BioMed Research International: Public Health The latest articles from Hindawi © 2017 , Hindawi Limited . All rights reserved. The Prognostic Value of Combined Smoking and Alcohol Consumption Habits for the Estimation of Cause-Specific Mortality in Middle-Age and Elderly Population: Results from a Long-Term Cohort Study in Lithuania Thu, 19 Oct 2017 08:35:52 +0000 Aim. To evaluate the prognostic value of combined smoking and alcohol consumption habits for the estimation of cause-specific mortality risk in middle-age and elderly population. Methods. The study presents data from the four surveys. A random sample of 6,729 subjects aged 35–64 years was selected for statistical analysis. During the follow-up of 31 years (1983–2014), there were 2,158 deaths from any cause. Multivariate Cox’s proportional hazards models were used to estimate hazard ratios (HR) for all-cause mortality and Competing Risk Regression analysis was used to estimate subdistribution hazard risk (SHR) for cause-specific mortality. Results. Smoking clearly increased the risk of all-cause mortality and mortality from cancer and cardiovascular disease (CVD), but alcohol use had little effect in men aged 35–64 years. However, heavy alcohol consumption (>14 units/week) increased the risk of all-cause mortality and mortality from external causes in the never-smokers men group who drank alcohol of 1–14 units/week (HR 2 = 1.57 and SHR 2 = 2.40, resp.). Conclusions. The smoking habits and alcohol consumption are modifiable risk factors, and thus efforts to support abstinence from alcohol and smoking use should be a public health priority. Dalia Luksiene, Abdonas Tamosiunas, Dalia Virviciute, and Ricardas Radisauskas Copyright © 2017 Dalia Luksiene et al. All rights reserved. Long-Term Effectiveness of a Stress Management Intervention at Work: A 9-Year Follow-Up Study Based on a Randomized Wait-List Controlled Trial in Male Managers Wed, 18 Oct 2017 09:49:43 +0000 Objective. Short- and medium-term effectiveness (up to 3 years) of individual level stress management interventions (SMI) at work were demonstrated, yet long-term effectiveness remains unexplored. We therefore aimed to address this research gap. Methods. 94 male middle managers participated in a randomized wait-list controlled trial between 2006 and 2008 and in a post-trial-follow-up survey in 2015. During the first two years, all received an 18-hour psychotherapeutic SMI intervention which was based on the Effort-Reward Imbalance (ERI) model: tackling stressor on mismatch between effort and reward and promoting recovery on overcommitment. Work stress (i.e., ERI indicators) was the primary outcome, and the secondary outcome was depressive symptoms. The long-term effectiveness of the SMI was examined by mixed modeling, using an external control group (). Results. Effort and reward were substantially improved with significant intervention time interaction effects () compared to the external control group; effects on overcommitment and depressive symptoms were also significant ( and , resp.), though their trajectories in the intervention group were less sustainable. Conclusions. The effectiveness of this psychotherapeutic SMI at work based on the ERI model was observed over a 9-year period, particularly on the effort-reward ratio. Jian Li, Natalie Riedel, Amira Barrech, Raphael M. Herr, Birgit Aust, Kathrin Mörtl, Johannes Siegrist, Harald Gündel, and Peter Angerer Copyright © 2017 Jian Li et al. All rights reserved. Prevalence and Association of Obesity with Self-Reported Comorbidity: A Cross-Sectional Study of 1321 Adult Participants in Lasbela, Balochistan Thu, 12 Oct 2017 00:00:00 +0000 Association of fatness with chronic metabolic diseases is a well-established fact, and a high prevalence of risk factors for these disorders has increasingly been reported in the third world. In order to incorporate any preventive strategies for such risk factors into clinical practice, decision-makers require objective evidence about the associated burden of disease. A cross-sectional study of 1321 adults from one of the districts of Balochistan, among the most economically challenged areas of Pakistan, was carried out for the measures of fatness and self-reported comorbidities. Body mass index (BMI), waist circumference (WC), and waist-to-hip ratio (WHR) were measured and demographic information and self-reported comorbidities were documented. The prevalence of obesity was 4.8% (95% CI: 3.8, 6.1]) and 21.7% (95% CI: 19.5, 24.0]), as defined by the World Health Organization (WHO) international and Asia/Asia-Pacific BMI cut-offs, respectively. The proportion exhibiting comorbidity increased with increasing levels of fatness in a dose-response relationship ( value < .001). An interaction of weight status with gender was observed to produce a significantly () higher comorbidity among overweight women (odds ratio (OR) = 6.1 [1.2, 31.7]) compared with overweight men (OR = 1.1 [0.48, 2.75], ). I. Khan, Z. Ul-Haq, A. S. Taj, A. Z. Iqbal, S. Basharat, and B. H. Shah Copyright © 2017 I. Khan et al. All rights reserved. Living Conditions and Helicobacter pylori in Adults Thu, 12 Oct 2017 00:00:00 +0000 Introduction. Infection by the bacterium Helicobacter pylori (H. pylori) is transmissible and is considered a public health issue which affects people of all ages. The objective of this study was to identify factors (lifestyles, dietary factors, and hygiene conditions) related to the prevalence of H. pylori infection. Methods. We carried out an observational cross-sectional study with a community sample of adults from the municipalities of Viseu and Sátão, Portugal. The final sample resulted in 166 adults. The data were collected through a self-administered questionnaire with questions regarding sociodemographic aspects and lifestyles. H. pylori infection was identified using the 13C-urea breath test. Results. No association was found between the prevalence of H. pylori infection and the use of tobacco, alcohol, or coffee or dietary factors. The prevalence of H. pylori infection was higher in adults who reported higher consumption of fried food and lower consumption of vegetables and fruit. H. pylori infection was significant for the variables of lower frequency of handwashing before going to the bathroom () and well water consumption (). Conclusion. A significant association was found for H. pylori infection with the lower frequency of handwashing before going to the bathroom and the consumption of well water. Odete Amaral, Isabel Fernandes, Nélio Veiga, Carlos Pereira, Claudia Chaves, Paula Nelas, and Daniel Silva Copyright © 2017 Odete Amaral et al. All rights reserved. Is Health Education at University Associated with Students’ Health Literacy? Evidence from Cross-Sectional Study Applying HLS-EU-Q Tue, 10 Oct 2017 00:00:00 +0000 Background. Despite the large number of studies assessing health literacy, little research has been conducted with young adults. Since health literacy is related to the setting in which health information is provided, our study aim was to measure health literacy competencies in a sample of university students and to evaluate the relationships between these competencies and their university health education. Methods. A total of 912 university students (aged 18–24 years) completed the 47-item European Health Literacy Survey Questionnaire (HLS-EU-Q47). Results. Perceived difficulties with health information were related to gender, with male students reporting significantly lower health literacy scores. Studying more health education-related subjects was associated with a higher health literacy competency, due to these students’ higher rates of accessing and understanding health information in the health promotion domain. Conclusion. Health literacy among young adult university students is insufficient. The subjects they study are related to their university health education; in particular, the number of health-related subjects they study is positively related to students’ health promotion domain-based competencies. Saulius Sukys, Vida Janina Cesnaitiene, and Zbigniew Marcin Ossowsky Copyright © 2017 Saulius Sukys et al. All rights reserved. Posttraumatic Psychiatric Disorders and Resilience in Healthcare Providers following a Disastrous Earthquake: An Interventional Study in Taiwan Mon, 09 Oct 2017 00:00:00 +0000 Background. Posttraumatic psychiatric disorders (PTPDs) are common in disaster workers; however, their incidence and resilience in healthcare providers (HCPs) following a disastrous earthquake are still unclear. Therefore, we conducted an interventional study to clarify this issue. Methods. After a medical response to the scene of a collapsed huge building, we conducted an assessment of the HCPs using an immediate self-administered questionnaire and a follow-up questionnaire 1 month later. Psychological support after the operation was implemented. We performed analysis of the risk for PTPDs and comparison between immediate and follow-up questionnaires. Results. The mean age (standard deviation) of the HCPs was 32.7 (5.2) years, with 33.5 (5.8) years for nurses and 32.4 (4.4) years for physicians. The proportion of females among the nurses and physicians was 94.3% and 12.5%, respectively. In total, 16.4% (11/67) of HCPs fit the criteria of PTPDs. Nurses had a trend of higher incidence than physicians. Female HCPs had a trend of higher incidence than male HCPs. After intervention, none of the HCPs reported PTPDs in the follow-up questionnaire (). Conclusion. This study delineated that PTPDs were common in HCPs following medical response to an earthquake; however, the resilience was good after the early intervention. Ya-Ting Ke, Hsiu-Chin Chen, Chien-Ho Lin, Wen-Fu Kuo, An-Chi Peng, Chien-Chin Hsu, Chien-Cheng Huang, and Hung-Jung Lin Copyright © 2017 Ya-Ting Ke et al. All rights reserved. Health Status and the Demand for Healthcare among the Elderly in the Rural Quoc-Oai District of Hanoi in Vietnam Sun, 24 Sep 2017 00:00:00 +0000 Background. Vietnam is experiencing an unprecedented demographic transition. Its proportion of elderly people is growing rapidly. Objective. This study explored the health status and health-related quality of life (HRQoL) of rural elderly Vietnamese and assessed their needs for healthcare services. Design. This study used a survey with stratified proportion sampling and quota assignment. In 2016, data was collected from 713 people in the rural Quoc-Oai district of Hanoi aged 60 or older. Results. The mean age of the respondents was 70.9. Both self-rated health status and functional status decreased with age. Women reported more functional limitations than men. Musculoskeletal disorders were the most frequently reported chronic diseases, followed by hypertension, gastrointestinal diseases, and cardiovascular diseases. Age, self-rated health status, BMIs, and the number of noncommunicable diseases (NCDs) were found to be significant determinants of HRQoL, after controlling for socioeconomic effects. More than half the respondents requested more healthcare information, particularly on disease management. Conclusions. Vietnam’s healthcare system is being challenged to make health services easily accessible and meet the growing needs for chronic illness management, risk reduction, promoting healthy lifestyles, and improving the aging population’s quality of life. Kyung-Sook Bang, Sunghee H. Tak, Juhwan Oh, Jinseon Yi, Soo-Young Yu, and Truong Quang Trung Copyright © 2017 Kyung-Sook Bang et al. All rights reserved. Leadership and Bullying in the Forestry Organization of Turkey Wed, 06 Sep 2017 10:19:43 +0000 It is observed that the importance of executive-employee relationships is continuously increasing in today’s professional life in addition to the importance of leadership types of managers along with the efficiency of employees as well as the sufficiency of these people in their social relations. Communication of employees with one another and with their manager, along with their social relations, is among the most important factors that sustain an organization. Bullying is a kind of psychological terror that takes place in the form of repeated attacks among workers, as well as by the manager on the employees, aiming to instill stress, job dissatisfaction, and exhaustion on the employees. It has been put forth especially by recent studies that the leadership styles of the managers are highly influential on bullying. The study was carried out with 1189 forest engineers working at 25 different Regional Directorates of Forestry in Turkey. The status of engineers subject to bullying in addition to the effects of leadership types on bullying was determined as a result of the statistical analyses carried out. The results of the study were evaluated comprehensively in comparison with other studies in the relevant literature, thus developing suggestions for preventing bullying behaviors that vary across leadership types. Mahmut M. Bayramoğlu and Devlet Toksoy Copyright © 2017 Mahmut M. Bayramoğlu and Devlet Toksoy. All rights reserved. The Needs and Resources of Drug Information at Community Pharmacies in Gondar Town, Northwest Ethiopia Tue, 29 Aug 2017 00:00:00 +0000 Background. Community pharmacists are in a key position to provide information on drugs and thus promote the rational use of drugs. Objectives. The present study was designed to determine the needs and resources of drug information in community pharmacies. Methods. A prospective institution based cross-sectional study was carried out and data were collected on 48 community pharmacists in Gondar, Northwest Ethiopia, using interviewer administered structured questionnaire. Results. Almost all pharmacists (, 97.9%) often receive drug related queries and these were mainly from consumers (, 85.4%). While most questions relate to drug price (, 60.4%) and dosage (, 43.8%), the information resources mainly referred to were drug package inserts and national standard treatment guidelines. However, limited availability of information resources as well as limited ability to retrieve relevant information influenced the practice of pharmacists. Female pharmacists claimed better use of different information resources than males (). Conclusions. Community pharmacists in Gondar, Northwest Ethiopia, are often accessed for drug related information. But there are limitations in using up to date and most reliable resources. Therefore, intervention aimed at improving pharmacists’ access to and evaluation of drug information is urgently needed. Dessalegn Asmelashe Gelayee, Gashaw Binega Mekonnen, and Mequanent Kassa Birarra Copyright © 2017 Dessalegn Asmelashe Gelayee et al. All rights reserved. The Risk Factors of High Blood Pressure among Young Adults in the Tujia-Nationality Settlement of China Mon, 28 Aug 2017 06:07:48 +0000 Demographics questionnaires, and fitness tests were utilized to identify the risk factors of hypertension among younger adults in the years 2005, 2010, and 2014 in China’s southwest province of Hubei. The results demonstrated that the prevalence of hypertension was higher between 2011 and 2014 among the young people in this area. The main risk factors of developing hypertension were found to be sex (as man), individuals over 40 years old, blue collar employees who worked in rural areas, overweight/obesity, and those with the low CRF. Xiaoli Liu, Zheng Xiang, Xiangrong Shi, Hannah Schenck, Xinfeng Yi, Rong Ni, and Chaoneng Liu Copyright © 2017 Xiaoli Liu et al. All rights reserved. Household Financial Burden and Poverty Impacts of Cancer Treatment in Vietnam Mon, 21 Aug 2017 00:00:00 +0000 Purpose. This paper aims to analyze the household financial burden and poverty impacts of cancer treatment in Vietnam. Methods. Under the “ASEAN CosTs in ONcology” study design, three major specialized cancer hospitals were employed to assemble the Vietnamese data. Factors of socioeconomic, direct, and indirect costs of healthcare were collected prospectively through both individual interviews and hospital financial records. Results. The rates of catastrophic expenditure based on the cut-off points of 20%, 30%, 40%, and 50% of household’s income were 82.6%, 73.7%, 64.7%, and 56.9%, respectively. 37.4% of the households with patient were impoverished by the treatment costs for cancer. The statistically significant correlates of the impoverishment problem were higher among older patients (40–60 years: 1.77, 95% CI 1.14–2.73; above 60 years: 1.75, 95% CI 1.03–2.98); poorer patients (less than 100% national income: 29, 95% CI 18.6–45.24; less than 200% national income: 2.89, 95% CI 1.69–4.93); patients who underwent surgery alone (receiving nonsurgery treatment: 2.46, 95% CI 1.32–4.59; receiving multiple treatments: 2.4, 95% CI 1.38–4.17). Conclusions. Lots of households were pushed into poverty due to their expenditure on cancer care; more actions are urgently needed to improve financial protection to the vulnerable groups. Van Minh Hoang, Cam Phuong Pham, Quynh Mai Vu, Thuy Trang Ngo, Dinh Ha Tran, Dieu Bui, Xuan Dung Pham, Dang Khoa Tran, and Trong Khoa Mai Copyright © 2017 Van Minh Hoang et al. All rights reserved. Predictors of Hypertension among Nonpregnant Females Attending Health Promotion Clinic with Special Emphasis on Smokeless Tobacco: A Cross-Sectional Study Wed, 16 Aug 2017 00:00:00 +0000 Aim. To determine the predictors of hypertension among nonpregnant females attending a health promotion clinic. Design and Setting. A cross-sectional study was conducted during March to June 2016, at the National Institute of Cancer Prevention and Research, India. Methods. The study included 319 nonpregnant females of age 20–70 years. Demographics such as age, literacy, and income were noted. History regarding use, frequency, and quantity of smokeless tobacco was taken. Height, weight, and blood pressure were measured and body mass index was calculated. Statistical Analysis. Pearson’s product-moment correlation coefficient was calculated between each of the variables of age, smokeless tobacco consumption, and body mass index versus systolic and diastolic blood pressure, respectively. The linear as well as multiple linear regression analysis was employed to identify the risk factors for hypertension. Results. A univariate linear regression analysis showed that age, smokeless tobacco consumption, and body mass index were associated with systolic blood pressure ( value < 0.001 for each). For diastolic blood pressure, high body mass index was a predictor. Multiple linear regression analysis showed that both systolic and diastolic hypertension were associated with high body mass index and low level of education. Moreover, the systolic hypertension was associated with higher age and smokeless tobacco use. Conclusion. Health promotion requires control of body mass index and smokeless tobacco cessation for preventing hypertension and its complications. Devika Bhatt, Shashi Sharma, Ruchika Gupta, Dhirendra N. Sinha, and Ravi Mehrotra Copyright © 2017 Devika Bhatt et al. All rights reserved. Can Mixed Parasite Infections Thwart Targeted Malaria Elimination Program in India? Wed, 16 Aug 2017 00:00:00 +0000 India is highly endemic to malaria with prevalence of all five species of human malaria parasites of Plasmodium genus. India is set for malaria elimination by 2030. Since cases of mixed Plasmodium species infections remain usually undetected but