, off-course, and preventive. The steps for daily self-management are adhering, adapting, and acting routinely. The steps for off-course self-management are becoming aware, reasoning, deciding, acting, and evaluating. The steps for preventive self-management are experiencing, learning, being cautious, and putting into practice. These processes are interwoven and recurring.
Conclusion
Self-management consists of a complex and dynamic set of processes and it is deeply embedded in one's unique life situation. Support from diabetes specialist nurses and family caregivers is a necessity of self-managing diabetes.
doi:10.1186/1471-2458-8-91
PMCID: PMC2292711  PMID: 18366665
24.  The prevalence of self-reported deliberate self harm in Irish adolescents 
BMC Public Health  2008;8:79.
Background
Deliberate self harm is major public health problem, in particular among young people. Although several studies have addressed the prevalence of deliberate self harm among young people in the community, little is known about the extent to which deliberate self harm comes to the attention of medical services, the self harm methods used and the underlying motives. The aim of this study was to determine the prevalence of deliberate self harm in adolescents and the methods, motives and help seeking behaviour associated with this behaviour.
Methods
A cross-sectional survey using an anonymous self-report questionnaire was administered in 39 schools in the Southern area of the Health Service Executive, Ireland. Of the 4,583 adolescents aged 15–17 years who were invited to participate in the survey, 3,881 adolescents took part (response: 85%).
Results
A lifetime history of DSH was reported by 9.1% (n = 333) of the adolescents. DSH was more common among females (13.9%) than males (4.3%). Self cutting (66.0%) and overdose (35.2%) were the most common DSH methods. A minority of participants accessed medical services after engaging in DSH (15.3%).
Conclusion
DSH is a significant problem in Irish adolescents and the vast majority do not come to the attention of health services. Innovative solutions for prevention and intervention are required to tackle DSH in adolescents.
doi:10.1186/1471-2458-8-79
PMCID: PMC2270271  PMID: 18307803
25.  Implementation of a national anti-tuberculosis drug resistance survey in Tanzania 
BMC Public Health  2008;8:427.
Background
A drug resistance survey is an essential public health management tool for evaluating and improving the performance of National Tuberculosis control programmes. The current manuscript describes the implementation of the first national drug resistance survey in Tanzania.
Methods
Description of the implementation process of a national anti-tuberculosis drug resistance survey in Tanzania, in relation to the study protocol and Standard Operating Procedures.
Results
Factors contributing positively to the implementation of the survey were a continuous commitment of the key stakeholders, the existence of a well organized National Tuberculosis Programme, and a detailed design of cluster-specific arrangements for rapid sputum transportation. Factors contributing negatively to the implementation were a long delay between training and actual survey activities, limited monitoring of activities, and an unclear design of the data capture forms leading to difficulties in form-filling.
Conclusion
Careful preparation of the survey, timing of planned activities, a strong emphasis on data capture tools and data management, and timely supervision are essential for a proper implementation of a national drug resistance survey.
doi:10.1186/1471-2458-8-427
PMCID: PMC2628900  PMID: 19116022

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