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1.  Methodological aspects of a GIS-based environmental health inspection program used in the Athens 2004 Olympic and Para Olympic Games 
BMC Public Health  2005;5:93.
Background
The use of geographical information system (GIS) technologies in public health surveillance is gradually gaining momentum around the world and many applications have already been reported in the literature. In this study, GIS technology was used to help county departments of Public Health to implement environmental health surveillance for the Athens 2004 Olympic and Para Olympic Games.
Methods
In order to assess the workload in each Olympic county, 19 registry forms and 17 standardized inspection forms were developed to register and inspect environmental health items requiring inspection (Hotels, restaurants, swimming pools, water supply system etc), respectively. Furthermore, related databases were created using Epi Info 2002 and a geographical information system (GIS) were used to implement an integrated Environmental Health inspection program. The project was conducted in Athens by the Olympic Planning Unit (OPU) of the National School of Public Health, in close cooperation with the Ministry of Health and Social Solidarity and the corresponding departments of Public Health in all municipalities that were scheduled to host events during the Athens 2004 Olympic and Para Olympic games.
Results
A total of 44,741 premises of environmental health interest were geocoded into GIS databases and several electronic maps were developed. Using such maps in association with specific criteria, we first identified the maximum workload required to execute environmental health inspections in all premises within the eleven Olympic County Departments of Public Health. Six different scenarios were created for each county, based on devised algorithms in order to design the most effective and realistic inspection program using the available inspectors from each municipality. Furthermore, GIS applications were used to organize the daily inspection program for the Olympic games, provide coloured displays of the inspection results and link those results with the public health surveillance of specific cases or outbreak investigation.
Conclusion
Our computerised program exhibited significant efficiency in facilitating the prudent use of public health resources in implementing environmental health inspections in densely populated urban areas as well as in rural counties. Furthermore, the application of simple algorithms in integrating human and other resources provided tailored and cost-effective applications to different public health agencies.
doi:10.1186/1471-2458-5-93
PMCID: PMC1232856  PMID: 16138924
2.  Public health education: A report from Mosul and a plan for change 
BMC Public Health  2005;5:29.
Background
Today Iraq suffers from severe shortages of food, medicine, clean water and adequate sanitation. Malnutrition and communicable diseases are major factors in the rising morbidity and mortality rates. However, supplies and equipment are insufficient or outmoded, and public health training is outdated. The Universities have been unable to help because under-funding and isolation from their professional colleagues has limited their effectiveness.
Methods
To revitalize public health education, we describe a partnership between a US education consortium and the University of Mosul that will be carried out in the next several years. The plan is based on "three R's": Recovery from the past damage due to war and neglect; Retooling of key public health faculty to remedy the years of isolation and restriction of activity; and Reestablishment of the University as a resource for the its constituents, for the community and for other educational institutions. In all these activities, Iraqi minorities, especially women, will participate and contribute.
Conclusion
The work to repair the public health educational infrastructure has just begun. When completed, it will represent a small but necessary step in restoring normalcy to the people of Mosul, and of Iraq.
doi:10.1186/1471-2458-5-29
PMCID: PMC1087850  PMID: 15801984
3.  Health system outcomes and determinants amenable to public health in industrialized countries: a pooled, cross-sectional time series analysis 
BMC Public Health  2005;5:81.
Background
Few studies have tried to assess the combined cross-sectional and temporal contributions of a more comprehensive set of amenable factors to population health outcomes for wealthy countries during the last 30 years of the 20th century. We assessed the overall ecological associations between mortality and factors amenable to public health. These amenable factors included addictive and nutritional lifestyle, air quality, public health spending, healthcare coverage, and immunizations.
Methods
We used a pooled cross-sectional, time series analysis with corrected fixed effects regression models in an ecological design involving eighteen member countries of the Organisation for Economic Cooperation and Development during the period 1970 to 1999.
Results
Alcohol, tobacco, and fat consumption, and sometimes, air pollution were significantly associated with higher all-cause mortality and premature death. Immunizations, health care coverage, fruit/vegetable and protein consumption, and collective health expenditure had negative effects on mortality and premature death, even after controlling for the elderly, density of practicing physicians, doctor visits and per capita GDP. However, tobacco, air pollution, and fruit/vegetable intake were sometimes sensitive to adjustments.
Conclusion
Mortality and premature deaths could be improved by focusing on factors that are amenable to public health policies. Tackling these issues should be reflected in the ongoing assessments of health system performance.
doi:10.1186/1471-2458-5-81
PMCID: PMC1185550  PMID: 16076396
4.  An automated, broad-based, near real-time public health surveillance system using presentations to hospital Emergency Departments in New South Wales, Australia 
BMC Public Health  2005;5:141.
Background
In a climate of concern over bioterrorism threats and emergent diseases, public health authorities are trialling more timely surveillance systems. The 2003 Rugby World Cup (RWC) provided an opportunity to test the viability of a near real-time syndromic surveillance system in metropolitan Sydney, Australia. We describe the development and early results of this largely automated system that used data routinely collected in Emergency Departments (EDs).