cause huge disease burden, in order to understand the distributional prevalence of both monospecies infections and mixed species infections in India, we collated published data on the differential infection incidences of the five different malaria parasites based on PCR diagnostic assay. About 11% of total cases were due to mixed species infection. Among several interesting observations on both single and mixed parasitic infections, incidences of Plasmodium falciparum monoinfection were found to be significantly higher than P. vivax monoinfection. Also, P. malariae seems to be emerging as a potential malaria threat in India. Putting all the facts together, it appears that the dream of achieving malaria elimination in India will not be completely successful without dealing with mixed species infection. Upasana Shyamsunder Singh, Nisha Siwal, Veena Pande, and Aparup Das Copyright © 2017 Upasana Shyamsunder Singh et al. All rights reserved. Overweight or Obesity, Gender, and Age Influence on High School Students of the City of Toluca’s Physical Fitness Sun, 06 Aug 2017 00:00:00 +0000 Material and Method. This is a prospective, cross-sectional, and correlational study with a probabilistic sampling in which 150 teenagers from three different high schools from the city of Toluca, Mexico, aged 15–17, were assessed. Objective. To determine if weight, age, and gender have an influence on physical fitness evaluated with the EUROFIT and ALPHA-FITNESS batteries. Results. Women have a higher overweight and obesity rate than men (3 : 1). Adolescents who have normal weight have regular physical fitness (74.9%). When comparing genders we found that men have a higher mean than women in the tests, except for skinfold thickness and waist circumference. Age was only correlated with the plate tapping test . There are significant differences in the standing broad jump test and the Course-Navette of the EUROFIT and ALPHA-FITNESS batteries . Conclusions. It is likely that regular physical activity, and not normal weight, helps generate healthy physical fitness. Male subjects had a higher mean than women, reporting a better physical fitness and more frequent physical activity. Flor de Maria Cruz Estrada, Patricia Tlatempa Sotelo, Roxana Valdes-Ramos, José Aldo Hernández Murúa, and Rafael Manjarrez-Montes-de-Oca Copyright © 2017 Flor de Maria Cruz Estrada et al. All rights reserved. Practice and Barriers towards Provision of Health Promotion Services among Community Pharmacists in Gondar, Northwest Ethiopia Mon, 31 Jul 2017 08:48:24 +0000 Background. Health promotion is now becoming an integral part of community pharmacy practice worldwide. Objectives. This study was intended to determine the level of involvement of community pharmacists in providing health promotion service and to identify the barriers to the practice. Methods. A cross-sectional study was conducted on 48 community pharmacists working in Gondar town, Northwest Ethiopia. Data on sociodemographic factors, practice, and barriers to health promotion service were collected and analyzed using SPSS version 20. Results. The majority of respondents were B.Pharm holders (, 56.3%). Almost all respondents (, 95.8%) were willing and claimed to be well involved in health promotion services. The top 5 services were related to drug misuse, asthma, diabetes, family planning, and cardiovascular diseases. However, involvement in some types of health promotion services significantly differed based on sex, educational level, and pharmacy ownership of respondents. The main barrier reported was lack of training. Conclusion. The community pharmacists in Gondar, Northwest Ethiopia, are engaged in health promotion activities. However lack of training has limited their level of involvement and practice differences were noted based on sex, educational level, and pharmacy ownership status of the respondents. Dessalegn Asmelashe Gelayee, Gashaw Binega Mekonnen, and Seyfe Asrade Atnafe Copyright © 2017 Dessalegn Asmelashe Gelayee et al. All rights reserved. Examining Health Inequalities in Latvia: A Decade of Association between Socioeconomic Position and Perceived Health Status Thu, 27 Jul 2017 07:07:19 +0000 The relationship between socioeconomic position (SEP) and population health is contextual. This study identifies the determinants of SEP producing health inequalities in the Latvian population. We also estimate the proportional contribution of different socioeconomic strata- (SES-) related determinants in Latvian health inequalities and measure the changes in the relative contributions of such determinants over the period 2005–2015. Using the household survey data (2005–2015), we construct a principal component analysis based SES index. A regression-based concentration index (CI) is our measure of health inequality to examine the distribution of perceived health status. Finally, we identify and estimate the contribution of predictors of health inequalities by decomposing CI with Oaxaca-Blinder decomposition. SES-related health inequalities have declined from 2005 (CI: 0.201) to 2015 (CI: 0.137) in Latvia—better-off Latvians enjoyed better perceived health during that period. The proportional contributions of education and working status have increased in 2015 compared to 2005. Although we have generated the first evidence to suggest policy relevant measures in addressing Latvian health inequalities, our decomposition method explains the extent of variation in perceived health instead of covariance between health and SEP. Anželika Berķe-Berga, Pavitra Paul, and Hannu Valtonen Copyright © 2017 Anželika Berķe-Berga et al. All rights reserved. Trends and Inequalities in Use of Maternal Health Care Services in Nepal: Strategy in the Search for Improvements Thu, 20 Jul 2017 00:00:00 +0000 Background. Nepal has made significant progress against the Millennium Development Goals for maternal and child health over the past two decades. However, disparities in use of maternal health services persist along geographic, economic, and sociocultural lines. Methods. Trends and inequalities in the use of maternal health services in Nepal between 1994 and 2011 were examined using four Nepal Demographic and Health Surveys (NDHS), nationally representative cross-sectional surveys conducted by interviewing women who gave birth 3–5 years prior to the survey. Sociodemographic disparities in maternal health service utilization were measured. Rate difference, rate ratios, and concentration index were calculated to measure income inequalities. Findings. The percentage of mothers that received four antenatal care (ANC) consultations increased from 9% to 54%, the institutional delivery rate increased from 6% to 47%, and the cesarean section (C-section) rate increased from 1% in 1994 to 6% in 2011. The ratio of the richest and the poorest quintile mothers for use of four ANC, institutional delivery, and C-section delivery were 5.08 (95% CI: 3.82–6.76), 9.00 (95% CI: 6.55–12.37), and 9.37 (95% CI: 4.22–20.83), respectively. However, inequality is reducing over time; for the use of four ANC services, the concentration index fell from 0.60 (95% CI: 0.56–0.64) in 1994–1996 to 0.31 (95% CI: 0.29–0.33) in 2009–2011. For institutional delivery, the concentration index fell from 0.65 (95% CI: 0.62–0.70) to 0.40 (95% CI: 0.38–0.40) between 1994–1996 and 2009–2011. For C-section deliveries, an increase in concentration index was observed, 0.64 (95% CI: 0.51–0.77); 0.76 (95% CI: 0.64–0.88); 0.77 (95% CI: 0.71–0.84); and 0.66 (95% CI: 0.60–0.72) in the periods 1994–1996, 1999–2001, 2004–2006, and 2009–2011, respectively. All sociodemographic variables were significant predictors of use of maternal health services, out of which maternal education was the most powerful. Conclusion. To increase equitable use of maternal health services in Nepal there is a need to strengthen the health system to increase access to and utilization of services among poorer women, those with less education, and those living in remote areas. Beyond the health sector stronger efforts are needed to tackle the root causes of health inequality, reduce poverty, increase female education, eradicate caste/ethnicity based social discrimination, and invest in the development of remote areas. Suresh Mehata, Yuba Raj Paudel, Maureen Dariang, Krishna Kumar Aryal, Bibek Kumar Lal, Mukti Nath Khanal, and Deborah Thomas Copyright © 2017 Suresh Mehata et al. All rights reserved. Identifying High-Cost, High-Risk Patients Using Administrative Databases in Tuscany, Italy Mon, 10 Jul 2017 00:00:00 +0000 Objective. (1) Assessing the performance of the algorithm in terms of sensitivity and positive predictive value, considering General Practitioners’ (GPs) judgement as benchmark, and (2) describing adverse events (hospitalisation, death, and health services’ consumption) of complex patients compared to the general population. Data Sources. (i) Tuscany administrative database containing health data (2013-5); (ii) lists of complex patients indicated by GPs; and (iii) annual health registry of Tuscany. Study Design. The present study is a validation study. It compares a list of complex patients extracted through an administrative algorithm (criteria of high health consumption) to a gold standard list of patients indicated by GPs. GPs’ decision was subjective but fairly well reasoned. The study compares also adverse outcomes (Emergency Room visits, hospitalisation, and death) between identified complex patients and general population. Principal Findings. Considering GPs’ judgement, the algorithm showed a sensitivity of 72.8% and a positive predictive value of 64.4%. The complex cases presented here have higher incidence rates/100,000 (death 46.8; ER visits 223.2, hospitalisations 110.87, laboratory tests 1284.01, and specialist examinations 870.37) compared to the general population. Conclusions. The final validated algorithm showed acceptable sensitivity and positive predictive value. Irene Bellini, Valentina Barletta, Francesco Profili, Alessandro Bussotti, Irene Severi, Maddalena Isoldi, Maria Bimbi, and Paolo Francesconi Copyright © 2017 Irene Bellini et al. All rights reserved. Ethnobotany of Indigenous Saraguros: Medicinal Plants Used by Community Healers “Hampiyachakkuna” in the San Lucas Parish, Southern Ecuador Tue, 04 Jul 2017 09:57:43 +0000 This paper reports the results of an ethnobotanical survey on the use of medicinal plants by community healers “Hampiyachakkuna” in the San Lucas Parish, province of Loja, Ecuador. A particular ethnic group, the indigenous Saraguros, inhabits this region. This study reports 183 plant species used in 75 different curative therapies by the Saraguro healers. José M. Andrade, Hernán Lucero Mosquera, and Chabaco Armijos Copyright © 2017 José M. Andrade et al. All rights reserved. Insomnia and Its Temporal Association with Academic Performance among University Students: A Cross-Sectional Study Thu, 29 Jun 2017 00:00:00 +0000 Introduction. Studies show that 9.4% to 38.2% of university students are suffering from insomnia. However, research data in developing countries is limited. Thus, the aim of the study was to assess insomnia and its temporal association with academic performance. Methods and Materials. Institution based cross-sectional study was conducted with 388 students at Debre Berhan University. Data were collected at the nine colleges. Logistic and linear regression analysis was performed for modeling insomnia and academic performance with a value threshold of 0.05, respectively. Data were entered using EPI-data version 3.1 and analyzed using SPSS version 20. Results. The prevalence of insomnia was 61.6%. Field of study ( value = 0.01), worshiping frequency ( value = 0.048), marital status ( value = 0.03), and common mental disorder ( value < 0.001) were identified associated factors of insomnia. There was no significant association between insomnia and academic performance ( value = 0.53, β = −0.04). Insomnia explained 1.2% ( = 0.012) of the difference in academic performance between students. Conclusions. Nearly 3 out of 5 students had insomnia. We recommended that universities would endorse sleep quality and mental health illness screening programs for students. Yohannes Gebreegziabhere Haile, Sisay Mulugeta Alemu, and Tesfa Dejenie Habtewold Copyright © 2017 Yohannes Gebreegziabhere Haile et al. All rights reserved. Individual, Social, and Environmental Correlates of Active Transportation Patterns in French Women Thu, 22 Jun 2017 06:12:40 +0000 The objectives were (1) to define physical activity (PA) and sedentary behaviors (SB) patterns in daily life contexts (work, leisure, and transportation) in French working women from NutriNet-Santé web-cohort and (2) to identify pattern(s) of active transportation and their individual, social, and environmental correlates. 23,432 participants completed two questionnaires to evaluate PA and SB in daily life contexts and individual representations of residential neighborhood and transportation modes. Hierarchical cluster analysis was performed which identified 6 distinct movement behavior patterns: (i) active occupation, high sedentary leisure, (ii) sedentary occupation, low leisure, (iii) sedentary transportation, (iv) sedentary occupation and leisure, (v) active transportation, and (vi) active leisure. Multinomial logistic regressions were performed to identify correlates of the “active transportation” cluster. The perceived environmental characteristics positively associated with “active transportation” included “high availability of destinations around home,” “presence of bicycle paths,” and “low traffic.” A “positive image of walking/cycling,” the “individual feeling of being physically active,” and a “high use of active transport modes by relatives/friends” were positively related to “active transportation,” identified as a unique pattern regarding individual and environmental correlates. Identification of PA and SB context-specific patterns will help to understand movement behaviors’ complexity and to design interventions to promote active transportation in specific subgroups. Camille Perchoux, Christophe Enaux, Jean-Michel Oppert, Mehdi Menai, Hélène Charreire, Paul Salze, Christiane Weber, Serge Hercberg, Thierry Feuillet, Franck Hess, Célina Roda, Chantal Simon, and Julie-Anne Nazare Copyright © 2017 Camille Perchoux et al. All rights reserved. Coproduction of Research Questions and Research Evidence in Public Health: The Study to Prevent Teen Drinking Parties Wed, 14 Jun 2017 00:00:00 +0000 Community-based participatory research (CBPR) provides a set of principles and practices intended to foster coproduction of knowledge. However, CBPR often has shortcomings when applied to population-level policy and practice interventions, including a focus on single communities and a lack of focus on policy change. At the same time, community trials focused on policy have shortcomings, including lack of stakeholder involvement in framing research questions and modest engagement in study implementation and interpretation and dissemination of results. We describe an attempt to hybridize CBPR and community trials by creating a partnership that included a national membership organization, a coalition advisory board, intervention and delayed intervention communities, and an academic study team, which collaborated on a study of community strategies to prevent underage drinking parties. We use qualitative and quantitative data to critically assess the partnership. Areas where the partnership was effective included (1) identifying a research question with high public health significance, (2) enhancing the intervention, and (3) improving research methods. Challenges included community coalition representatives’ greater focus on their own communities rather than the production of broader scientific knowledge. This model can be applied in future attempts to narrow the gap between research, policy, and practice. Mark Wolfson, Kimberly G. Wagoner, Scott D. Rhodes, Kathleen L. Egan, Michael Sparks, Dylan Ellerbee, Eunyoung Y. Song, Beata Debinski, Albert Terrillion, Judi Vining, and Evelyn Yang Copyright © 2017 Mark Wolfson et al. All rights reserved. Hand Hygiene Practices and Microbial Investigation of Hand Contact Swab among Physiotherapists in an Ebola Endemic Region: Implications for Public Health Sun, 11 Jun 2017 10:41:53 +0000 Background. Hand hygiene practices (HHP), as a critical component of infection prevention/control, were investigated among physiotherapists in an Ebola endemic region. Method. A standardized instrument was administered to 44 randomly selected physiotherapists (23 males and 21 females), from three tertiary hospitals in Enugu, Nigeria. Fifteen participants (aged 22–59 years) participated in focus group discussions (FGDs) and comprised 19 participants in a subsequent laboratory study. After treatment, the palms/fingers of physiotherapists were swabbed and cultured, then incubated aerobically overnight at 37°C, and examined for microbial growths. An antibiogram of the bacterial isolates was obtained. Results. The majority (34/77.3%) of physiotherapists were aware of the HHP protocol, yet only 15/44.1% rated self-compliance at 71–100%. FGDs identified forgetfulness/inadequate HHP materials/infrastructure as the major barriers to HHP. Staphylococcus aureus were the most prevalent organisms, prior to (8/53.33%) and after (4/26.67%) HPP, while Pseudomonas spp. were acquired thereafter. E. coli were the most antibiotic resistant microbes but were completely removed after HHP. Ciprofloxacin and streptomycin were the most effective antibiotics. Conclusion. Poor implementation of HPP was observed due to inadequate materials/infrastructure/poor behavioral orientation. Possibly, some HPP materials were contaminated; hence, new microbes were acquired. Since HPP removed the most antibiotic resistant microbes, it might be more effective in infection control than antibiotic medication. S. Ibeneme, V. Maduako, G. C. Ibeneme, A. Ezuma, T. U. Ettu, N. F. Onyemelukwe, D. Limaye, and G. Fortwengel Copyright © 2017 S. Ibeneme et al. All rights reserved. Factors Associated with Dental Pain in Mexican Schoolchildren Aged 6 to 12 Years Thu, 08 Jun 2017 00:00:00 +0000 Objective. To identify dental pain prevalence and associated factors in Mexican schoolchildren. Methods. This cross-sectional study included 1,404 schoolchildren aged 6 to 12 years from public schools in the city of Pachuca de Soto, Hidalgo, Mexico. Data were collected through a questionnaire that addressed sociodemographic and socioeconomic factors, eating and dental hygiene habits, and behavior variables. The dependent variable was self-reported dental pain in the 12 months prior to the survey. Data were analyzed using nonparametric statistics and a binary logistical regression model. Results. Dental pain prevalence among the studied children was 49.9%. The variables associated in the final model () were younger mother’s age, higher socioeconomic level, absence of an automobile in the home, fried food, fruit intake, lower tooth brushing frequency, never having used mouthwash or not knowing about it, and parents/guardians with regular to high levels of knowledge about oral health and a regular or good/very good perception of their child’s oral health. Conclusions. One in two children in the study had experienced dental pain in the twelve months prior to