Methods
Twelve of 49 EDs in the Sydney metropolitan area automatically transmitted surveillance data from their existing information systems to a central database in near real-time. Information captured for each ED visit included patient demographic details, presenting problem and nursing assessment entered as free-text at triage time, physician-assigned provisional diagnosis codes, and status at departure from the ED. Both diagnoses from the EDs and triage text were used to assign syndrome categories. The text information was automatically classified into one or more of 26 syndrome categories using automated "naïve Bayes" text categorisation techniques. Automated processes were used to analyse both diagnosis and free text-based syndrome data and to produce web-based statistical summaries for daily review. An adjusted cumulative sum (cusum) was used to assess the statistical significance of trends.
Results
During the RWC the system did not identify any major public health threats associated with the tournament, mass gatherings or the influx of visitors. This was consistent with evidence from other sources, although two known outbreaks were already in progress before the tournament. Limited baseline in early monitoring prevented the system from automatically identifying these ongoing outbreaks. Data capture was invisible to clinical staff in EDs and did not add to their workload.
Conclusion
We have demonstrated the feasibility and potential utility of syndromic surveillance using routinely collected data from ED information systems. Key features of our system are its nil impact on clinical staff, and its use of statistical methods to assign syndrome categories based on clinical free text information. The system is ongoing, and has expanded to cover 30 EDs. Results of formal evaluations of both the technical efficiency and the public health impacts of the system will be described subsequently.
doi:10.1186/1471-2458-5-141
PMCID: PMC1361771  PMID: 16372902
5.  International public health research involving interpreters: a case study from Bangladesh 
BMC Public Health  2005;5:71.
Background
Cross-cultural and international research are important components of public health research, but the challenges of language barriers and working with interpreters are often overlooked, particularly in the case of qualitative research.
Methods
A case-study approach was used to explore experiences of working with an interpreter in Bangladesh as part of a research project investigating women's experiences of emergency obstetric care.
The case study
Data from the researcher's field notes provided evidence of experiences in working with an interpreter and show how the model of interviewing was adapted over time to give a more active role to the interpreter. The advantages of a more active role were increased rapport and "flow" in interviews. The disadvantages included reduced control from the researcher's perspective. Some tensions between the researcher and interpreter remained hard to overcome, irrespective of the model used. Independent transcription and translation of the interviews also raised questions around accuracy in translation.
Conclusion
The issues examined in this case study have broader implications for public health research. Further work is needed in three areas: 1) developing effective relationships with interpreters; 2) the impact of the interpreter on the research process; and 3) the accuracy of the translation and level of analysis needed in any specific public health research. Finally, this paper highlights the importance to authors of reflecting on the potential impact of translation and interpretation on the research process when disseminating their research.
doi:10.1186/1471-2458-5-71
PMCID: PMC1200559  PMID: 15985161
6.  Time trends in the impact factor of Public Health journals 
BMC Public Health  2005;5:24.
Background
Journal impact factor (IF) is linked to the probability of a paper being cited and is progressively becoming incorporated into researchers' curricula vitae. Furthermore, the decision as to which journal a given study should be submitted, may well be based on the trend in the journal's overall quality. This study sought to assess time trends in journal IF in the field of public, environmental and occupational health.
Methods
We used the IFs of 80 public health journals that were registered by the Science Citation Index from 1992 through 2003 and had been listed for a minimum period of the previous 3 years. Impact factor time trends were assessed using a linear regression model, in which the dependent variable was IF and the independent variable, the year. The slope of the model and its statistical significance were taken as the indicator of annual change.
Results
The IF range for the journals covered went from 0.18 to 5.2 in 2003. Although there was no statistical association between annual change and mean IF, most of the fastest growing journals registered mean IFs in excess of 1.5, and some represented emerging areas of public health research. Graphs displaying IF trends are shown.
Conclusion
In view of the delay between the publication of IFs and that of any given paper, knowing the trend in IF is essential in order to make a correct choice of journal.
doi:10.1186/1471-2458-5-24
PMCID: PMC555948  PMID: 15777471
7.  An evaluation of a morphine public health programme for cancer and AIDS pain relief in Sub-Saharan Africa 
BMC Public Health  2005;5:82.
Background
Despite growing HIV and cancer prevalence in Sub-Saharan Africa, and WHO advocacy for a public health approach to palliative care provision, opioid availability is severely limited. Uganda has achieved a morphine roll-out programme in partnership with the Ministry of Health. This study aimed to evaluate that programme by identifying challenges to implementation that may inform replication.
Methods
A multi-methods protocol appraised morphine regulation, storage, prescribing, and consumption in three phases: key informant interviews throughout the opioid supply chain, and direct observation and audit of clinical practice.
Results
Regulation had achieved its goal of preventing misuse and leakage from the supply chain. However, the Government felt that relaxation of regulation was now appropriate. Confusion and complexity in storage and authorisation rules led to discontinuation of opioid pain management at the patient level and also wasted service time in trying to obtain supplies to which they were entitled. Continued neglect to prescribe among clinicians and public fear of opioids led to under prescribing, and clinical skills showed some evidence of need for improvement with respect to physical assessment and follow-up.