the survey. The association of socioeconomic variables with dental pain suggested inequalities among the children in terms of oral health. Mauricio Escoffié-Ramirez, Leticia Ávila-Burgos, Elena Saraí Baena-Santillan, Fernando Aguilar-Ayala, Edith Lara-Carrillo, Mirna Minaya-Sánchez, Martha Mendoza-Rodríguez, María de Lourdes Márquez-Corona, and Carlo Eduardo Medina-Solís Copyright © 2017 Mauricio Escoffié-Ramirez et al. All rights reserved. Promoting Mental Health in Italian Middle and High School: A Pilot Study Wed, 31 May 2017 00:00:00 +0000 Aim. In Italy, a handbook has been developed based on the principles of cooperative learning, life skills, self-effectiveness, and problem-solving at high school level. Early studies have shown the handbook’s effectiveness. It has been hypothesized that the revised handbook could be more effective in middle schools. Method. The study design is a “pre- and posttest” that compares the results obtained from 91 students of the high schools with those of the 38 students from middle schools. The assessment was made through “self-reporting” questionnaires of (a) learning skills including problem-solving and (b) perceived self-efficacy in managing emotions, dysfunctional beliefs, and unhealthy behaviours (i.e., drinking/smoking). Results. Significant improvements were observed in both groups with the exceptions of perceived self-efficacy in managing emotions. The improvement of dysfunctional beliefs and the learning of problem-solving skills were better in middle schools. Conclusion. The results confirm the authors’ hypothesis that the use of this approach is much more promising in middle school. Franco Veltro, Valentina Ialenti, Manuel Alejandro Morales García, Emiliana Bonanni, Claudia Iannone, Marinella D’Innocenzo, and Antonella Gigantesco Copyright © 2017 Franco Veltro et al. All rights reserved. Quality Improvement Interventions for Nutritional Assessment among Pregnant Mothers in Northeastern Uganda Tue, 30 May 2017 00:00:00 +0000 Introduction. Assessment of pregnant mothers for nutritional status is a neglected intervention. In Kaabong Hospital, nutritional status of pregnant mothers was not assessed during antenatal care (ANC) visits. A quality improvement (QI) project was initiated to increase nutritional assessment using midupper arm circumference (MUAC) among pregnant mothers during ANC visits from 0 to 90% between April and September 2015. Method. Baylor-Uganda formed ANC Work Improvement Team (WIT) that reviewed ANC register, identified gaps in quality of care, analyzed root causes using cause-effect diagram, developed solutions, and tested and implemented the solution using Plan-Do-Study-Act cycles. Planned and tested changes included the provision of anthropometric tools, integrated ANC register, and data use. Result. In April 2015 (baseline), none (0/235) of the pregnant women were assessed for nutritional status using MUAC. Following QI interventions, nutritional assessment improved to 79% (200/252) in May 2015 and to 100% (241/241) in June 2015. The 100% performance was sustained until August 2016. Overall, 39 cases of malnutrition—1 (2.6%) severe (MUAC < 19.0 cm) and 38 (97.4%) moderate acute malnutrition (MUAC 19–22.0 cm)—were identified and linked to nutritional rehabilitation program. Conclusion. QI interventions are critical in achieving high rates of nutritional status assessment and identifying malnourished pregnant women during ANC visits. Jonathan Izudi, Calvin Epidu, Andrew Katawera, and Adeodata Kekitiinwa Copyright © 2017 Jonathan Izudi et al. All rights reserved. Health Brokers: How Can They Help Deal with the Wickedness of Public Health Problems? Thu, 25 May 2017 00:00:00 +0000 Background. The role of health broker is a relatively new one in public health. Health brokers aim to create support for efforts to optimise health promotion in complex or even “wicked” public health contexts by facilitating intersectoral collaborations and by exchanging knowledge with different stakeholders. The current study aimed to explore the role of health brokers, by examining the motivational, contextual, and behaviour-related factors they have to deal with. Methods. Fifteen professionals from various backgrounds and from various policy and practice organisations were recruited for a semistructured interview. To structure the interviews, we developed the “Health Broker Wheel” (HBW), a framework we then specified with more details derived from the interviews. Results. We identified seven primary types of behaviour that health brokers need to engage in: recognizing opportunities, agenda setting, implementing, network formation, intersectoral collaboration, adaptive managing, and leadership. Determinants of health brokers’ behaviours were identified and categorised as capability, opportunities, motivation, and local or national contextual factors. Conclusion. The health brokers’ role can be seen as an operational approach and is visualised in the HBW. This framework can assist further research to monitor and evaluate this role, and health promotion practitioners can use it as a tool to implement the health brokers’ role and to facilitate intersectoral collaboration. Celeste E. van Rinsum, Sanne M. P. L. Gerards, Geert M. Rutten, Ien A. M. van de Goor, and Stef P. J. Kremers Copyright © 2017 Celeste E. van Rinsum et al. All rights reserved. Perception of Community Pharmacists towards Dispensing Errors in Community Pharmacy Setting in Gondar Town, Northwest Ethiopia Mon, 22 May 2017 08:07:57 +0000 Background. Dispensing errors are inevitable occurrences in community pharmacies across the world. Objective. This study aimed to identify the community pharmacists’ perception towards dispensing errors in the community pharmacies in Gondar town, Northwest Ethiopia. Methods. A cross-sectional study was conducted among 47 community pharmacists selected through convenience sampling. Data were analyzed using SPSS version 20. Descriptive statistics, Mann–Whitney U test, and Pearson’s Chi-square test of independence were conducted with considered statistically significant. Result. The majority of respondents were in the 23–28-year age group (, 55.3%) and with at least B.Pharm degree (, 53.2%). Poor prescription handwriting and similar/confusing names were perceived to be the main contributing factors while all the strategies and types of dispensing errors were highly acknowledged by the respondents. Group differences () in opinions were largely due to educational level and age. Conclusion. Dispensing errors were associated with prescribing quality and design of dispensary as well as dispensing procedures. Opinion differences relate to age and educational status of the respondents. Dessalegn Asmelashe Gelayee and Gashaw Binega Mekonnen Copyright © 2017 Dessalegn Asmelashe Gelayee and Gashaw Binega Mekonnen. All rights reserved. Extremely Low-Frequency Electromagnetic Fields Affect Myogenic Processes in C2C12 Myoblasts: Role of Gap-Junction-Mediated Intercellular Communication Sun, 21 May 2017 06:41:14 +0000 Extremely low-frequency electromagnetic fields (ELF-EMFs) can interact with biological systems. Although they are successfully used as therapeutic agents in physiatrics and rehabilitative practice, they might represent environmental pollutants and pose a risk to human health. Due to the lack of evidence of their mechanism of action, the effects of ELF-EMFs on differentiation processes in skeletal muscle were investigated. C2C12 myoblasts were exposed to ELF-EMFs generated by a solenoid. The effects of ELF-EMFs on cell viability and on growth and differentiation rates were studied using colorimetric and vital dye assays, cytomorphology, and molecular analysis of MyoD and myogenin expression, respectively. The establishment of functional gap junctions was investigated analyzing connexin 43 expression levels and measuring cell permeability, using microinjection/dye-transfer assays. The ELF-EMFs did not affect C2C12 myoblast viability or proliferation rate. Conversely, at ELF-EMF intensity in the mT range, the myogenic process was accelerated, through increased expression of MyoD, myogenin, and connexin 43. The increase in gap-junction function suggests promoting cell fusion and myotube differentiation. These data provide the first evidence of the mechanism through which ELF-EMFs may provide therapeutic benefits and can resolve, at least in part, some conditions of muscle dysfunction. Caterina Morabito, Nathalie Steimberg, Francesca Rovetta, Jennifer Boniotti, Simone Guarnieri, Giovanna Mazzoleni, and Maria A. Mariggiò Copyright © 2017 Caterina Morabito et al. All rights reserved. Genetic Epidemiology of Type 2 Diabetes in Mexican Mestizos Thu, 18 May 2017 08:12:31 +0000 There are currently about 415 million people with diabetes worldwide, a figure likely to increase to 642 million by 2040. In 2015, Mexico was the second Latin American country and sixth in the world in prevalence of this disorder with nearly 11.5 million of patients. Type 2 diabetes (T2D) is the main kind of diabetes and its etiology is complex with environmental and genetic factors involved. Indeed, polymorphisms in several genes have been associated with this disease worldwide. To estimate the genetic epidemiology of T2D in Mexican mestizos a systematic bibliographic search of published articles through PubMed, Scopus, Google Scholar, and Web of Science was conducted. Just case-control studies of candidate genes about T2D in Mexican mestizo inhabitants were included. Nineteen studies that met the inclusion criteria were found. In total, 68 polymorphisms of 41 genes were assessed; 26 of them were associated with T2D risk, which were located in ABCA1, ADRB3, CAPN10, CDC123/CAMK1D, CDKAL1, CDKN2A/2B, CRP, ELMO1, FTO, HHEX, IGF2BP2, IRS1, JAZF1, KCNQ1, LOC387761, LTA, NXPH1, SIRT1, SLC30A8, TCF7L2, and TNF-α genes. Overall, 21 of the 41 analyzed genes were associated with T2D in Mexican mestizos. Such a genetic heterogeneity compares with findings in other ethnic groups. Eiralí Guadalupe García-Chapa, Evelia Leal-Ugarte, Valeria Peralta-Leal, Jorge Durán-González, and Juan Pablo Meza-Espinoza Copyright © 2017 Eiralí Guadalupe García-Chapa et al. All rights reserved. Effect of Lower and Upper Body High Intensity Training on Genes Associated with Cellular Stress Response Mon, 15 May 2017 10:23:45 +0000 This study aimed to compare the effect of upper and lower body high intensity exercise (HIE) on select gene expression in athletes. Fourteen elite male artistic gymnasts (age years; weight  kg; fat free mass  kg; height  m) performed lower and upper body 30 s Wingate Tests (WAnTs) before and after eight weeks of specific HIIT. Two milliliters of blood was collected before and after (5, 30 min, resp.) lower and upper body WAnTs, and select gene expression was determined by PCR. Eight weeks of HIIT caused a significant increase in maximal power (722 to 751 Wat), relative peak power in the lower body WAnTs (10.1 to 11 W/kg), mean power (444 to 464 W), and relative mean power (6.5 to 6.8 W/kg). No significant differences in lower versus upper body gene expression were detected after HIIT, and a significant decrease in the IL6/IL10 ratio was observed after lower (−2∧0.57 ) and upper (−2∧0.5 ) WAnTs following eight weeks of HIIT. It is hypothesized that a similar adaptive response to exercise may be obtained by lower and upper body exercise. Małgorzata Żychowska, Andrzej Kochanowicz, Kazimierz Kochanowicz, Jan Mieszkowski, Bartłomiej Niespodziński, and Stanisław Sawczyn Copyright © 2017 Małgorzata Żychowska et al. All rights reserved. Towards a Better Understanding of Sickness Absence in Adolescence: A Qualitative Study among Dutch Intermediate Vocational Education Students Tue, 09 May 2017 00:00:00 +0000 An adequate approach to sickness absence can reduce school dropout which is a major problem in Intermediate Vocational Education (IVE). This practice-based study explores the sickness absence reasons and factors influencing reporting the sickness, from a student’s perspective. Semistructured interviews were held until saturation. Data were collected and analysed by a multidisciplinary research team including youth health care physicians working with IVE students. The results show that, according to the students, reasons for sickness reporting were health-related or related to problems at home or in school. Students view their sickness absence as necessity, as asking for understanding, or as pardonable. Their views depended on (1) the perception of medical legitimacy, (2) feeling able to take their own responsibility, (3) feeling being taken seriously at school, and (4) the perception that the sickness reporting procedure at school is anonymous and easy. In conclusion, reporting sickness seems more a reaction to a necessity or opportunity than the result of a conscious decision-making process. Personalizing the sickness reporting procedures and demonstrating interest rather than control while discussing the sickness absence with the individual IVE student might very well affect their sickness absence levels. Yvonne T. M. Vanneste, Frans J. M. Feron, Marlieke A. W. van Mook, and Angelique de Rijk Copyright © 2017 Yvonne T. M. Vanneste et al. All rights reserved. Two-Step Optimization for Spatial Accessibility Improvement: A Case Study of Health Care Planning in Rural China Tue, 18 Apr 2017 09:07:43 +0000 A recent advancement in location-allocation modeling formulates a two-step approach to a new problem of minimizing disparity of spatial accessibility. Our field work in a health care planning project in a rural county in China indicated that residents valued distance or travel time from the nearest hospital foremost and then considered quality of care including less waiting time as a secondary desirability. Based on the case study, this paper further clarifies the sequential decision-making approach, termed “two-step optimization for spatial accessibility improvement (2SO4SAI).” The first step is to find the best locations to site new facilities by emphasizing accessibility as proximity to the nearest facilities with several alternative objectives under consideration. The second step adjusts the capacities of facilities for minimal inequality in accessibility, where the measure of accessibility accounts for the match ratio of supply and demand and complex spatial interaction between them. The case study illustrates how the two-step optimization method improves both aspects of spatial accessibility for health care access in rural China. Jing Luo, Lingling Tian, Lei Luo, Hong Yi, and Fahui Wang Copyright © 2017 Jing Luo et al. All rights reserved. Level of Knowledge and Practice of Mothers on Minimum Dietary Diversity Practices and Associated Factors for 6–23-Month-Old Children in Adea Woreda, Oromia, Ethiopia Wed, 12 Apr 2017 00:00:00 +0000 Background. Globally, undernutrition is responsible for at least 35% of deaths in children less than 5 years of age and estimated 6% of under-five deaths can be prevented by ensuring optimal complementary feeding especially the dietary diversity and meal frequency. In Ethiopia, 5% of children were fed according to minimum standards with respect to food diversity. Objective. To assess the level of knowledge and practice of mothers on dietary diversity practices and associated factors for children 6–23 months in Adea woreda. Methods. Community-based cross-sectional study was conducted. A sample of 730 mothers who have children in the age group of 6–23 months were selected using systematic sampling. Logistic regression model was fitted in order to identify factors associated with knowledge and practice of dietary diversity practice. Result. Of the total 700, 357 (51%) were knowledgeable on dietary diversity but 112 (16%) practiced appropriate dietary diversity practice for their 6–23-month-old children. Husbands’ education (AOR = 2.79, 95% CI = (1.55, 5.00)), mothers’ age, and marital status were significantly associated with knowledge of mothers. Mothers’ age, husbands’ education, marital status, and knowledge of mothers were significantly associated with mothers’ dietary diversity for 6–23-month-old children. Conclusion. This study showed that approximately half of the mothers have good knowledge on minimum dietary diversity for children 6–23 months old and very low proportion of children 6–23 months old received diversified meal according to Infant and Young Child Feeding indicators. It was identified that different factors are responsible for this discrepancy. Andualem Agize, Dube Jara, and Getiye Dejenu Copyright © 2017 Andualem Agize et al. All rights reserved. Impact of an Intensive Perinatal Handwashing Promotion Intervention on Maternal Handwashing Behavior in the Neonatal Period: Findings from a Randomized Controlled Trial in Rural Bangladesh Tue, 11 Apr 2017 00:00:00 +0000 One-quarter of neonatal deaths are attributed to infections. Maternal handwashing with soap may prevent neonatal sepsis. We examined impact of intensive handwashing promotion on handwashing behavior of mothers of neonates. In Matlab, Bangladesh, we randomly allocated pregnant women at 28–32 weeks’ gestation to intensive handwashing promotion or control. Behavior change communicators used a participatory approach to motivate maternal handwashing with soap and provided soap and handwashing stations. In the neonatal period, we observed soap and water at handwashing places and, at the end of the neonatal period, we estimated impact on maternal handwashing by structured observation. Among 253 women enrolled, intervention households were between 5.7 and 15.2 times as likely as control households to have soap and water present at the handwashing station in the baby’s sleeping area. Intervention mothers washed hands with soap 4.1 times as frequently as controls (95% CI 2.55–6.59); handwashing with soap at recommended times was infrequent in both intervention (9%) and control (2%) groups. Intensively promoting handwashing with soap resulted in increased availability of soap and water at handwashing places, but only a modest increase in maternal handwashing with soap. Novel approaches to motivating handwashing behavior to protect newborns should be developed and evaluated. Pavani Kalluri Ram, Sharifa Nasreen, Kelly Kamm, Jelena Allen, Swapna Kumar, Mohammad Anisur Rahman, K. Zaman, Shams El Arifeen, and Stephen P. Luby Copyright © 2017 Pavani Kalluri Ram et al. All rights reserved. Vitamin D and Parathyroid Hormone Status in Female Garment Workers: A Case-Control Study in Bangladesh Mon, 03 Apr 2017 10:32:57 +0000 Despite the abundant sunlight, vitamin D deficiency is prevalent in South Asian countries including Bangladesh. Information on vitamin D level is insufficient in adults particularly in female garment workers in Bangladesh. This study was designed to evaluate the status of vitamin D, parathormone (PTH), calcium, and alkaline phosphatase (ALP) among the female garment workers in Bangladesh. Blood samples were collected from female garment workers (, case group) and general female workers (, control group) in Dhaka. Serum vitamin D, PTH, calcium, and ALP were measured by chemiluminescence microparticle immunoassay. The mean level of vitamin D was significantly () lower in case ( ng/mL) than in the control ( ng/mL) group. No significant difference was found at mean of PTH and calcium between case ( pg/mL;  mg/dL, resp.) and control ( pg/mL;  mg/dL, resp.) group. The mean ALP in case ( U/L) group was significantly () higher than the control group ( U/L). Overall, PTH level did not show significant correlation with vitamin D. However, calcium and ALP levels showed a significant positive () and negative () correlation with vitamin D, respectively. This study indicates a high prevalence of vitamin D deficiency in the female garment workers in Bangladesh. Shakil Mahmood, Matiur Rahman, Subrata Kumar Biswas, Shaikh Nazmus Saqueeb, Shiblee Zaman, M. Manirujjaman, Rasheda Perveen, and Nurshad Ali Copyright © 2017 Shakil Mahmood et al. All rights reserved. Effects of an Ad Libitum Consumed Low-Fat Plant-Based Diet Supplemented with Plant-Based Meal Replacements on Body Composition Indices Tue, 28 Mar 2017 09:46:35 +0000 Objective. To document the effect of a diet free from animal-sourced nutrients on body composition indices. Methods. This was a nonrandomized interventional ()-control () trial with a 10-week, low-fat, plant-based diet supplemented with two daily meal replacements. The meals were allowed to be eaten to full satiety without prespecified calorie restrictions. Control subjects received weekly lectures on the rationale and expected benefits of plant-based nutrition. Body composition indices were measured with bioimpedance analysis. Results. Relative to controls, in cases, postintervention body fat percentage was reduced by 4.3 (95% CI 4.1–4.6)% points (a relative decrement of −13.4%), visceral fat by 1.6 (95% CI 1.5–1.7) fat cross-sectional surface units, and weight by 5.6 kg (95% CI 5.2–6), while muscle mass was reduced by 0.3 kg (95% CI 0.06–0.5) with a relative increase of muscle mass percentage of 4.2 (3.9–4.4)% points. Analysis of covariance showed significantly larger adjusted fat reductions in cases compared to controls. Late follow-up revealed further weight loss in 60% of cases and no significant change in controls. Conclusions. Low-fat, plant-based diet in free-living nonresidential conditions eaten ad libitum enables significant and meaningful body fat reductions with relative preservation of muscle mass. This trial is registered with NCT02906072, Boštjan Jakše, Stanislav Pinter, Barbara Jakše, Maja Bučar Pajek, and Jernej Pajek Copyright © 2017 Boštjan Jakše et al. All rights reserved. Chronic Health Conditions as a Risk Factor for Falls among the Community-Dwelling US Older Adults: A Zero-Inflated Regression Modeling Approach Tue, 28 Mar 2017 00:00:00 +0000 Falls are an important health concern among older adults due to age-related changes in the body. Having a medical history of chronic health condition may pose even higher risk of falling. Only few studies have assessed a number of chronic health conditions as risk factor for falls over a large nationally representative sample of US older adults. In this study, Behavioral Risk Factor Surveillance System (BRFSS) 2014 participants aged 65 years and older ( = 159,336) were evaluated. It was found that 29.7% (,550) of the sample experienced at least one fall and 16.3% (,444) experienced more than one fall in the past 12 months. According to the study findings, having a medical history of stroke, CKD, arthritis, depression, and diabetes independently predict the risk of first-time falling as well as the risk of recurrent falling in older adult population while controlling for other factors. On the other hand, having a medical history of the heart attack, angina, asthma, and COPD did not predict the risk of first-time falling, but did predict the risk of recurrent falling after experiencing the first fall in this population. Yoshita Paliwal, Patricia W. Slattum, and Scott M. Ratliff Copyright © 2017 Yoshita Paliwal et al. All rights reserved. Improving Health and Reducing Comorbidity Associated with HIV: The Development of TAVIE en santé, a Web-Based Tailored Intervention to Support the Adoption of Health Promoting Behaviors among People Living with HIV Tue, 14 Mar 2017 06:18:30 +0000 Background. In the domain of health behavior change, the deployment and utilization of information and communications technologies as a way to deliver interventions appear to be promising. This article describes the development of a web-based tailored intervention, TAVIE en santé, to support people living with HIV in the adoption of healthy behaviors. Methods. This intervention was developed through an Intervention Mapping (IM) framework and is based on the theory of planned behavior. Results. Crucial steps of IM are the selection of key determinants of behavior and the selection of useful theory-based intervention methods to change the targeted determinants (active ingredients). The content and the sequence of the intervention are then created based on these parameters. TAVIE en santé is composed of 7 interactive web sessions hosted by a virtual nurse. It aims to develop and strengthen skills required for behavior change. Based on an algorithm using individual cognitive data (attitude, perceived behavioral control, and intention), the number of sessions, theory-based intervention methods, and messages contents are tailored to each user. Conclusion. TAVIE en santé is currently being evaluated. The use of IM allows developing intervention with a systematic approach based on theory, empirical evidence, and clinical and experiential knowledge. José Côté, Sylvie Cossette, Pilar Ramirez-Garcia, Geneviève Rouleau, Patricia Auger, François Boudreau, and Marie-Pierre Gagnon Copyright © 2017 José Côté et al. All rights reserved. Prevalence and Complications of Pregestational and Gestational Diabetes in Saudi Women: Analysis from Riyadh Mother and Baby Cohort Study (RAHMA) Sun, 12 Mar 2017 09:01:53 +0000 The objectives of this study were to estimate the burden of diabetes and to explore the adverse pregnancy outcomes associated with pregestational diabetes mellitus (pre-GDM) and gestational diabetes mellitus (GDM) among the Saudi pregnant population. In this subcohort, we compared the maternal and the neonatal outcomes of diabetic women with pre-GDM and GDM to the outcomes of nondiabetic mothers who delivered during the same period. From the total cohort, 9723 women participated in this study. Of the participants, 24.2% had GDM, 4.3% had pre-GDM, and 6951 were nondiabetic. After adjustment for confounders, women with GDM had increased odds of delivering a macrosomic baby (OR: 1.6; 95% CI: 1.2–2.1). Women with pre-GDM were more likely to deliver by Cesarean section (OR: 1.65; CI: 1.32–2.07) and to have preterm delivery < 37 weeks (OR: 2.1; CI: 1.5–2.8). Neonates of mothers with pre-GDM were at increased risk of being stillbirth (OR: 3.66; CI: 1.98–6.72), at increased risk of admission to NICU (OR: 2.21; CI: 1.5–3.27), and at increased risk for being macrosomic (OR: 2.40; CI: 1.50–3.8). The prevalence of GDM and pre-GDM in the Saudi pregnant population is among the highest in the world. The conditions are associated with high maternal and neonatal morbidities and mortalities. Hayfaa Wahabi, Amel Fayed, Samia Esmaeil, Heba Mamdouh, and Reham Kotb Copyright © 2017 Hayfaa Wahabi et al. All rights reserved. Growth Profile and Its Association with Nutrient Intake and Dietary Patterns among Children and Adolescents in Hail Region of Saudi Arabia Mon, 20 Feb 2017 13:52:11 +0000 Hail region of Saudi Arabia (KSA) has the highest adult obesity rates in the entire kingdom and limited information is available about the prevalence and patterns of growth markers. Therefore, it is important to monitor the growth trends to implement effective public health preventive strategies for the region. This study aims to estimate the prevalence of growth profile patterns (stunting, wasting, underweight, and overweight) and its associations with nutrient intake and dietary patterns among children and adolescents. A cross-sectional survey was conducted involving 1420 children and adolescents (2–18 years), selected using a multistage stratified random-sampling technique representing both female and male schools from Hail region, KSA. Growth profile -scores were generated using 2006 and 2007 WHO growth standards. The overall prevalence of 4.73% moderate and 1.54% severe underweight; 6.65% moderate and 2.59% severe stunting; 6.34% moderate and 2.55% severe wasting was present in the study population. Stunting decreased as age progressed with concurrent increase in the prevalence of overweight and obesity. There was a significantly higher prevalence of overweight (18.55% versus 23.05%; ) and obesity (8.7% versus 13.85%; ) in adolescents than in school-age children with higher prevalence in females as compared to males. Both stunted and overweight/obesity groups had significantly lower mean intakes for critical micronutrients necessary for growth as compared to normal children. Eyad Alshammari, Epuru Suneetha, Mohd Adnan, Saif Khan, and Awfa Alazzeh Copyright © 2017 Eyad Alshammari et al. All rights reserved. Design, Implementation, and Study Protocol of a Kindergarten-Based Health Promotion Intervention Mon, 20 Feb 2017 00:00:00 +0000 Inactivity and an unhealthy diet amongst others have led to an increased prevalence of overweight and obesity even in young children. Since most health behaviours develop during childhood health promotion has to start early. The setting kindergarten has been shown as ideal for such interventions. “Join the Healthy Boat” is a kindergarten-based health promotion programme with a cluster-randomised study focussing on increased physical activity, reduced screen media use, and sugar-sweetened beverages, as well as a higher fruit and vegetable intake. Intervention and materials were developed using Bartholomew’s Intervention Mapping approach considering Bandura’s social-cognitive theory and Bronfenbrenner’s ecological framework for human development. The programme is distributed using a train-the-trainer approach and currently implemented in 618 kindergartens. The effectiveness of this one-year intervention with an intervention and a control group will be examined in 62 kindergartens using standardised protocols, materials, and tools for outcome and process evaluation. A sample of 1021 children and their parents provided consent and participated in the intervention. Results of this study are awaited to give a better understanding of health behaviours in early childhood and to identify strategies for effective health promotion. The current paper describes development and design of the intervention and its implementation and planned evaluation. Trial Registration. The study is registered at the German Clinical Trials Register (DRKS), Freiburg University, Germany, ID: DRKS00010089. Susanne Kobel, Olivia Wartha, Tamara Wirt, Jens Dreyhaupt, Christine Lämmle, Eva-Maria Friedemann, Anne Kelso, Claire Kutzner, Lina Hermeling, and Jürgen M. Steinacker Copyright © 2017 Susanne Kobel et al. All rights reserved. Perceived Psychological, Economic, and Social Impact of Khat Chewing among Adolescents and Adults in Nekemte Town, East Welega Zone, West Ethiopia Mon, 06 Feb 2017 08:31:58 +0000 The main aim of this study was to assess psychological, economic, and social impact of khat chewing among adolescents, in Nekemte town, East Welega Zone. A community based cross-sectional study was conducted from March to June 2016 using both quantitative and qualitative methods of data collection. A total of 359 samples were included in the study. A pretested, interviewer based structured questionnaire was employed during data collection. The study found the current prevalence of khat chewing practices was 48.6%. Perceived psychological problems especially depression and anxiety were associated with khat chewing practices. The risk of depression was about 25 times higher among khat chewers compared to nonchewers. Similarly the risk of anxiety among khat chewers was about 5 times higher compared to nonchewers. Generally current khat chewing practices in the study area are relatively high. The occurrence of reported, perceived psychological problems mainly depression and anxiety was significantly higher among khat chewers compared to nonchewers. Thus efforts like creating awareness about negative effect, making different recreation methods available, and formulating common conventions regarding khat use mainly by young generations are necessary to decrease the magnitude of chewing practices and thereby its associated consequences. Amsalu Taye Wondemagegn, Melese Chego Cheme, and Kelemu Tilahun Kibret Copyright © 2017 Amsalu Taye Wondemagegn et al. All rights reserved. Patient Payment and Unhealthy Behavior: A Comparison across European Countries Sun, 05 Feb 2017 08:47:34 +0000 Introduction. Prior research has documented that unhealthy behaviors result in greater health care use and greater health care costs. However, there are few studies on out-of-pocket expenditure paid by those engaging in unhealthy behaviors. We provide cross-country evidence on the association of smoking, alcohol consumption, and obesity with health care use and health care cost as well as out-of-pocket payments among the elderly in Europe. Method. Using SHARE dataset for 13 European countries, the study uses a sequential logit model to analyze use and payments for outpatient and inpatient health care service in addition to a two-part model for the analysis of use and payments for prescribed drugs. Results. Former smoking is associated with a higher rate of health care use. However, current smoking is associated with lower health care use. Former smoking is also associated with paying higher amount of out-of-pocket payments. Alcohol consumption is associated with lower health care use. Conclusion. We do not find systematic evidence that unhealthy behaviors among elderly (50+) are associated with more utilization of health care and more out-of-pocket payments. The results can be of interest for policies that aim to make people more responsible toward their health behaviors. Reza Rezayatmand, Milena Pavlova, and Wim Groot Copyright © 2017 Reza Rezayatmand et al. All rights reserved. Comparisons of Waist Circumference Measurements at Five Different Anatomical Sites in Chinese Children Thu, 02 Feb 2017 08:12:27 +0000 This study compared the waist circumference (WC) measurements of Chinese children at different sites to determine the relationship between WC measurements and body fat. WC was measured at five sites in 255 subjects aged 9–19 years: immediately below the lowest rib (WC1), at the narrowest waist (WC2), the midpoint between the lowest rib and the iliac crest (WC3), 1 cm above the umbilicus (WC4), and immediately above the iliac crest (WC5). Body fat mass (FM), body fat percentage (% BF), body fat mass in the trunk (FM in the trunk), and fat percentage in the trunk (% BF in the trunk) were determined by dual-energy X-ray absorptiometry. The WCs were then compared through ANOVA with repeated measurement. The relationship of WC of each site with FM, % BF, FM in the trunk, and % BF in the trunk was examined through partial correlation. The WCs exhibited the following pattern: WC2 < WC1 < WC3 < WC4 < WC5 () in males and WC2 < WC1 < WC4, WC3 < WC5 () in females. The measured WCs were strongly correlated with FM, % BF, FM in the trunk, and % BF in the trunk. The WC measurements at five commonly used sites among Chinese children are different from one another. Results indicate that standardizing the anatomic point for the WC measurements is necessary. Chaoran Yang and Lin Wang Copyright © 2017 Chaoran Yang and Lin Wang. All rights reserved. Assessment of Pulmonary Toxicity Induced by Inhaled Toner with External Additives Mon, 16 Jan 2017 00:00:00 +0000 We investigated the harmful effects of exposure to a toner with external additives by a long-term inhalation study using rats, examining pulmonary inflammation, oxidative stress, and histopathological changes in the lung. Wistar rats were exposed to a well-dispersed toner (mean of MMAD: 2.1 μm) at three mass concentrations of 1, 4, and 16 mg/m3 for 22.5 months, and the rats were sacrificed after 6 months, 12 months, and 22.5 months of exposure. The low and medium concentrations did not induce statistically significant pulmonary inflammation, but the high concentration did, and, in addition, a histopathological examination showed fibrosis in the lung. Although lung tumor was observed in one sample of high exposure for 22.5 months, the cause was not statistically significant. On the other hand, a persistent increase in 8-OHdG was observed in the high exposure group, indicating that DNA damage by oxidative stress with persistent inflammation leads to the formation of tumorigenesis. The results of our studies show that toners with external additives lead to pulmonary inflammation, oxidative stress, and fibrosis only at lung burdens beyond overload. These data suggest that toners with external additives may have low toxicity in the lung. Taisuke Tomonaga, Hiroto Izumi, Yukiko Yoshiura, Toshihiko Myojo, Takako Oyabu, Byeong-Woo Lee, Takami Okada, Yunshan Li, Kazuaki Kawai, Toshiaki Higashi, and Yasuo Morimoto Copyright © 2017 Taisuke Tomonaga et al. All rights reserved. Developing Intervention Strategies to Optimise Body Composition in Early Childhood in South Africa Mon, 16 Jan 2017 00:00:00 +0000 Purpose. The purpose of this research was to collect data to inform intervention strategies to optimise body composition in South African preschool children. Methods. Data were collected in urban and rural settings. Weight status, physical activity, and gross motor skill assessments were conducted with 341 3–6-year-old children, and 55 teachers and parents/caregivers participated in focus groups. Results. Overweight and obesity were a concern in low-income urban settings (14%), but levels of physical activity and gross motor skills were adequate across all settings. Focus group findings from urban and rural settings indicated that teachers would welcome input on leading activities to promote physical activity and gross motor skill development. Teachers and parents/caregivers were also positive about young children being physically active. Recommendations for potential intervention strategies include a teacher-training component, parent/child activity mornings, and a home-based component for parents/caregivers. Conclusion. The findings suggest that an intervention focussed on increasing physical activity and improving gross motor skills per se is largely not required but that contextually relevant physical activity and gross motor skills may still be useful for promoting healthy weight and a vehicle for engaging with teachers and parents/caregivers for promoting other child outcomes, such as cognitive development. Catherine E. Draper, Simone A. Tomaz, Matthew Stone, Trina Hinkley, Rachel A. Jones, Johann Louw, Rhian Twine, Kathleen Kahn, and Shane A. Norris Copyright © 2017 Catherine E. Draper et al. All rights reserved. Associations of Occupational Stressors, Perceived Organizational Support, and Psychological Capital with Work Engagement among Chinese Female Nurses Thu, 12 Jan 2017 00:00:00 +0000 This study aimed to explore the associations of occupational stressors (extrinsic effort, reward, and overcommitment), perceived organizational support (POS), and psychological capital (PsyCap) and its components (self-efficacy, hope, resilience, and optimism) with work engagement and the mediating roles of PsyCap and its components among Chinese female