Conclusion
The Ugandan programme offers a successful model for both advocacy and Governmental support in achieving opioid roll-out across health districts. Despite initial concerns, abuse of opioids has not been evident. Further work is required to ensure that available supplies of opioids are prescribed to those in need, and that clinical standards are met. However, the programme for roll-out has proved a useful model to expand opioid availability as the first step in improving patient care, and may prove a useful template for other Sub-Saharan African countries.
doi:10.1186/1471-2458-5-82
PMCID: PMC1232854  PMID: 16092958
8.  Parental educational level and cardiovascular disease risk factors in schoolchildren in large urban areas of Turkey: Directions for public health policy 
BMC Public Health  2005;5:13.
Background
It is widely accepted that the development of atherosclerosis starts at an early age. However, there are very few studies evaluating the prevalence of the common clinical and behavioral cardiovascular disease (CVD) risk factors among children, especially in developing countries. The aim of the present cross-sectional survey was to evaluate the distribution of blood lipid profile and various behavioral (i.e. dietary habits, physical activity status) factors related to CVD risk and its relationships to paternal (PEL) and maternal educational level (MEL) among primary schoolchildren in Turkey.
Methods
In three major metropolises in Turkey (Istanbul, Ankara and Izmir), a random sample of 1044 children aged 12 and 13 years old was examined. ANOVA was applied to evaluate the tested hypothesis, after correcting for multiple comparisons (Tukey correction).
Results
After controlling for energy and fat intake, physical activity status and Body Mass Index (BMI), it was found that mostly PEL had a significant positive effect for most of the subgroups examined (Lower vs. Higher and Medium vs. Higher) on TC and HDL-cholesterol and a negative effect on TC/HDL ratio for both genders. Furthermore, both boys and girls with higher PEL and MEL were found to have higher energy intake derived from fat and protein than their counterparts with Medium and Lower PEL and MEL, while the opposite was observed for the percentage of energy derived from carbohydrates.
Conclusions
Our study provides indications for a possible association between an adverse lipid profile, certain dietary patterns and Higher PEL and MEL among schoolchildren in Turkey. These findings underline the possible role of social status, indicated by the degree of education of both parents, in developing certain health behaviors and health indices among Turkish children and provide some guidance for Public Health Policy.
doi:10.1186/1471-2458-5-13
PMCID: PMC549186  PMID: 15693995
Educational level; parents; adolescents; cholesterol; developing country; diet; physical activity
9.  Cardiovascular comorbidities among public health clinic patients with diabetes: the Urban Diabetics Study 
BMC Public Health  2005;5:15.
Background
We sought to determine the frequency and distribution of cardiovascular comorbidities in a large cohort of low-income patients with diabetes who had received primary care for diabetes at municipal health clinics.
Methods
Outpatient data from the Philadelphia Health Care Centers was linked with hospital discharge data from all Pennsylvania hospitals and death certificates.
Results
Among 10,095 primary care patients with diabetes, with a mean observation period of 4.6 years (2.8 after diabetes diagnosis), 2,693 (14.3%) were diagnosed with heart disease, including 270 (1.4%) with myocardial infarction and 912 (4.8%) with congestive heart failure. Cerebrovascular disease was diagnosed in 588 patients (3.1%). Over 77% of diabetic patients were diagnosed with hypertension. Incidence rates of new complications ranged from 0.6 per 100 person years for myocardial infarction to 26.5 per 100 person years for hypertension. Non-Hispanic whites had higher rates of myocardial infarction, and Hispanics and Asians had fewer comorbid conditions than African Americans and non-Hispanic whites.
Conclusion
Cardiovascular comorbidities were common both before and after diabetes diagnosis in this low-income cohort, but not substantially different from mixed-income managed care populations, perhaps as a consequence of access to primary care and pharmacy services.
doi:10.1186/1471-2458-5-15
PMCID: PMC550650  PMID: 15701166
10.  Permissive nicotine regulation as a complement to traditional tobacco control 
BMC Public Health  2005;5:18.
Background
Cigarette smoking takes a staggering toll on human health and attracts considerable public health attention, yet real solutions seem distant. The 2004 Family Smoking Prevention and Tobacco Control Act (US Senate bill S2461) would have given the US Food and Drug Administration limited authority to regulate cigarettes to "protect the public health." However, such legislation is unlikely to substantially reduce smoking or related deaths.
Discussion
The past 500 years of tobacco control efforts demonstrate that nicotine prohibition is a practical impossibility for numerous reasons, state revenue being one of the most ominous. The FDA already has regulatory authority over pharmaceutical grade nicotine products, and requires pharmacists to dispense the most addictive of these only with prescriptions. Meanwhile, every corner store can sell far more addictive and dangerous cigarettes to any adult. The FDA could immediately increase competition between cigarettes and clean nicotine products by approving available nicotine products for over-the-counter sales to adults. Similarly permissive regulation of cigarettes and addictive nicotine products will reduce tobacco use and improve smokers' health, but increase nicotine use in the population. Fortunately, restricted youth access and accurate labeling of nicotine's absolute risks will dissuade many non-smokers from experimenting with it, while accurate depiction of its risks relative to cigarette smoking will encourage many smokers to switch. The FDA could take a series of small steps that might ultimately replace a large proportion of cigarette smoking with equally addictive nicotine products, without risking serious public health setbacks. Vaccine, methadone, and injury prevention policies establish relevant public health precedents.