nurses within the framework of the job demands-resources (JD-R) model. A cross-sectional sample (1,330) completed the Utrecht Work Engagement Scale, Effort-Reward Imbalance Scale, Survey of POS, and PsyCap Questionnaire, and effective respondents were 1,016 (76.4%). Hierarchical regression analysis and Preacher and Hayes’ asymptotic and resampling strategies were used. Extrinsic effort was negatively associated with vigor, dedication, and absorption, while POS, PsyCap, and hope were positively associated with them. Reward and overcommitment were positively associated with dedication and absorption. Optimism was positively associated with vigor and dedication. Optimism mediated the associations of extrinsic effort, reward, and POS with vigor and dedication. PsyCap and hope mediated the associations of POS with vigor, dedication, and absorption. There is a low level of work engagement among Chinese female nurses. Extrinsic effort could reduce work engagement, while reward, overcommitment, POS, PsyCap, hope, and optimism could enhance work engagement. Hospital managers should develop the PsyCap of female nurses through controlling occupational stressors and establishing supportive organizational climate to enhance their work engagement. Xiaoxi Wang, Li Liu, Futing Zou, Junhui Hao, and Hui Wu Copyright © 2017 Xiaoxi Wang et al. All rights reserved. R&D in Vaccines Targeting Neglected Diseases: An Exploratory Case Study Considering Funding for Preventive Tuberculosis Vaccine Development from 2007 to 2014 Wed, 04 Jan 2017 00:00:00 +0000 Based on an exploratory case study regarding the types of institutions funding the research and development to obtain new tuberculosis vaccines, this article intends to provoke discussion regarding the provision of new vaccines targeting neglected disease. Although our findings and discussion are mainly relevant to the case presented here, some aspects are more generally applicable, especially regarding the dynamics of development in vaccines to prevent neglected diseases. Taking into account the dynamics of innovation currently seen at work in the vaccine sector, a highly concentrated market dominated by few multinational pharmaceutical companies, we feel that global PDP models can play an important role throughout the vaccine development cycle. In addition, the authors call attention to issues surrounding the coordination of actors and resources in the research, development, manufacturing, and distribution processes of vaccine products arising from PDP involvement. Theolis Costa Barbosa Bessa, Erika Santos de Aragão, Jane Mary Medeiros Guimarães, and Bethânia de Araújo Almeida Copyright © 2017 Theolis Costa Barbosa Bessa et al. All rights reserved. Evidence of Allergic Reactions and Cardiopulmonary Impairments among Traders Operating from Foodstuff Warehouses Wed, 28 Dec 2016 14:19:47 +0000 Background. Foodstuff traders operating from warehouses (FTFW) are potentially exposed to dangerous rodenticides/pesticides that may have adverse effects on cardiopulmonary function. Methods. Fifty consenting male foodstuff traders, comprising 15 traders (21–63 years) operating outside warehouses and 35 FTFW (20–64 years), were randomly recruited at Ogbete Market, Enugu, in a cross-sectional observational study of spirometric and electrocardiographic parameters. Seventeen FTFW (21–57 years) participated in focus group discussions. Qualitative and quantitative data were analysed thematically and with independent t-test and Pearson correlation coefficient at , respectively. Results. Most FTFW experienced respiratory symptoms, especially dry cough (97.1%) and wheezing (31.4%) with significant reductions in forced vital capacity (FVC) (; ), forced expiratory volume in one second (FEV1) (; ), maximum expiratory flow rate () (; ), and forced end-expiratory flow () (; ). The maximum mid-expiratory flow () was marginally decreased () with a significantly prolonged () QTc interval. Conclusion. Allergic response was evident in the FTFW. Significant decrease in FVC may negatively impact lung flow rates and explains the marginal decrease in , which implies a relative limitation in airflow of peripheral/distal airways and elastic recoil of the lungs. This is consistent with obstructive pulmonary disease; a significant decrease in /FEV1 supports this conclusion. Significant decrease in indicates abnormalities in the large airways/larynx just as significantly prolonged ventricular repolarization suggests cardiac arrhythmias. Sam Ibeneme, Viola Egbosionu, Georgian Ibeneme, Amarachi Ezuma, Theresa Ettu, Joseph Nwankwo, Dnyanesh Limaye, and Emmanuel Nna Copyright © 2016 Sam Ibeneme et al. All rights reserved. Comparison of Sexual Knowledge, Attitude, and Behavior between Female Chinese College Students from Urban Areas and Rural Areas: A Hidden Challenge for HIV/AIDS Control in China Thu, 22 Dec 2016 15:21:55 +0000 Currently, research in sexual behavior and awareness in female Chinese college students (FCCSs) is limited, particularly regarding the difference and the influencing factors between students from rural areas and urban areas. To fill the gap in available data, a cross-sectional study using anonymous questionnaires was conducted among 3193 female students from six universities located in Beijing, Shanghai, and Guangzhou, China, from February to June, 2013. Of the 2669 respondents, 20.6% and 20.9% of the students from urban and rural areas, respectively, reported being sexually experienced. The proportion of students who received safe-sex education prior to entering university from rural areas (22.4%, 134/598) was lower () than the proportion from urban areas (41.8%, 865/2071). Sexual behavior has become increasingly common among FCCSs, including high-risk sexual behavior such as unprotected commercial sex. However, knowledge concerning human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) transmission and the risks is insufficient, particularly for those from rural areas, which is a challenge for HIV/AIDS control in China. The Chinese government should establish more specific HIV/AIDS prevention policies for Chinese young women, strengthen sex education, and continue to perform relevant research. Min Chen, Yong Liao, Jia Liu, Wenjie Fang, Nan Hong, Xiaofei Ye, Jianjun Li, Qinglong Tang, Weihua Pan, and Wanqing Liao Copyright © 2016 Min Chen et al. All rights reserved. Knowledge, Perceptions, and Practice of Nurses on Surveillance of Adverse Events following Childhood Immunization in Nairobi, Kenya Mon, 19 Dec 2016 10:55:37 +0000 Background. Although vaccines currently approved for routine childhood immunization are safe and effective, frequent adverse events following immunization often cause illnesses and sometimes loss of public trust in immunization programs. Nurses are essential in this surveillance system. Objective. To determine nurses’ knowledge, perception, and practice towards surveillance of postimmunization adverse events within Nairobi County health centers, Kenya. Methods. This is a cross-sectional survey involving nurses . Data were collected using self-administered questionnaires. Data analysis was performed using SPSS version 20. Differences in proportions of categorical variables were compared between groups using chi-square tests. Binary logistic regression model was used to compute independent predictors of outcome. Results. 29.2%, 32.1%, and 45.3% of the respondents had good knowledge, good practices, and good perceptions on AEFI surveillance, respectively. Respondents with diploma or degree nursing training level were 1.8 times and 2.5 times more likely to have good knowledge and good perception in AEFI surveillance, respectively. Nurses with previous AEFI training were 9.7 times and 1.8 times more likely to have good AEFI knowledge and practices, respectively. Conclusion. There is a need to train and mentor nurses on AEFI surveillance. Findings of this study will be valuable in informing policy review on childhood immunization programs. Calistus Wanjala Masika, Harrysone Atieli, and Tom Were Copyright © 2016 Calistus Wanjala Masika et al. All rights reserved. Identification and Prioritization of the Economic Impacts of Vaccines Mon, 12 Dec 2016 11:56:35 +0000 Understanding the most important economic impacts of vaccines can provide relevant information to stakeholders when selecting vaccine immunization strategies from a broader perspective. This study was therefore designed to first identify economic impacts to vaccinated individuals and, second, assess the relative importance of these economic impacts. A four-step approach was used, including a review of the literature, a pilot study, and expert consultation. As a fourth step, a survey utilizing a best-worst scaling was conducted among 26 different stakeholders to assess the relative importance of the identified economic impacts. In each of the 15 choice tasks, participants were asked to choose the most important and the least important economic impact from a set of four from the master list. We identified 23 economic impacts relevant for vaccine introduction. Four domains were identified, namely, health related benefits to vaccinated individuals, short- and long-term productivity gains, community or health systems externalities, and broader economic indicators. The first domain was seen as especially important with mortality, health care expenditure, and morbidity ranking in the top three overall. In conclusion, our study suggests that domain A “health related benefits to vaccinated individuals” are valued as more important than the other economic impacts. Ingeborg M. van der Putten, Aggie T. G. Paulus, Silvia M. A. A. Evers, Raymond C. W. Hutubessy, and Mickael Hiligsmann Copyright © 2016 Ingeborg M. van der Putten et al. All rights reserved. Informing Active Play and Screen Time Behaviour Change Interventions for Low Socioeconomic Position Mothers of Young Children: What Do Mothers Want? Thu, 08 Dec 2016 10:38:44 +0000 Introduction. This study investigated views of mothers from disadvantaged urban and regional areas (i.e., beyond major capital cities) as potential end users of child active play and screen time behaviour change interventions, with a focus on text messaging and web-based delivery platforms. Methods. Thirty-two mothers (22 urban; 10 regional) were interviewed. Purpose-designed questions covered topics regarding mothers’ preferences for accessing and receiving information related to parenting and child active play and screen time. Data from transcribed interviews were analysed to identify responses and key themes. Results. Mothers reported frequently accessing parenting- and child-related information online. Regional mothers reported seeking information by talking with other people less frequently than urban mothers and seemed to have a stronger preference for receiving information online. There were few differences between responses from low and high educated mothers. The majority of mothers reported that they would be happy to receive text messages containing information about active play and screen time and that they would find a dedicated website with this information useful. Conclusions. Mothers in this study held favourable views on the potential of receiving information via new communication technologies. Future interventions targeting socioeconomically disadvantaged mothers may benefit from delivering intervention messages via these technologies. Katherine L. Downing, Keren Best, Karen J. Campbell, and Kylie D. Hesketh Copyright © 2016 Katherine L. Downing et al. All rights reserved. Factors Affecting Adverse Drug Reaction Reporting of Healthcare Professionals and Their Knowledge, Attitude, and Practice towards ADR Reporting in Nekemte Town, West Ethiopia Wed, 30 Nov 2016 13:08:56 +0000 Background. Adverse drug reactions are global problems of major concern. Adverse drug reaction reporting helps the drug monitoring system to detect the unwanted effects of those drugs which are already in the market. Aims. To assess the knowledge, attitude, and practice of health care professionals working in Nekemte town towards adverse drug reaction reporting. Methods and Materials. A cross-sectional study design was conducted on a total of 133 health care professionals by interview to assess their knowledge, attitude, and practice using structured questionnaire. Results. Of the total respondents, only 64 (48.2%), 56 (42.1%), and 13 (9.8%) health care professionals have correctly answered the knowledge, attitude, and practice assessment questions, respectively. Lack of awareness and knowledge on what, when, and to whom to report adverse drug reactions and lack of commitments of health care professionals were identified as the major discouraging factors against adverse drug reaction reporting. Conclusion. This study has revealed that the knowledge, attitude, and practice of the health care professionals working in Nekemte town towards spontaneous adverse drug reaction reporting were low that we would like to recommend the concerned bodies to strive on the improvement of the knowledge, attitude, and practice status of health care professionals. Lense Temesgen Gurmesa and Mohammed Gebre Dedefo Copyright © 2016 Lense Temesgen Gurmesa and Mohammed Gebre Dedefo. All rights reserved. Short Duration Small Sided Football and to a Lesser Extent Whole Body Vibration Exercise Induce Acute Changes in Markers of Bone Turnover Tue, 29 Nov 2016 08:36:53 +0000 We aimed to study whether short-duration vibration exercise or football sessions of two different durations acutely changed plasma markers of bone turnover and muscle strain. Inactive premenopausal women () were randomized to complete a single bout of short (FG15) or long duration (FG60) small sided football or low magnitude whole body vibration training (VIB). Procollagen type 1 amino-terminal propeptide (P1NP) was increased during exercise for FG15 ( to  μg·L−1, mean ± SD, ) and FG60 ( to  μg·L−1, ) but not for VIB ( to  μg·L−1, ). An increase in osteocalcin was observed 48 h after exercise (), which did not differ between exercise groups. C-terminal telopeptide of type 1 collagen was not affected by exercise. Blood lactate concentration increased during exercise for FG15 ( to  mM) and FG60 ( to  mM), but not for VIB ( to  mM) (). Plasma creatine kinase increased by % and % 48 h after FG15 and FG60 (), but not after VIB (%, NS). In contrast to the minor elevation in osteocalcin in response to a single session of vibration exercise, both short and longer durations of small sided football acutely increased plasma P1NP, osteocalcin, and creatine kinase. This may contribute to favorable effects of chronic training on musculoskeletal health. J. L. Bowtell, S. R. Jackman, S. Scott, L. J. Connolly, M. Mohr, G. Ermidis, R. Julian, F. Yousefian, E. W. Helge, N. R. Jørgensen, J. Fulford, K. M. Knapp, and P. Krustrup Copyright © 2016 J. L. Bowtell et al. All rights reserved. The Costs and Their Determinant of Cesarean Section and Vaginal Delivery: An Exploratory Study in Chongqing Municipality, China Tue, 22 Nov 2016 13:29:41 +0000 Objectives. This study aims to analyze the cesarean section (CS) rates and vaginal delivery rates in tertiary hospitals of China, explore the costs of two different deliveries, and examine the relative influencing factors of the costs in both CS and vaginal deliveries. Methods. 30,168 anonymized obstetric medical cases were selected from three sample tertiary hospitals in Chongqing Municipality from 2011 to 2013. Chi-square test was used to compare the distributions of CS and vaginal deliveries under different indicators. Mann–Whitney test and Kruskal-Wallis test were adopted to analyze the differences under different items. Multiple linear regression was used to determine the influencing factors of the costs of different delivery modes. Results. (1) The rates of CS were 69%, 65.5%, and 59.2% in the three sample tertiary hospitals in Chongqing from 2011 to 2013. (2) The costs and the length of stay of CS were greater than those of vaginal delivery, which had significant differences (). (3) The areas, length of stay, age, medical insurance, and modes of delivery were the influencing factors of both CS and vaginal delivery costs. Discussion. The high CS rates in China must be paid significant attention. The indicators of two modes of delivery should be regulated strictly. CS rate reduction and saving medical resources will be the benefits if vaginal delivery is chosen by pregnant women. Zhifei He, Zhaohui Cheng, Tailai Wu, Yan Zhou, Junguo Chen, Qian Fu, and Zhanchun Feng Copyright © 2016 Zhifei He et al. All rights reserved. Comparison of Extended-Spectrum β-Lactamase-Producing Escherichia coli Isolates from Drinking Well Water and Pit Latrine Wastewater in a Rural Area of China Mon, 14 Nov 2016 06:33:28 +0000 The present study was conducted to gain insights into the occurrence and characteristics of extended-spectrum beta-lactamase- (ESBL-) producing Escherichia coli (E. coli) from drinking well water in the rural area of Laiwu, China, and to explore the role of the nearby pit latrine as a contamination source. ESBL-producing E. coli from wells were compared with isolates from pit latrines in the vicinity. The results showed that ESBL-producing E. coli isolates, with the same antibiotic resistance profiles, ESBL genes, phylogenetic group, plasmid replicon types, and enterobacterial repetitive intergenic consensus-polymerase chain reaction (ERIC-PCR) fingerprints, were isolated from well water and the nearby pit latrine in the same courtyard. Therefore, ESBL-producing E. coli in the pit latrine may be a likely contributor to the presence of ESBL-producing E. coli in rural well water. Hongna Zhang, Yanxia Gao, and Weishan Chang Copyright © 2016 Hongna Zhang et al. All rights reserved. Application of Machine Learning Approaches for Classifying Sitting Posture Based on Force and Acceleration Sensors Thu, 27 Oct 2016 06:38:14 +0000 Occupational musculoskeletal disorders, particularly chronic low back pain (LBP), are ubiquitous due to prolonged static sitting or nonergonomic sitting positions. Therefore, the aim of this study was to develop an instrumented chair with force and acceleration sensors to determine the accuracy of automatically identifying the user’s sitting position by applying five different machine learning methods (Support Vector Machines, Multinomial Regression, Boosting, Neural Networks, and Random Forest). Forty-one subjects were requested to sit four times in seven different prescribed sitting positions (total 1148 samples). Sixteen force sensor values and the backrest angle were used as the explanatory variables (features) for the classification. The different classification methods were compared by means of a Leave-One-Out cross-validation approach. The best performance was achieved using the Random Forest classification algorithm, producing a mean classification accuracy of 90.9% for subjects with which the algorithm was not familiar. The classification accuracy varied between 81% and 98% for the seven different sitting positions. The present study showed the possibility of accurately classifying different sitting positions by means of the introduced instrumented office chair combined with machine learning analyses. The use of such novel approaches for the accurate assessment of chair usage could offer insights into the relationships between sitting