Summary
Cigarettes, or an equally addictive alternative, will be a permanent and common product in most societies. Regulations restricting only the safest addictive nicotine products are hard to justify. Addictive nicotine compliments other tobacco control strategies. Modern tobacco control policies are applicable to addictive nicotine. Controlled trials and test market studies are urgently needed to evaluate addictive nicotine as an alternative to smoking. Meanwhile, legislators should preserve the Food and Drug Administration's option to permit non-prescription sales of addictive nicotine.
doi:10.1186/1471-2458-5-18
PMCID: PMC554785  PMID: 15730554
11.  Blood pressure patterns in rural, semi-urban and urban children in the Ashanti region of Ghana, West Africa 
BMC Public Health  2005;5:114.
Background
High blood pressure, once rare, is rapidly becoming a major public health burden in sub-Saharan/Africa. It is unclear whether this is reflected in children. The main purpose of this study was to assess blood pressure patterns among rural, semi-urban, and urban children and to determine the association of blood pressure with locality and body mass index (BMI) in this sub-Saharan Africa setting.
Methods
We conducted a cross-sectional survey among school children aged 8–16 years in the Ashanti region of Ghana (West-Africa). There were 1277 children in the study (616 boys and 661 females). Of these 214 were from rural, 296 from semi-urban and 767 from urban settings.
Results
Blood pressure increased with increasing age in rural, semi-urban and urban areas, and in both boys and girls. The rural boys had a lower systolic and diastolic blood pressure than semi-urban boys (104.7/62.3 vs. 109.2/66.5; p < 0.001) and lower systolic blood pressure than urban boys (104.7 vs. 107.6; p < 0.01). Girls had a higher blood pressure than boys (109.1/66.7 vs. 107.5/63.8; p < 0.01). With the exception of a lower diastolic blood pressure amongst rural girls, no differences were found between rural girls (107.4/64.4) and semi-urban girls (108.0/66.1) and urban girls (109.8/67.5). In multiple linear regression analysis, locality and BMI were independently associated with blood pressure in both boys and girls.
Conclusion
These findings underscore the urgent need for public health measures to prevent increasing blood pressure and its sequelae from becoming another public health burden. More work on blood pressure in children in sub-Saharan African and other developing countries is needed to prevent high blood pressure from becoming a major burden in many of these countries.
doi:10.1186/1471-2458-5-114
PMCID: PMC1289286  PMID: 16262905
12.  Development and evaluation of a hand held computer based on-call pack for health protection out of hours duty: A pilot study 
BMC Public Health  2005;5:35.
Background
The on call service for health protection in most parts of the UK is provided by general public health consultants, registrars and nurses as the first tier of response backed up by medical consultants in health protection. The first tier responder usually carries a large bag of papers containing both local and national guidance on the management of common cases/incidents. An electronic on call pack may provide a suitable practical alternative to large paper based systems and help professionals deliver out of hours health protection advice and response to incidents.
Methods
We developed and piloted an electronic on call pack in Hertfordshire for use at the health protection unit level containing key local and national guidelines, contact information and useful references. The on-call pack was initially piloted using a laptop and more recently using a personal digital assistant (PDA). The use of the on-call pack was evaluated.
Results
Key advantages of the electronic system include reduced size, faster access to information that is clearly indexed and the relative ease of updating information. As part of the pilot, the electronic on call pack was presented to a local and regional training meeting with good response from participants using qualitative and quantitative methods.
Conclusion
It is anticipated that with suitable evaluation this system can be adapted and utilised by other health protection practitioners. This system provides a fast, reliable and easily maintained source of information for the public health on-call team.
doi:10.1186/1471-2458-5-35
PMCID: PMC1084354  PMID: 15823207
13.  Patients' request for and emergency physicians' prescription of antimicrobial prophylaxis for anthrax during the 2001 bioterrorism-related outbreak 
BMC Public Health  2005;5:2.
Background
Inappropriate use of antibiotics by individuals worried about biological agent exposures during bioterrorism events is an important public health concern. However, little is documented about the extent to which individuals with self-identified risk of anthrax exposure approached physicians for antimicrobial prophylaxis during the 2001 bioterrorism attacks in the United States.
Methods
We conducted a telephone survey of randomly selected members of the Pennsylvania Chapter of the American College of Emergency Physicians to assess patients' request for and emergency physicians' prescription of antimicrobial agents during the 2001 anthrax attacks.
Results
Ninety-seven physicians completed the survey. Sixty-four (66%) respondents had received requests from patients for anthrax prophylaxis; 16 (25%) of these physicians prescribed antibiotics to a total of 23 patients. Ten physicians prescribed ciprofloxacin while 8 physicians prescribed doxycycline.