position, sitting behaviour, and the occurrence of musculoskeletal disorders. Roland Zemp, Matteo Tanadini, Stefan Plüss, Karin Schnüriger, Navrag B. Singh, William R. Taylor, and Silvio Lorenzetti Copyright © 2016 Roland Zemp et al. All rights reserved. Missed Opportunities for Vaccination in the Dominican Republic: Results of an Operational Investigation Wed, 12 Oct 2016 13:34:21 +0000 Background. Despite the success of the Dominican Republic’s National Immunization Program, homogenous vaccine coverage has not been achieved. In October 2012, the country implemented a study on missed opportunities for vaccination (MOVs) in children aged <5 years. Methods. A cross-sectional study of 102 healthcare facilities was implemented in 30 high-risk municipalities. Overall, 1500 parents and guardians of children aged <5 years were interviewed. A MOV is defined as when a person who is eligible for vaccination and with no contraindications visits a health facility and does not receive a required vaccine. We evaluated the causes of MOVs and identified risk factors associated with MOVs in the Dominican Republic. Results. Of the 514 children with available and reliable vaccination histories, 293 (57.0%) were undervaccinated after contact with a health provider. Undervaccinated children had 836 opportunities to receive a needed vaccine. Of these, 358 (42.8%) qualified as MOVs, with at least one MOV observed in 225 children (43.7%). Factors associated with MOVs included urban geographic area (OR = 1.80; ), age 1–4 years (OR = 3.63; ), and the purpose of the health visit being a sick visit (OR = 1.65; ). Conclusions. MOVs were associated primarily with health workers failing to request and review patients’ immunization cards. Zacarías Garib, Aida Lucía Vargas, Silas P. Trumbo, Kathleen Anthony, Jose Luis Diaz-Ortega, Pamela Bravo-Alcántara, Irene Leal, M. Carolina Danovaro-Holliday, and Martha Velandia-González Copyright © 2016 Zacarías Garib et al. All rights reserved. Height and Risk of Hip Fracture: A Meta-Analysis of Prospective Cohort Studies Wed, 12 Oct 2016 08:56:22 +0000 The association between height and risk of hip fracture has been investigated in several studies, but the evidence is inconclusive. We therefore conducted this meta-analysis of prospective cohort studies to explore whether an association exists between height and risk of hip fracture. We searched PubMed and EMBASE, Web of Science, and the Cochrane Library for studies of height and risk of hip fracture up to February 16, 2016. The random-effects model was used to combine results from individual studies. Seven prospective cohort studies, with 7,478 incident hip fracture cases and 907,913 participants, were included for analysis. The pooled relative risk (RR) was 1.65 (95% confidence interval (CI): 1.26–2.16) comparing the highest with the lowest category of height. Result from dose-response analysis suggested a linear association between height and hip fracture risk (-nonlinearity = 0.0378). The present evidence suggests that height is positively associated with increased risk of hip fracture. Further well-designed cohort studies are needed to confirm the present findings in other ethnicities. Zhihong Xiao, Dong Ren, Wei Feng, Yan Chen, Wusheng Kan, and Danmou Xing Copyright © 2016 Zhihong Xiao et al. All rights reserved. Prevalence and Characteristics of Salmonella Isolated from Free-Range Chickens in Shandong Province, China Sun, 09 Oct 2016 13:32:51 +0000 Compared with chickens raised in intensively managed breeding farms, free-range chickens in China are quite popular due to lower breeding density and less antibiotics usage. However, investigations about Salmonella enterica from free-range chickens are quite rare. The aim of the present study was to investigate prevalence and characteristics of Salmonella in free-range chickens in Shandong province, China. During the period of August and November 2015, 300 fresh fecal swabs from different broilers in three free-range chicken farms (100 samples per farm) were collected to isolate Salmonella, and then these isolates were subjected to serotyping, antibiotic sensitivity testing, enterobacterial repetitive intergenic consensus-polymerase chain reaction (ERIC-PCR), and multilocus sequence typing (ST). A total of 38 Salmonella isolates (38/300, 12.7%) were recovered. The most common serotype was Enteritidis (81.6%), followed by Indiana (13.2%) and Typhimurium (5.3%). Twenty-two out of 38 isolates (57.9%) were resistant to ampicillin, the highest resistance rate, but resistance rates to cefazolin, cefotaxime, and ceftazidime were only 7.9%. The multidrug resistance (MDR) rate was 26.3%. Additionally, the Salmonella isolates could be classified into 25 genotypes by ERIC-PCR and were divided into three ST types (ST11, ST17, and ST19), with ST11 the highest isolation rate (81.6%). In summary, as with other poultry, free-ranging chickens may also serve as potential reservoir for antibiotic resistant Salmonella, thereby posing a threat to public health. Xiaonan Zhao, Yanxia Gao, Chaoqun Ye, Lingling Yang, Tao Wang, and Weishan Chang Copyright © 2016 Xiaonan Zhao et al. All rights reserved. Analysis of Relationship between the Body Mass Composition and Physical Activity with Body Posture in Children Wed, 28 Sep 2016 13:46:13 +0000 Introduction. Excessive body mass in turn may contribute to the development of many health disorders including disorders of musculoskeletal system, which still develops intensively at that time. Aim. The aim of this study was to assess the relationship between children’s body mass composition and body posture. The relationship between physical activity level of children and the parameters characterizing their posture was also evaluated. Material and Methods. 120 school age children between 11 and 13 years were enrolled in the study, including 61 girls and 59 boys. Each study participant had the posture evaluated with the photogrammetric method using the projection moiré phenomenon. Moreover, body mass composition and the level of physical activity were evaluated. Results. Children with the lowest content of muscle tissue showed the highest difference in the height of the inferior angles of the scapulas in the coronal plane. Children with excessive body fat had less slope of the thoracic-lumbar spine, greater difference in the depth of the inferior angles of the scapula, and greater angle of the shoulder line. The individuals with higher level of physical activity have a smaller angle of body inclination. Conclusion. The content of muscle tissue, adipose tissue, and physical activity level determines the variability of the parameter characterizing the body posture. Justyna Wyszyńska, Justyna Podgórska-Bednarz, Justyna Drzał-Grabiec, Maciej Rachwał, Joanna Baran, Ewelina Czenczek-Lewandowska, Justyna Leszczak, and Artur Mazur Copyright © 2016 Justyna Wyszyńska et al. All rights reserved. Positive Impact on Physical Activity and Health Behaviour Changes of a 15-Week Family Focused Intervention Program: “Juniors for Seniors” Tue, 27 Sep 2016 15:43:34 +0000 The promotion of physical activity (PA) in children and their parents requires effective planning and sometimes even interventions. This study shows the effect of PA during a 15-week intervention program “Junior for Seniors” by applying a socioecological model to the interpretation of the data. This comprehensive approach emphasizes the fact that health promotion should focus not only on intrapersonal factors but also on the multilevel factors that might be determinants and modulators of increased PA. In 2015, 24 children (“juniors,” 14 girls and 10 boys, aged ) and 22 parents (“seniors,” 14 mothers aged and 8 fathers aged ) were voluntarily enrolled in a study spread across three primary schools in the city of Poznań, Poland. The effectiveness of the intervention was determined according to postintervention behavioural changes in PA in comparison to preintervention levels, as reported by the parents and children. Overall, the study found increases in PA levels and reductions in sedentary time. Although the changes are modest, there are some unrecognized benefits of the intervention which may have occurred, such as improved sport and motor skills, more frequent family social behaviours (walks, meals, and visiting relatives), or simply improved quality of “do-together” leisure time PA. Michał Bronikowski, Małgorzata Bronikowska, Beata Pluta, Janusz Maciaszek, Maciej Tomczak, and Agata Glapa Copyright © 2016 Michał Bronikowski et al. All rights reserved. Exploring and Promoting Prosocial Vaccination: A Cross-Cultural Experiment on Vaccination of Health Care Personnel Tue, 20 Sep 2016 09:13:55 +0000 Influenza vaccination for health care personnel (HCP) is recommended particularly because it indirectly protects patients from contracting the disease. Vaccinating can therefore be interpreted as a prosocial act. However, HCP vaccination rates are often far too low to prevent nosocomial infections. Effective interventions are needed to increase HCP’s influenza vaccine uptake. Here we devise a novel tool to experimentally test interventions that aim at increasing prosocially motivated vaccine uptake under controlled conditions. We conducted a large-scale and cross-cultural experiment with participants from countries with either a collectivistic (South Korea) or an individualistic (USA) cultural background. Results showed that prosocially motivated vaccination was more likely in South Korea compared to the US, mediated by a greater perception of vaccination as a social act. However, changing the default of vaccination, such that participants had to opt out rather than to opt in, increased vaccine uptake in the US and therefore compensated for the lower level of prosocial vaccination. In sum, the present study provides both a novel method to investigate HCP influenza vaccination behavior and interventions to increase their vaccine uptake. Robert Böhm, Cornelia Betsch, Lars Korn, and Cindy Holtmann Copyright © 2016 Robert Böhm et al. All rights reserved. Comment on “Effect of Health Education on Willingness to Undergo HIV Screening among Antenatal Attendees in a Teaching Hospital in North Central Nigeria” Wed, 14 Sep 2016 13:06:08 +0000 Siddharudha Shivalli and Soujanya Kaup Copyright © 2016 Siddharudha Shivalli and Soujanya Kaup. All rights reserved. Obstacles and Enablers on the Way towards Integrated Physical Activity Policies for Childhood Obesity Prevention: An Exploration of Local Policy Officials’ Views Wed, 07 Sep 2016 14:18:21 +0000 Background. Limited physical activity (PA) is a risk factor for childhood obesity. In Netherlands, as in many other countries worldwide, local policy officials bear responsibility for integrated PA policies, involving both health and nonhealth domains. In practice, its development seems hampered. We explore which obstacles local policy officials perceive in their effort. Methods. Fifteen semistructured interviews were held with policy officials from health and nonhealth policy domains, working at strategic, tactic, and operational level, in three relatively large municipalities. Questions focused on exploring perceived barriers for integrated PA policies. The interviews were deductively coded by applying the Behavior Change Ball framework. Findings. Childhood obesity prevention appeared on the governmental agenda and all officials understood the multicausal nature. However, operational officials had not yet developed a tradition to develop integrated PA policies due to insufficient boundary-spanning skills and structural and cultural differences between the domains. Tactical level officials did not sufficiently support intersectoral collaboration and strategic level officials mainly focused on public-private partnerships. Conclusion. Developing integrated PA policies is a bottom-up innovation process that needs to be supported by governmental leaders through better guiding organizational processes leading to such policies. Operational level officials can assist in this by making progress in intersectoral collaboration visible. Anna-Marie Hendriks, Jolanda M. Habraken, Stef P. J. Kremers, Maria W. J. Jansen, Hans van Oers, and Albertine J. Schuit Copyright © 2016 Anna-Marie Hendriks et al. All rights reserved. Evaluation of Influenza Vaccination Efficacy: A Universal Epidemic Model Wed, 07 Sep 2016 09:24:18 +0000 By means of a designed epidemic model, we evaluated the influence of seasonal vaccination coverage as well as a potential universal vaccine with differing efficacy on the aftermath of seasonal and pandemic influenza. The results of the modeling enabled us to conclude that, to control a seasonal influenza epidemic with a reproduction coefficient , a 35% vaccination coverage with the current seasonal influenza vaccine formulation is sufficient, provided that other epidemiology measures are regularly implemented. Increasing level of pandemic strains will obviously require stronger intervention. In addition, seasonal influenza vaccines fail to confer protection against antigenically distinct pandemic influenza strains. Therefore, the necessity of a universal influenza vaccine is clear. The model predicts that a potential universal vaccine will be able to provide sufficient reliable (90%) protection against pandemic influenza only if its efficacy is comparable with the effectiveness of modern vaccines against seasonal influenza strains (70%–80%); given that at least 40% of the population has been vaccinated in advance, ill individuals have been isolated (observed), and a quarantine has been introduced. If other antiepidemic measures are absent, a vaccination coverage of at least 80% is required. Lily Ph. Nizolenko, Alexander G. Bachinsky, and Sergei I. Bazhan Copyright © 2016 Lily Ph. Nizolenko et al. All rights reserved. Complementarity of Clinician Judgment and Evidence Based Models in Medical Decision Making: Antecedents, Prospects, and Challenges Wed, 24 Aug 2016 15:08:49 +0000 Early accounts of the development of modern medicine suggest that the clinical skills, scientific competence, and doctors’ judgment were the main impetus for treatment decision, diagnosis, prognosis, therapy assessment, and medical progress. Yet, clinician judgment has its own critics and is sometimes harshly described as notoriously fallacious and an irrational and unfathomable black box with little transparency. With the rise of contemporary medical research, the reputation of clinician judgment has undergone significant reformation in the last century as its fallacious aspects are increasingly emphasized relative to the evidence based options. Within the last decade, however, medical forecasting literature has seen tremendous change and new understanding is emerging on best ways of sharing medical information to complement the evidence based medicine practices. This review revisits and highlights the core debate on clinical judgments and its interrelations with evidence based medicine. It outlines the key empirical results of clinician judgments relative to evidence based models and identifies its key strengths and prospects, the key limitations and conditions for the effective use of clinician judgment, and the extent to which it can be optimized and professionalized for medical use. Zhou Lulin, Ethel Yiranbon, and Henry Asante Antwi Copyright © 2016 Zhou Lulin et al. All rights reserved. Comment on “Workplace Bullying as a Risk Factor for Musculoskeletal Disorders: The Mediating Role of Job-Related Psychological Strain” Wed, 17 Aug 2016 13:39:06 +0000 Pracheth Raghuveer Copyright © 2016 Pracheth Raghuveer. All rights reserved. A Cross-Sectional Survey to Estimate the Cat Population and Ownership Profiles in a Semirural Area of Central Italy Wed, 17 Aug 2016 13:00:55 +0000 Understanding animal population size and its demographic features is essential to address Public Health policies as well as to provide valuable information to pet industries and veterinary practitioners. Nevertheless, official data on feline population are not available worldwide. In the present study, the owned cat population size, its demographic attributes, and the ownership profiles have been investigated through a face-to-face questionnaire in a semirural area of Central Italy. The human : cat ratio was equal to 6.8 (95% CI: 5.7–7.5); 29.3% of households own at least one cat. The majority of cats were living in a rural area (67.8%) and outdoors, were neutered (70.5%), and were fed with commercial food (54.8%) and they visited a veterinarian 1-2 times a year (43.3%). The cat ownership was strongly associated with people living in a rural area and owning another pet. As the cat owned population was mainly kept outdoors in rural areas, the possible relation between the owned and the stray animals is worthy to be monitored in future researches. Our study revealed that the feline owned population was larger than expected and that social and economic human factors do not influence the cat ownership. Health Authorities and veterinary practitioners should promote responsible ownership to increase the veterinary care, to intensify the official identification, and to properly manage the outdoor lifestyle. Andrea Carvelli, Francesca Iacoponi, and Paola Scaramozzino Copyright © 2016 Andrea Carvelli et al. All rights reserved. Analysis of Spatiotemporal Characteristics of Pandemic SARS Spread in Mainland China Mon, 15 Aug 2016 09:04:50 +0000 Severe acute respiratory syndrome (SARS) is one of the most severe emerging infectious diseases of the 21st century so far. SARS caused a pandemic that spread throughout mainland China for 7 months, infecting 5318 persons in 194 administrative regions. Using detailed mainland China epidemiological data, we study spatiotemporal aspects of this person-to-person contagious disease and simulate its spatiotemporal transmission dynamics via the Bayesian Maximum Entropy (BME) method. The BME reveals that SARS outbreaks show autocorrelation within certain spatial and temporal distances. We use BME to fit a theoretical covariance model that has a sine hole spatial component and exponential temporal component and obtain the weights of geographical and temporal autocorrelation factors. Using the covariance model, SARS dynamics were estimated and simulated under the most probable conditions. Our study suggests that SARS transmission varies in its epidemiological characteristics and SARS outbreak distributions exhibit palpable clusters on both spatial and temporal scales. In addition, the BME modelling demonstrates that SARS transmission features are affected by spatial heterogeneity, so we analyze potential causes. This may benefit epidemiological control of pandemic infectious diseases. Chunxiang Cao, Wei Chen, Sheng Zheng, Jian Zhao, Jinfeng Wang, and Wuchun Cao Copyright © 2016 Chunxiang Cao et al. All rights reserved. Advancing Implementation of Evidence-Based Public Health in China: An Assessment of the Current Situation and Suggestions for Developing Regions Sun, 14 Aug 2016 09:45:46 +0000 Objective. Existing research shows a serious scarcity of EBPH practice in China and other developing regions; as an exploratory study, this study aimed to assess the current EBPH implementation status in Shanghai of China qualitatively. Methods. Using semistructured key informant interviews, we examined the status of and impediments to the lagging EBPH in China. Data