Conclusion
During the 2001 bioterrorist attacks, the majority of the emergency physicians we surveyed encountered patients who requested anthrax prophylaxis. Public fears may lead to a high demand for antibiotic prophylaxis during bioterrorism events. Elucidation of the relationship between public health response to outbreaks and outcomes would yield insights to ease burden on frontline clinicians and guide strategies to control inappropriate antibiotic allocation during bioterrorist events.
doi:10.1186/1471-2458-5-2
PMCID: PMC546188  PMID: 15634353
14.  Public perception of drinking water from private water supplies: focus group analyses 
BMC Public Health  2005;5:129.
Background
Over four million Canadians receive their drinking water from private water supplies, and numerous studies report that these supplies often exceed the minimal acceptable standards for contamination. Canadians in rural areas test their water intermittently, if at all, and treatment of water from private supplies is not common. Understanding the perceptions of drinking water among residents served by private systems will enable public health professionals to better target education and outreach activities, and to address the needs and concerns of residents in their jurisdictions. The purpose of this study was to explore the drinking water perceptions and self-described behaviours and needs of participants served by private water systems in the City of Hamilton, Ontario (Canada).
Methods
In September 2003, three focus group discussions were conducted; two with men and women aged 36–65 years, and one with men and women 20–35 years of age.
Results
Overall, participants had positive perceptions of their private water supplies, particularly in the older age group. Concerns included bacterial and chemical contamination from agricultural sources. Testing of water from private supplies was minimal and was done less frequently than recommended by the provincial government. Barriers to water testing included the inconvenience of the testing process, acceptable test results in the past, resident complacency and lack of knowledge. The younger participants greatly emphasized their need for more information on private water supplies. Participants from all groups wanted more information on water testing, and various media for information dissemination were discussed.
Conclusion
While most participants were confident in the safety of their private water supply, the factual basis for these opinions is uncertain. Improved dissemination of information pertaining to private water supplies in this population is needed. Observed differences in the concerns expressed by users of different water systems and age groups may suggest the need for targeted public education strategies. These focus groups provided significant insight into the public perception of private water supplies and the need for public health outreach activities; however, to obtain a more representative understanding of the perceptions in this population, it is important that a larger scale investigation be performed.
doi:10.1186/1471-2458-5-129
PMCID: PMC1325020  PMID: 16336678
15.  Safer injections following a new national medicine policy in the public sector, Burkina Faso 1995 – 2000 
BMC Public Health  2005;5:136.
Background
The common failure of health systems to ensure adequate and sufficient supplies of injection devices may have a negative impact on injection safety. We conducted an assessment in April 2001 to determine to which extent an increase in safe injection practices between 1995 and 2000 was related to the increased access to injection devices because of a new essential medicine policy in Burkina Faso.
Methods
We reviewed outcomes of the new medicine policy implemented in1995. In April 2001, a retrospective programme review assessed the situation between 1995 and 2000. We visited 52 health care facilities where injections had been observed during a 2000 injection safety assessment and their adjacent operational public pharmaceutical depots. Data collection included structured observations of available injection devices and an estimation of the proportion of prescriptions including at least one injection. We interviewed wholesaler managers at national and regional levels on supply of injection devices to public health facilities.
Results
Fifty of 52 (96%) health care facilities were equipped with a pharmaceutical depot selling syringes and needles, 37 (74%) of which had been established between 1995 and 2000. Of 50 pharmaceutical depots, 96% had single-use 5 ml syringes available. At all facilities, patients were buying syringes and needles out of the depot for their injections prescribed at the dispensary. While injection devices were available in greater quantities, the proportion of prescriptions including at least one injection remained stable between 1995 (26.5 %) and 2000 (23.8 %).
Conclusion
The implementation of pharmaceutical depots next to public health care facilities increased geographical access to essential medicines and basic supplies, among which syringes and needles, contributing substantially to safer injection practices in the absence of increased use of therapeutic injections.
doi:10.1186/1471-2458-5-136
PMCID: PMC1343564  PMID: 16364178
16.  Rationale, design and conduct of a comprehensive evaluation of a school-based peer-led anti-smoking intervention in the UK: the ASSIST cluster randomised trial [ISRCTN55572965] 
BMC Public Health  2005;5:43.
Background
To date, no school-based intervention has been proven to be effective in preventing adolescent smoking, despite continuing concern about smoking levels amongst young people in the United Kingdom. Although formal teacher-led smoking prevention interventions are considered unlikely to be effective, peer-led approaches to reducing smoking have been proposed as potentially valuable.
Methods/design
ASSIST (A Stop Smoking in Schools Trial) is a comprehensive, large-scale evaluation to rigorously test whether peer supporters in Year 8 (age 11–12) can be recruited and trained to effect a reduction in smoking uptake among their fellow students. The evaluation is employing a cluster randomised controlled trial (RCT) design with secondary school as the unit of randomisation, and is being undertaken in 59 schools in South East Wales and the West of England. Embedded within the trial are an economic evaluation of the intervention costs, a process evaluation to provide detailed information on how the intervention was delivered and received, and an analysis of social networks to consider whether such a peer group intervention could work amongst schoolchildren in this age group.
Schools were randomised to either continue with normal smoking education (n = 29 schools, 5562 students), or to do so and additionally receive the ASSIST intervention (n = 30 schools, 5481 students). No schools withdrew once the trial had started, and the intervention was successfully implemented in all 30 schools, with excellent participation rates from the peer supporters. The primary outcome is regular (weekly) smoking, validated by salivary cotinine, and this outcome has been obtained for 94.4%, 91.0% and 95.6% of eligible students at baseline, immediate post-intervention, and one-year follow-up respectively.
Discussion
Comprehensive evaluations of complex public health interventions of this scale and nature are rare in the United Kingdom. This paper demonstrates the feasibility of conducting cluster RCTs of complex public health interventions in schools, and how the rigour of such designs can be maximised both by thorough implementation of the protocol and by broadening the scope of questions addressed in the trial by including additional evaluative components.
doi:10.1186/1471-2458-5-43
PMCID: PMC1097740  PMID: 15847695
17.  Lithuanian health care in transitional state: ethical problems 
BMC Public Health  2005;5:117.
Background
Throughout the economic and political reforms in post-communist countries, significant changes have also occurred in public morality. One of the tasks of the Lithuanian health policy is to create mechanisms for strengthening the significance of ethical considerations in the decision-making processes concerning health care of individuals and groups of individuals, as well as considering the positions of physicians and the health care system itself in a general way. Thus, health care ethics could be analyzed at two levels: the micro level (the ethics of doctor-patient relationships) and the macro level (the ethics of health policy-making, which can be realized by applying the principles of equal access, reasonable quality, affordable care and shared responsibilities). To date, the first level remains dominant, but the need arises for our attention to refocus now from the micro level to the patterns of managing and delivering care, managing the health care resources, and conducting business practices.
Discussion
In attempting to increase the efficiency of health services in Lithuania, a common strategy has been in place for the last fifteen years. Decentralization and privatization have been implemented as part of its policy to achieve greater efficiency. Although decentralization in theory is supposed to improve efficiency, in practice the reform of decentralization has still to be completely implemented in Lithuania. Debates on health policy in Lithuania also include the issue of private versus public health care. Although the approach of private health care is changing in a positive way, it is obvious that reduced access to health services is the most vulnerable aspect. In the Lithuanian Health Program adopted in July 1998, the target of equity was stressed, stating that by 2010, differences in health and health care between various socio-economic groups should be reduced by 25%.
Summary
The restructuring of health care system in Lithuania should be based on a balance between decentralization and centralization, and between public and private health care sectors. Successful transition requires a balanced role of the government. Today it is obvious in Lithuania that continuous encouragement to make sacrifices was not enough to induce the system to function well, and in an ethical manner.
doi:10.1186/1471-2458-5-117
PMCID: PMC1310618  PMID: 16281969
18.  A mass vaccination campaign targeting adults and children to prevent typhoid fever in Hechi; Expanding the use of Vi polysaccharide vaccine in Southeast China: A cluster-randomized trial 
BMC Public Health  2005;5:49.
Background
One of the goals of this study was to learn the coverage, safety and logistics of a mass vaccination campaign against typhoid fever in children and adults using locally produced typhoid Vi polysaccharide (PS) and group A meningococcal PS vaccines in southern China.
Methods
The vaccination campaign targeted 118,588 persons in Hechi, Guangxi Province, aged between 5 to 60 years, in 2003. The study area was divided into 107 geographic clusters, which were randomly allocated to receive one of the single-dose parenteral vaccines. All aspects regarding vaccination logistics, feasibility and safety were documented and systematically recorded. Results of the logistics, feasibility and safety are reported.
Results
The campaign lasted 5 weeks and the overall vaccination coverage was 78%. On average, the 30 vaccine teams gave immunizations on 23 days. Vaccine rates were higher in those aged ≤ 15 years (90%) than in adolescents and young adults (70%). Planned mop-up activities increased the coverage by 17%. The overall vaccine wastage was 11%. The cold chain was maintained and documented. 66 individuals reported of adverse events out of all vaccinees, where fever (21%), malaise (19%) and local redness (19%) were the major symptoms; no life-threatening event occurred. Three needle-sharp events were reported.
Conclusion
The mass immunization proved feasible and safe, and vaccine coverage was high. Emphasis should be placed on: injection safety measures, community involvement and incorporation of mop-up strategies into any vaccination campaign. School-based and all-age Vi mass immunizations programs are potentially important public health strategies for prevention of typhoid fever in high-risk populations in southern China.
doi:10.1186/1471-2458-5-49
PMCID: PMC1156911  PMID: 15904514
19.  Washing our hands of the congenital cytomegalovirus disease epidemic 
BMC Public Health  2005;5:70.
Background
Each year in the United States, an estimated 40,000 children are born with congenital cytomegalovirus (CMV) infection, causing an estimated 400 deaths and leaving approximately 8000 children with permanent disabilities such as hearing or vision loss, or mental retardation. More children are affected by serious CMV-related disabilities than by several better-known childhood maladies, including Down syndrome, fetal alcohol syndrome, and spina bifida.