were analyzed based on the Consolidated Framework for Implementation Research (CFIR). Results. Chinese public health practitioners knew more about evidence-based medicine but less about EBPH. The situation was worse in community healthcare centers. Participants perceived that evidence sources were limited and the quality of evidence was low. Concerning the inner setting factors, the structural characteristics, networks and communications, implementation climate, and leadership engagement were confronted with many problems. Among the outer setting factors, external government policies and incentives and low patient compliance were the key problems. Additionally, public health practitioners in Shanghai lacked sufficient awareness of EBPH. Furthermore, the current project-based EBPH lacks a systematic implementation system. Conclusions. Existing practical perspectives on EBPH indicate a lag in the advocacy of this new ideology in China. It would be advisable for healthcare institutions to take the initiative to explore feasible and multiple methods of EBPH promotion. Jianwei Shi, Chenghua Jiang, Duxun Tan, Dehua Yu, Yuan Lu, Pengfei Sun, Ying Pan, Hanzhi Zhang, Zhaoxin Wang, and Beilei Yang Copyright © 2016 Jianwei Shi et al. All rights reserved. The Effect of Neurobehavioral Test Performance on the All-Cause Mortality among US Population Wed, 10 Aug 2016 11:14:40 +0000 Evidence of the association between global cognitive function and mortality is much, but whether specific cognitive function is related to mortality is unclear. To address the paucity of knowledge on younger populations in the US, we analyzed the association between specific cognitive function and mortality in young and middle-aged adults. We analyzed data from 5,144 men and women between 20 and 59 years of age in the Third National Health and Nutrition Examination Survey (1988–94) with mortality follow-up evaluation through 2006. Cognitive function tests, including assessments of executive function/processing speed (symbol digit substitution) and learning recall/short-term memory (serial digit learning), were performed. All-cause mortality was the outcome of interest. After adjusting for multiple variables, total mortality was significantly higher in males with poorer executive function/processing speed (hazard ratio (HR) 2.02; 95% confidence interval 1.36 to 2.99) and poorer recall/short-term memory (HR 1.47; 95% confidence interval 1.02 to 2.12). After adjusting for multiple variables, the mortality risk did not significantly increase among the females in these two cognitive tests groups. In this sample of the US population, poorer executive function/processing speed and poorer learning recall/short-term memory were significantly associated with increased mortality rates, especially in males. This study highlights the notion that poorer specific cognitive function predicts all-cause mortality in young and middle-aged males. Tao-Chun Peng, Wei-Liang Chen, Li-Wei Wu, Ying-Jen Chen, Fang-Yih Liaw, Gia-Chi Wang, Chung-Ching Wang, and Ya-Hui Yang Copyright © 2016 Tao-Chun Peng et al. All rights reserved. National Survey of Workplaces Handling and Manufacturing Nanomaterials, Exposure to and Health Effects of Nanomaterials, and Evaluation of Nanomaterial Safety Data Sheets Sun, 31 Jul 2016 07:12:37 +0000 A national survey on workplace environment nanomaterial handling and manufacturing was conducted in 2014. Workplaces relevant to nanomaterials were in the order of TiO2 (91), SiO2 (88), carbon black (84), Ag (35), Al2O3 (35), ZnO (34), Pb (33), and CeO2 (31). The survey results indicated that the number of workplaces handling or manufacturing nanomaterials was 340 (0.27% of total 126,846) workplaces. The number of nanomaterials used and products was 546 (1.60 per company) and 583 (1.71 per company), respectively. For most workplaces, the results on exposure to hazardous particulate materials, including nanomaterials, were below current OELs, yet a few workplaces were above the action level. As regards the health status of workers, 9 workers were diagnosed with a suspected respiratory occupational disease, where 7 were recommended for regular follow-up health monitoring. 125 safety data sheets (SDSs) were collected from the nanomaterial-relevant workplaces and evaluated for their completeness and reliability. Only 4 CNT SDSs (3.2%) included the term nanomaterial, while most nanomaterial SDSs were not regularly updated and lacked hazard information. When taken together, the current analysis provides valuable national-level information on the exposure and health status of workers that can guide the next policy steps for nanomaterial management in the workplace. Jeongho Kim and Il Je Yu Copyright © 2016 Jeongho Kim and Il Je Yu. All rights reserved. Corrigendum to “Prognostic Factors of Returning to Work after Sick Leave due to Work-Related Common Mental Disorders: A One- and Three-Year Follow-Up Study” Mon, 25 Jul 2016 12:37:34 +0000 Bo Netterstrøm, Nanna Hurwitz Eller, and Marianne Borritz Copyright © 2016 Bo Netterstrøm et al. All rights reserved. Association of Living Arrangement Conditions and Socioeconomic Differentials with Anemia Status among Women in Rural Bangladesh Tue, 19 Jul 2016 09:10:31 +0000 In Bangladesh, iron deficiency is the most common cause of anemia and remains a significant public health concern. Being a high anemia prevalent country, numerous efforts have been made to confront the issue especially among women and children by both local and international actors. Though the situation has substantially improved in recent years, a staggering number of adult women are currently living with anemia. The etiology of anemia is a multifactorial problem and has been proposed to be associated with various household, societal, economic, cultural factors apart from dietary habits. However, evidence regarding the household arrangements and socioeconomic determinants of anemia is scarce, especially in the context of Bangladesh. To this end, we utilized the 2011 demographic and health survey data to explore the association between anemia status and selected demographic, socioeconomic, and household characteristics. Our result showed significant correlation of anemia with both sociodemographic and household characteristics. Among the sociodemographic variables the following were found to be significantly associated with anemia status: age (; OR = 1.195; 95% CI = 1.036–1.378) and microcredit membership (; OR = 1.19; 95% CI = 1.037–1.386). Regarding the household arrangements, women utilizing biomass fuel for cooking (; OR = 1.82; 95% CI = 0.981–2.460) were more likely to be anemic. Ghose Bishwajit, Sanni Yaya, Shangfeng Tang, Akmal Hossain, Yang Fan, Mahmuda Akter, and Zhanchun Feng Copyright © 2016 Ghose Bishwajit et al. All rights reserved. Effects of a Lifestyle-Based Physical Activity Intervention on Medical Expenditure in Japanese Adults: A Community-Based Retrospective Study Thu, 14 Jul 2016 16:48:36 +0000 Background. This study aimed to investigate whether a lifestyle-based physical activity program could contribute to reduced medical expenditure. Methods. The study participants were 60 adults aged 63.1 (standard deviation, 4.4) years in the intervention group; the case-control group consisted of 300 adults who were randomly selected from Japan’s national health insurance system. This community-based retrospective study incorporated a 3-year follow-up. Results. The total and outpatient medical expenditure in the intervention group were significantly lower than in the control group: total expenditure, $US640.4/year; outpatient expenditure, $369.1/year. The odds ratio for outpatient visiting was 6.47-fold higher in the control than in the intervention group. Conclusion. Our study suggests that a health program to promote physical activity can result in reduced total medical expenditure, outpatient medical expenditure, and possibly also inpatient medical expenditure. Yasuyo Yoshizawa, Junghoon Kim, and Shinya Kuno Copyright © 2016 Yasuyo Yoshizawa et al. All rights reserved. Demographics and Personality Factors Associated with Burnout among Nurses in a Singapore Tertiary Hospital Tue, 12 Jul 2016 11:02:28 +0000 Background. The aim of the study was to evaluate the prevalence and extent of burnout among nurses in Singapore and investigate the influence of demographic factors and personal characteristics on the burnout syndrome. Methods. A cross-sectional survey design was adopted. All registered nurses working in Singapore General Hospital were approached to participate. A questionnaire eliciting data on demographics, burnout (measured using the Maslach Burnout Inventory, MBI), and personality profile (measured using the NEO Five-Factor Inventory, NEO-FFI) was used. Results. 1830 nurses out of 3588 responded (response rate: 51%). Results from 1826 respondents were available for analysis. The MBI identified 39% to have high emotional exhaustion (EE, cut-off score of >27), 40% having high depersonalization (DP, cut-off score of >10), and 59% having low personal accomplishment (PA, cut-off score of <33). In multivariable analysis, age, job grade, and neuroticism were significantly associated with each of the 3 components of the MBI. Staff nurses less than 30 years with high to very high neuroticism were more likely to experience high EE, high DP, and low PA. Conclusion. Younger nurses in Singapore are at increased risk of burnout. Personality traits also played a significant role in the experience of burnout. Shin Yuh Ang, Satvinder S. Dhaliwal, Tracy Carol Ayre, Thendral Uthaman, Kuan Yok Fong, Choo Eng Tien, Huaqiong Zhou, and Phillip Della Copyright © 2016 Shin Yuh Ang et al. All rights reserved. Exploration of the Dietary and Lifestyle Behaviors and Weight Status and Their Self-Perceptions among Health Sciences University Students in North Lebanon Mon, 27 Jun 2016 07:02:25 +0000 University students may experience significant environmental changes that exert a negative influence on the quality of their diet and lifestyle. There is scarcity of data concerning the dietary and lifestyle behaviors and weight status of students in the health field in North Lebanon. To investigate these data, a cross-sectional survey was conducted including 369 health sciences students aged 18–25 chosen from four public and private universities in North Lebanon. Data were collected using a standardized interview questionnaire to determine sociodemographic, dietary, and lifestyle behaviors, appetite changes, stress related dietary behaviors, and food cravings, as well as self-perceptions of dietary adequacy, physical activity levels, and weight status. Body mass index was assessed. Results had revealed significant differences in some of the dietary consumption patterns and weight status among seniors compared to juniors. However, the overall prevalence of overweight and obesity recorded 32.2% and the dietary consumption patterns fall below recommended levels. Multivariate regression analysis showed that parental obesity, comfort eating, increased appetite, food cravings, and stressful eating were associated with increased risk of obesity while a healthy diet score was associated with decreased risk. The study’s findings call for tailoring culture specific intervention programs which enable students to improve their dietary and lifestyle behaviors and control stress. Germine El-Kassas and Fouad Ziade Copyright © 2016 Germine El-Kassas and Fouad Ziade. All rights reserved. Overweight and General and Abdominal Obesity in a Representative Sample of Spanish Adults: Findings from the ANIBES Study Sun, 12 Jun 2016 08:09:37 +0000 Objective. To analyze the anthropometric parameters from a representative sample of Spanish adults participating in ANIBES study and the prevalence of general and abdominal obesity. Methods. This cross-sectional study focused on 1655 adults aged 18–64 years. Weight, height, and waist circumference (WC) were evaluated, and body mass index (BMI) and waist to height ratio (WHtR) were calculated. A composite index combining BMI and WHtR was designed to establish five groups with different anthropometric status. Results. The prevalence of overweight (OW) was 35.8% and that of obesity was 19.9%. Obesity (OB) was higher among men (OR 1.725, 1.415–2.104; ) and each year of age increased the risk of obesity (OR 1.054, 1.045–1.064; ). The prevalence of abdominal obesity (WHtR ≥ 0.5) was 58.4%. Only 36.1% of the population had an optimal anthropometric situation (BMI < 25 kg/m2, WHtR < 0.5), whereas 50.1% had weight excess and high WHtR (BMI ≥ 25 kg/m2, WHtR ≥ 0.5). Conclusions. More than half of Spanish population has weight excess and cardiometabolic risk. The results of this study provide an understanding of the current anthropometric situation in the Spanish population, as a first step toward planning interventions and assessing their effectiveness in the future. Ana M. López-Sobaler, Aránzazu Aparicio, Javier Aranceta-Bartrina, Ángel Gil, Marcela González-Gross, Lluis Serra-Majem, Gregorio Varela-Moreiras, and Rosa M. Ortega Copyright © 2016 Ana M. López-Sobaler et al. All rights reserved. The Preventive Effect of Head Injury by Helmet Type in Motorcycle Crashes: A Rural Korean Single-Center Observational Study Thu, 02 Jun 2016 11:15:28 +0000 Introduction. The goal of this study was to determine the preventive effect on head injury by helmet type: full face helmet (FFH), open face helmet (OFH), and half-coverage helmet (HCH). Methods. This is a retrospective observational study of motorcycle crash victims between June 2012 and May 2015 in a rural town in Korea. We performed multiple linear regression to predict the effect of each type of helmet compared to unhelmeted status in preventing head injury using dependent variables based on the Abbreviated Injury Scale (AIS) and applied logistic regression modeling to compare the incidence of head injury. Results. Of the 738 patients, the number of FFH patients was 33.5%, followed by unhelmeted (27.8%), OFH (17.6%), and HCH (13.0%) patients. The FFH and OFH group had a lower head maximum AIS than unhelmeted group (coefficient: −0.368, 95% CI: −0.559 to −0.177 and coefficient: −0.235, 95% CI: −0.459 to −0.010, resp.) and only FFHs experienced a reduction effect of severe and minor head injury (OR: 0.206, 95% CI: 0.080 to 0.533 and OR: 0.589, 95% CI: 0.377 to 0.920, resp.). Conclusions. FFHs and OFHs reduce the risk of head injury, and FFHs have a more preventive effect on head injury in motorcycle crashes. Kang-Min Sung, Jennifer Noble, Sang-Chul Kim, Hyeok-Jin Jeon, Jin-Yong Kim, Han-Ho Do, Sang-O Park, Kyeong-Ryong Lee, and Kwang-Je Baek Copyright © 2016 Kang-Min Sung et al. All rights reserved. The Impact of External Factors on the Epigenome: In Utero and over Lifetime Wed, 18 May 2016 11:26:35 +0000 Epigenetic marks change during fetal development, adult life, and aging. Some changes play an important role in the establishment and regulation of gene programs, but others seem to occur without any apparent physiological role. An important future challenge in the field of epigenetics will be to describe how the environment affects both of these types of epigenetic change and to learn if interaction between them can determine healthy and disease phenotypes during lifetime. Here we discuss how chemical and physical environmental stressors, diet, life habits, and pharmacological treatments can affect the epigenome during lifetime and the possible impact of these epigenetic changes on pathophysiological processes. Estela G. Toraño, María G. García, Juan Luis Fernández-Morera, Pilar Niño-García, and Agustín F. Fernández Copyright © 2016 Estela G. Toraño et al. All rights reserved. Association between the Type of Workplace and Lung Function in Copper Miners Thu, 05 May 2016 14:17:29 +0000 The aim of the analysis was to retrospectively assess changes in lung function in copper miners depending on the type of workplace. In the groups of 225 operators, 188 welders, and 475 representatives of other jobs, spirometry was performed at the start of employment and subsequently after 10, 20, and 25 years of work. Spirometry Longitudinal Data Analysis software was used to estimate changes in group means for FEV1 and FVC. Multiple linear regression analysis was used to assess an association between workplace and lung function. Lung function assessed on the basis of calculation of longitudinal FEV1 (FVC) decline was similar in all studied groups. However, multiple linear regression model used in cross-sectional analysis revealed an association between workplace and lung function. In the group of welders, FEF75 was lower in comparison to operators and other miners as early as after 10 years of work. Simultaneously, in smoking welders, the FEV1/FVC ratio was lower than in nonsmokers ( < 0,05). The interactions between type of workplace and smoking ( < 0,05) in their effect on FVC, FEV1, PEF, and FEF50 were shown. Among underground working copper miners, the group of smoking welders is especially threatened by impairment of lung ventilatory function. Anna Skoczyńska, Leszek Gruszczyński, Anna Wojakowska, Marek Ścieszka, Barbara Turczyn, and Edward Schmidt Copyright © 2016 Anna Skoczyńska et al. All rights reserved. Association of Microalbuminuria with Metabolic Syndrome among Aged Population Thu, 21 Apr 2016 08:02:21 +0000 Background. The impact of the various components of metabolic syndrome (MetS) on chronic kidney disease has been conflicting. We aim to investigate the association between MetS and microalbuminuria and identify the major contributing components of MetS that result in microalbuminuria in the Chinese aged population. Methods. A total of 674 adults aged 55–98 years (males: 266; mean age: years) were studied. MetS was defined by the 2004 Chinese Diabetes Society criteria and microalbuminuria by urine albumin-creatinine ratio (UACR) ≥3 mg/mmoL. Results. The prevalence of microalbuminuria was gradually increased with increasing number of MetS components (). In multivariate regression, after adjusting for age and sex, MetS was the strongest correlate of microalbuminuria (OR = 1.781, 95% CI = 1.226–2.587; ) followed by the fasting plasma glucose (FPG) (OR = 1.217, 95% CI = 1.044–1.092; ), systolic blood pressure (SBP) (OR = 1.011, 95% CI = 1.107–1.338; ), and high-density lipoprotein cholesterol (HDL-C) (OR = 0.576, 95% CI = 0.348–0.953; ). Conclusions. MetS is independently associated with microalbuminuria in the Chinese aged population. Elevated FPG is the most predominant component of metabolic syndrome associated with microalbuminuria followed by elevated SBP and reduced HDL-C. Xiao-Hong Li, Hai-Yan Lin, Shu-Hua Wang, Li-Ying Guan, and Yi-Bing Wang Copyright © 2016 Xiao-Hong Li et al. All rights reserved. Association between Family Structure and Physical Activity of Chinese Adolescents Wed, 30 Mar 2016 16:16:01 +0000 Background. This study examines the association between family structure and moderate-to-vigorous physical activity (MVPA) of adolescents in China. Methods. The participants included 612 adolescents (317 boys and 295 girls) from Shanghai with ages ranging from 10 to 16 years. Accelerometers were used to measure the duration of MVPA of adolescents, and questionnaires on family structure were completed by the parents of these adolescents. Results. Findings suggested that family structure significantly increased the