Discussion
Congenital CMV is a prime target for prevention not only because of its substantial disease burden but also because the biology and epidemiology of CMV suggest that there are ways to reduce viral transmission. Because exposure to the saliva or urine of young children is a major cause of CMV infection among pregnant women, it is likely that good personal hygiene, especially hand-washing, can reduce the risk of CMV acquisition. Experts agree that such measures are likely to be efficacious (i.e., they will work if consistently followed) and the American College of Obstetricians and Gynecologists recommends that physicians counsel pregnant women about preventing CMV acquisition through careful attention to hygiene. However, because of concerns about effectiveness (i.e., Will women consistently follow hygienic practices as the result of interventions?), the medical and public health communities appear reluctant to embrace primary CMV prevention via improved hygienic practices, and educational interventions are rare. Current data on the effectiveness of such measures in preventing CMV infection are promising, but limited. There is strong evidence, however, that educational interventions can prevent other infectious diseases with similar transmission modes, suggesting that effective interventions can also be found for CMV. Until a CMV vaccine becomes available, effective educational interventions are needed to inform women about congenital CMV prevention.
Summary
Perhaps no single cause of birth defects and developmental disabilities in the United States currently provides greater opportunity for improved outcomes in more children than congenital CMV. Given the present state of knowledge, women deserve to be informed about how they can reduce their risk of CMV infection during pregnancy, and trials are needed to identify effective educational interventions.
doi:10.1186/1471-2458-5-70
PMCID: PMC1182379  PMID: 15967030
20.  Rural residence is not a risk factor for frequent mental distress: a behavioral risk factor surveillance survey 
BMC Public Health  2005;5:46.
Background
Residents of rural areas may be at increased risk of mental health problems. If so, public health programs aimed at preventing poor mental health may have to be customized for delivery to rural areas. The purpose of this study was to examine the relationship between residing in a rural area and frequent mental distress, which is one indicator of poor mental health.
Methods
The Behavioral Risk Factor Surveillance System (BRFSS) survey for the state of Texas was the source of information about obesity, demographic characteristics, and frequent mental distress (FMD). FMD was defined as poor self-rated mental health during at least half of the days in the last month. Adjusted odds for FMD were computed for rural and suburban respondents relative to urban respondents.
Results
FMD was found to be independently associated with lower education, being younger, being non-Hispanic, being unmarried, and being female. FMD also was associated with being obese or underweight and suburban residence (relative to metro-central city). FMD was not more common among rural respondents than in the metro-central city.
Conclusion
Rural respondents were not at greater risk of frequent mental distress than urban respondents in this sample. Programs seeking to improve community mental health should target persons with less education and extremes in body weight, along with women and single persons, regardless of whether they live in rural or urban areas.
doi:10.1186/1471-2458-5-46
PMCID: PMC1173113  PMID: 15904511
21.  Socio-demographic factors associated with smoking and smoking cessation among 426,344 pregnant women in New South Wales, Australia 
BMC Public Health  2005;5:138.
Background
This study explores the socio-demographic characteristics of pregnant women who continue to smoke during the pregnancy, and identifies the characteristics of the smokers who were likely to quit smoking during the pregnancy period.
Methods
This was secondary analysis of the New South Wales (NSW) Midwives Data Collection (MDC) 1999–2003, a surveillance system covering all births in NSW public and private hospitals, as well as home births. Bivariate and multiple logistic regression analyses were performed to explore the associations between socio-demographic characteristics and smoking behaviour during pregnancy.
Results
Data from 426,344 pregnant women in NSW showed that 17.0% continued to smoke during pregnancy. The smoking rate was higher among teenage mothers, those with an Aboriginal (indigenous) background, and lower among more affluent and overseas-born mothers. This study also found that unbooked confinements, and lack of antenatal care in the first trimester were strongly associated with increased risk of smoking during pregnancy. About 4.0% of the smoking women reported they may quit smoking during their pregnancy. Findings showed that mothers born overseas, of higher socio-economic status, first time mothers and those who attended antenatal care early showed an increased likelihood of smoking cessation during pregnancy. Those who were heavy smokers were less likely to quit during pregnancy.
Conclusion
Although the prevalence of smoking during pregnancy has been declining, it remains a significant public health concern. Smoking cessation programs should target the population subgroups of women at highest risk of smoking and who are least likely to quit. Effective antismoking interventions could reduce the obstetric and perinatal complications of smoking in pregnancy.
doi:10.1186/1471-2458-5-138
PMCID: PMC1352372  PMID: 16371166
22.  Gender and age differences among current smokers in a general population survey 
BMC Public Health  2005;5:57.
Background
Evidence suggests a higher proportion of current smokers among female than among male ever smokers at the age above 50. However, little is known about the proportion of current smokers among ever smokers in old age groups with consideration of women in comparison to men from general population samples. The goal was to analyze the proportions of current smokers among female and among male ever smokers including those older than 80.
Methods
Cross-sectional survey study with a national probability household sample in Germany. Data of 179,472 participants aged 10 or older were used based on face-to-face in-home interviews or questionnaires. The proportions of current smokers among ever smokers were analyzed dependent on age, age of onset of smoking and cigarettes per day including effect modification by gender.
Results
Proportions of current smokers tended to be larger among female than among male ever smokers aged 40 or above. Women compared to men showed adjusted odds ratios of 1.7 to 6.9 at ages 40 to 90 or older in contrast to men. No such interaction existed for age of onset of smoking or cigarettes per day.
Conclusion
Special emphasis should be given to current smokers among the female general population at the age of 40 or above in public health intervention.
doi:10.1186/1471-2458-5-57
PMCID: PMC1175093  PMID: 15935091
23.  Self-rated health in Pakistan: results of a national health survey 
BMC Public Health  2005;5:51.
Background
Self-rated health (SRH) is a robust predictor of mortality. In UK, migrants of South Asian descent, compared to native Caucasian populations, have substantially poorer SRH. Despite its validation among migrant South Asian populations and its popularity in developed countries as a useful public health tool, the SRH scale has not been used at a population level in countries in South Asia. We determined the prevalence of and risk factors for poor/fair SRH among individuals aged ≥15 years in Pakistan (n = 9442).
Methods
The National Health Survey of Pakistan was a cross-sectional population-based survey, conducted between 1990 and 1994, of 18 135 individuals aged 6 months and above; 9442 of them were aged ≥15 years. Our main outcome was SRH which was assessed using the question: "Would you say your health in general is excellent, very good, good, fair, or poor?" SRH was dichotomized into poor/fair, and good (excellent, very good, or good).
Results
Overall 65.1% respondents – 51.3 % men vs. 77.2 % women – rated their health as poor/fair. We found a significant interaction between sex and age (p < 0.0001). The interaction was due to the gender differences only in the ages 15–19 years, whereas poor/fair SRH at all older ages was more prevalent among women and increased at the same rate as it did among men. We also found province of dwelling, low or middle SES, literacy, rural dwelling and current tobacco use to be independently associated with poor/fair SRH.
Conclusion
This is the first study reporting on poor/fair SRH at a population-level in a South Asian country. The prevalence of poor/fair health in Pakistan, especially amongst women, is one of the worst ever reported, warranting immediate attention. Further research is needed to explain why women in Pakistan have, at all ages, poorer SRH than men.
doi:10.1186/1471-2458-5-51
PMCID: PMC1164420  PMID: 15943882
24.  Risk factors for treatment delay in pulmonary tuberculosis in Recife, Brazil 
BMC Public Health  2005;5:25.
Background
Tuberculosis is still a great challenge to public health in Brazil and worldwide. Early detection followed by effective therapy is extremely important in controlling the disease. Recent studies have investigated reasons for delays in treatment, but there is no agreed definition of what constitutes an "acceptable" delay. This study investigates factors associated with total delay in treatment of tuberculosis.
Methods
A cohort of adult cases of pulmonary tuberculosis diagnosed over a two-year period was studied. Patients were interviewed on entry, reporting the duration of symptoms before the start of treatment, and sputum and blood samples were collected. It was decided that sixty days was an acceptable total delay. Associations were investigated using univariable and multivariable analysis and the population attributable fraction was estimated.
Results
Of 1105 patients, 62% had a delay of longer than 60 days. Age, sex, alcoholism and difficulty of access were not associated with delays, but associations were found in the case of unemployment, having given up smoking, having lost weight and being treated in two of the six health districts. The proportion attributable to: not being an ex-smoker was 31%; unemployment, 18%; weight loss, 12%, and going to the two worst health districts, 25%.
Conclusion
In this urban area, delays seem to be related to unemployment and general attitudes towards health. Although they reflect the way health services are organized, delays are not associated with access to care.
doi:10.1186/1471-2458-5-25
PMCID: PMC1084352  PMID: 15777473
25.  Birth outcomes in Colorado's undocumented immigrant population 
BMC Public Health  2005;5:100.
Background
The birth outcomes of undocumented women have not been systematically studied on a large scale. The growing number of undocumented women giving birth in the United States has important implications for clinical care and public health policy. The objective of this study was to describe birth outcomes of undocumented immigrants in Colorado.
Methods
Retrospective descriptive study of singleton births to 5961 undocumented women using birth certificate data for 1998–1999.
Results
Undocumented mothers were younger, less educated, and more likely to be single. They had higher rates of anemia, were less likely to gain enough weight, and less likely to receive early prenatal care. They were much less likely to use alcohol or tobacco. Undocumented women had a lower rate of low birth weight (5.3% v 6.5%, P < .001) or preterm infants (12.9% v 14.5%; p = .001). Undocumented women experienced higher rates of labor complications including excessive bleeding (2.3% v 0.8%, p < .001) and fetal distress (8.7% v 3.6%, p < .001).
Conclusion
Undocumented women have lower rates of preterm delivery and low birth weight infants, but higher rates of pregnancy related risk factors. Higher prevalence of some risk factors which are amenable to medical intervention reveals the need for improved prenatal care in this group.
doi:10.1186/1471-2458-5-100
PMCID: PMC1262728  PMID: 16202159

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