likelihood of adolescents engaging in physical activity (PA) and explained 6% of MPVA variance. Adolescents living in single-parent households and step families were more physically active than those living in two-parent homes and with biological parents, respectively. However, adolescents residing with grandparents were less active than those living with neither grandparent. No significant difference was found in MVPA time between adolescents living with one sibling and those without siblings. Conclusion. Family environment may be considered in the development of PA interventions and policies, and adolescents living with their grandparents may be targeted in PA promotion. Lijuan Wang and Jing Qi Copyright © 2016 Lijuan Wang and Jing Qi. All rights reserved. Public versus Private Healthcare Systems following Discharge from the ICU: A Propensity Score-Matched Comparison of Outcomes Wed, 30 Mar 2016 13:22:30 +0000 Purpose. The long-term outcomes of patients after discharge from tertiary ICUs as they relate to the public versus private healthcare systems in Brazil have not yet been evaluated. Materials and Methods. A multicenter prospective cohort study was conducted to compare the all-cause mortality and the physical functional status (PFS) 24 months after discharge from the ICU between adult patients treated in the public and private healthcare systems. A propensity score- (PS-) matched comparison of all causes of mortality and PFS 24 months after discharge from the ICU was performed. Results. In total, 928 patients were discharged from the ICU including 172 (18.6%) patients in the public and 756 (81.4%) patients in the private healthcare system. The results of the PS-matched comparison of all-cause mortality revealed higher mortality rates among the patients of the public healthcare system compared to those of the private healthcare system (47.3% versus 27.6%, ). The comparison of the PS-matched Karnofsky performance and Lawton activities of daily living scores between the ICU survivors of the public and private healthcare systems revealed no significant differences. Conclusions. The patients of private healthcare system exhibited significantly greater survival rates than the patients of the public healthcare system with similar PFS following ICU discharge. Felippe Leopoldo Dexheimer Neto, Regis Goulart Rosa, Bruno Achutti Duso, Jaqueline Sanguiogo Haas, Augusto Savi, Cláudia da Rocha Cabral, Juçara Gasparetto Maccari, Roselaine Pinheiro de Oliveira, Ana Carolina Peçanha Antônio, Priscylla de Souza Castro, and Cassiano Teixeira Copyright © 2016 Felippe Leopoldo Dexheimer Neto et al. All rights reserved. Sociodemographic Correlates of Tobacco Consumption in Rural Gujarat, India Wed, 30 Mar 2016 11:32:53 +0000 Background. The purpose of this study was to examine occupation-, education-, and gender-specific patterns of tobacco use and knowledge of its health effects among 23,953 rural Asian Indians ≥18 years in Gujarat. Methodology. A statewide, community-based, cross-sectional survey was conducted in 26 districts of Gujarat (December 2010–May 2015), using face-to-face interviews by trained community health workers called SEVAKS. Results. Mean age was 39.8 ± 15.2 years. Eighteen percent of respondents used tobacco in various forms. Tobacco consumption was significantly higher among males (32%), 18–34 years’ age group (35%), those who were self-employed (72%), and those with elementary education (40%). The prevalence was 11 times higher among males than females (95% CI = 9.78, 13.13). Adjusted ORs for tobacco use showed strong gradient by age and educational level; consumption was lower among the illiterates and higher for older participants (≥55 years). Tobacco consumption also varied by occupation; that is, those who were self-employed and employed for wages were more likely to use tobacco than those who were unemployed. Knowledge of health effects of tobacco lowered the odds of consumption by 30–40%. Conclusions. Effective educational programs should be tailored by gender, to improve knowledge of health risks and dispel myths on perceived benefits of tobacco. Payal Kahar, Ranjita Misra, and Thakor G. Patel Copyright © 2016 Payal Kahar et al. All rights reserved. Knowledge, Attitudes, and Behaviors about Breast Self-Examination and Mammography among Female Primary Healthcare Workers in Diyarbakır, Turkey Wed, 30 Mar 2016 09:45:38 +0000 Aim. This study aims to determine the knowledge level of the female primary healthcare workers about breast cancer and to reveal their attitude and behaviors about breast self-examination and mammography. Methods. This cross-sectional study was conducted on female primary healthcare workers who work in family health centres. 91% () of female primary healthcare workers agreed to participate in the study. The questionnaire consisted of three parts: sociodemographic characteristics, knowledge about breast self-examination, and actual practice of breast self-examination. Results. The mean (SD) age of the female primary healthcare workers was (range, 20–54 years). The healthcare workers who practiced breast self-examination had significantly higher knowledge level () than those who had not. The respondents had high knowledge level of breast self-examination; however, the knowledge level of breast cancer and mammography screen was low. Conclusions. While the female primary healthcare workers in this study had adequate knowledge of breast self-examination, this is not reflected in their attitudes and practices. Emphasis should be laid on breast self-examination in undergraduate and postgraduate courses for primary healthcare workers, since they are mostly involved in patient education. Özgür Erdem and İzzettin Toktaş Copyright © 2016 Özgür Erdem and İzzettin Toktaş. All rights reserved. Evaluation of Stress Intensity and Anxiety Level in Preoperative Period of Cardiac Patients Wed, 02 Mar 2016 11:59:56 +0000 Introduction. The stress related to patient’s stay in a hospital increases when it is necessary to perform a surgery. Therefore, the study of the phenomenon of stress intensity in hospitalized patients has become an important issue for public health. Material and Method. The study was conducted in University Hospital No. 1 in the cardiosurgery clinic. The study involved 58 patients who were admitted as planned to the hospital. The study used a standardized questionnaire measuring intensity of the stress and also deepened interviews with patients about stress and anxiety felt before the surgery. Results. The greater the patient’s anxiety resulting from his state of health, the greater the intensity of stress in the preoperative period. This relationship is linear. The results of the study also made it possible to see intrapersonal factors (pain, illness, and suffering) and extrapersonal factors (anesthesia, surgery, and complications after surgery), which are causes of anxiety before surgery. Conclusion. The research showed high (negative) results of anxiety and stress associated with the disease, surgery, and complications after cardiac surgery. Active involvement in hospitalization elements, such as patient education before surgery, psychological support, and medical care organization taking into account patient’s preferences, reduces the impact of stressors. Anna Rosiek, Tomasz Kornatowski, Aleksandra Rosiek-Kryszewska, Łukasz Leksowski, and Krzysztof Leksowski Copyright © 2016 Anna Rosiek et al. All rights reserved. Khat Dependency and Psychophysical Symptoms among Chewers in Jazan Region, Kingdom of Saudi Arabia Sun, 28 Feb 2016 11:53:49 +0000 Background. Khat chewing is highly prevalent in Africa, Yemen and Jazan region, southwest of Saudi Arabia. Most of Jazani Khat chewers consider khat session as a social activity and do not consider khat dependency. The aim of this study was to explore khat dependency and its relationship with the psychophysical symptoms among chewers. Methods. Cross-sectional study on seventy Saudi male khat chewers living in Jazan area. Psychological dependence to khat chewing was evaluated using the Severity of Dependency Scale (SDS). The participants filled in a self-administrated assisted structured questionnaire designed to collect data about their medical history, neurological symptoms, and their chewing behavior. Results. Half (52.2%) of khat chewers showed psychological dependency. Those having longer khat sessions (≥6 hours) were more liable for dependency. Physical and psychological symptoms were more prevalent among khat dependent chewers. Conclusions. khat has a psychological dependence effect that can be measured by the SDS, even in low doses and with irregular use. SDS scale is a useful tool to expect the burden of either physical or psychological symptoms on khat chewers. Maged El-Setouhy, Rashad M. Alsanosy, Abdallah Alsharqi, and Ahmed A. Ismail Copyright © 2016 Maged El-Setouhy et al. All rights reserved. Evidence-Based Public Health Thu, 28 Jan 2016 09:59:12 +0000 Stefan K. Lhachimi, Malgorzata M. Bala, and Giedrius Vanagas Copyright © 2016 Stefan K. Lhachimi et al. All rights reserved. The Development and Validation of a Rapid Assessment Tool of Primary Care in China Sun, 17 Jan 2016 12:08:44 +0000 Introduction. With Chinese health care reform increasingly emphasizing the importance of primary care, the need for a tool to evaluate primary care performance and service delivery is clear. This study presents a methodology for a rapid assessment of primary care organizations and service delivery in China. Methods. The study translated and adapted the Primary Care Assessment Tool-Adult Edition (PCAT-AE) into a Chinese version to measure core dimensions of primary care, namely, first contact, continuity, comprehensiveness, and coordination. A cross-sectional survey was conducted to assess the validity and reliability of the Chinese Rapid Primary Care Assessment Tool (CR-PCAT). Eight community health centers in Guangdong province have been selected to participate in the survey. Results. A total of 1465 effective samples were included for data analysis. Eight items were eliminated following principal component analysis and reliability testing. The principal component analysis extracted five multiple-item scales (first contact utilization, first contact accessibility, ongoing care, comprehensiveness, and coordination). The tests of scaling assumptions were basically met. Conclusion. The standard psychometric evaluation indicates that the scales have achieved relatively good reliability and validity. The CR-PCAT provides a rapid and reliable measure of four core dimensions of primary care, which could be applied in various scenarios. Jie Mei, Yuan Liang, LeiYu Shi, JingGe Zhao, YuTan Wang, and Li Kuang Copyright © 2016 Jie Mei et al. All rights reserved. Mental Health Services in Rural China: A Qualitative Study of Primary Health Care Providers Thu, 24 Dec 2015 12:27:59 +0000 This study aimed to understand the challenges that primary health care providers faced in the process of delivering mental healthcare and assess their attitudes towards patients with mental health problems. In-depth interviews were conducted among 42 primary health care providers in two counties of Guangxi province, China. All interviews were audio-recorded and analyzed thematically. Primary health care providers in both counties faced the same difficulties: lack of professional knowledge, fear of patients’ attack, more extra work, and less subsidies. However, most of primary health care providers (30/42) were still willing to do mental healthcare management. All the interviewees considered that communication skills with patients and their family members, proper attitude (without discrimination), and the professional knowledge of mental health are required. There are still several participants (15/42) who showed negative attitude toward mental disorders. Nearly all the respondents (39/42) emphasized the importance of increasing their income or subsidies by the government. This qualitative study provides insights into mental health services in rural communities of Guangxi and identified issues that could be considered in engaging primary health care providers in the management of mental disorders. Zhenyu Ma, Hui Huang, Qiang Chen, Faqin Chen, Abu S. Abdullah, Guanghui Nie, Qiming Feng, and Bo Wei Copyright © 2015 Zhenyu Ma et al. All rights reserved. Comment on “The Prevalence of Skilled Birth Attendant Utilization and Its Correlates in North West Ethiopia” Sun, 13 Dec 2015 08:52:57 +0000 Siddharudha Shivalli and Soujanya Kaup Copyright © 2015 Siddharudha Shivalli and Soujanya Kaup. All rights reserved. Evidence-Based Decision Making in Public Health: Capacity Building for Public Health Students at King Saud University in Riyadh Tue, 08 Dec 2015 09:47:04 +0000 Translation of research evidence into public health programs is lagging in Eastern Mediterranean Region. Graduate level public health curriculum at King Saud University (KSU), College of Medicine, Riyadh, is designed to equip students to integrate best available evidence in public health decision making. The objectives of study were to explore students’ opinion about the evidence based public health (EBPH) courses and to survey the knowledge, opinion, and attitude of the students towards EBPH and perceived barriers for implementation of EBPH in decision making in public health. EBPH courses are designed based on a sequential framework. A survey was conducted at the completion of EBPH courses. Forty-five graduate students were invited to complete a validated self-administered questionnaire. It included questions about demography, opinion, and attitude towards EBPH and perceived barriers towards implementation of EBPH in the work environment. The response rate was 73%. Mean age of students was 30.1 (SD 2.3) years, and 51% were males. More than 80% had sound knowledge and could appreciate the importance of EBPH. The main perceived barriers to incorporate EBPH in decision making were lack of system of communication between researchers and policy makers and scarcity of research publications related to the public health problems. Hayfaa A. Wahabi, Amna Rehana Siddiqui, Ashry G. Mohamed, Ali M. Al-hazmi, Nasriah Zakaria, and Lubna A. Al-Ansary Copyright © 2015 Hayfaa A. Wahabi et al. All rights reserved. Sexual Risk Behaviors and HIV Infection among Men Who Have Sex with Men and Women in China: Evidence from a Systematic Review and Meta-Analysis Tue, 08 Dec 2015 08:11:23 +0000 Objectives. To understand the current risk of HIV infection and transmission and further elucidate the underlying risk factors among men who have sex with men and women (MSMW) in China. Methods. Following PRISMA guidelines, we conducted a systematic review and meta-analysis of searching through Chinese and English available literature databases between January 2000 and June 2014 to identify articles. Results. Thirty-six articles (including 19,730 MSMW and 53,536 MSMO) met the selection criteria and the aggregated results found that MSMW have significantly higher HIV prevalence than MSMO (6.6% versus 5.4%, OR = 1.27, 95% CI = 1.01–1.58). A higher proportion of MSMW had commercial male partners in the past 6 months (18.3% versus 12.2%, OR = 1.56, 95% CI = 1.01–2.42). Additionally, substance use in the past 6 months was significantly more frequent among MSMW than MSMO (alcohol use: 27.1% versus 13.1%, OR = 2.53, 95% CI = 2.14–2.99; illicit drug use: 5.3% versus 2.5%, OR = 2.09, 95% CI = 1.48–2.95). Conclusion. A higher proportion of commercial sex and substance use among MSMW may be a potentially indicative factor for significantly higher HIV prevalence compared to MSMO. Targeted interventions should aim at increasing the frequency of HIV/STIs screening and preventing high risk commercial sex and substance use among MSMW to decrease their HIV transmission to the general population. Hong-Yi Wang, Jun-Jie Xu, Hua-Chun Zou, Kathleen Heather Reilly, Christiana Meng Zhang, Ke Yun, Yong-Ze Li, Yong-Jun Jiang, Wen-Qing Geng, Hong Shang, and Ning Wang Copyright © 2015 Hong-Yi Wang et al. All rights reserved. Perinatal Health Statistics as the Basis for Perinatal Quality Assessment in Croatia Sun, 29 Nov 2015 13:04:17 +0000 Context. Perinatal mortality indicators are considered the most important measures of perinatal outcome. The indicators reliability depends on births and deaths reporting and recording. Many publications focus on perinatal deaths underreporting and misclassification, disabling proper international comparisons. Objective. Description of perinatal health care quality assessment key indicators in Croatia. Methods. Retrospective review of reports from all maternities from 2001 to 2014. Results. According to reporting criteria for birth weight ≥500 g, perinatal mortality (PNM) was reduced by 31%, fetal mortality (FM) by 32%, and early neonatal mortality (ENM) by 29%. According to reporting criteria for ≥1000 g, PNM was reduced by 43%, FM by 36%, and ENM by 54%. PNM in ≥22 weeks’ (wks) gestational age (GA) was reduced by 28%, FM by 30%, and ENM by 26%. The proportion of FM at 32–36 wks GA and at term was the highest between all GA subgroups, as opposed to ENM with the highest proportion in 22–27 wks GA. Through the period, the maternal mortality ratio varied from 2.4 to 14.3/100,000 live births. The process indicators have been increased in number by more than half since 2001, the caesarean deliveries from 11.9% in 2001 to 19.6% in 2014. Conclusions. The comprehensive perinatal health monitoring represents the basis for the perinatal quality assessment. Urelija Rodin, Boris Filipović-Grčić, Josip Đelmiš, Tatjana Glivetić, Josip Juras, Željka Mustapić, and Ruža Grizelj Copyright © 2015 Urelija Rodin et al. All rights reserved. Strong Public Health Recommendations from Weak Evidence? Lessons Learned in Developing Guidance on the Public Health Management of Meningococcal Disease Thu, 26 Nov 2015 13:58:49 +0000 The evidence underpinning public health policy is often of low quality, leading to inconsistencies in recommended interventions. One example is the divergence in national policies across Europe for managing contacts of invasive meningococcal disease. Aiming to develop consistent guidance at the European level, a group of experts reviewed the literature and formulated recommendations. The group defined eight priority research questions, searched the literature, and formulated recommendations using GRADE methodology. Five of the research questions are discussed in this paper. After taking into account quality of evidence, benefit, harm, value, preference, burden on patient of the intervention, and resource implications, we made four strong recommendations and five weak recommendations for intervention. Strong recommendations related not only to one question with very low quality of evidence as well as to two questions with moderate to high quality of evidence. The weak recommendations related to two questions with low and very low quality of evidence but also to one question with moderate quality of evidence. GRADE methodology ensures a transparent process and explicit recognition of additional factors that should be considered when making recommendations for policy. This approach can be usefully applied to many areas of public health policy where evidence quality is often low. Germaine Hanquet, Pawel Stefanoff, Wiebke Hellenbrand, Sigrid Heuberger, Pierluigi Lopalco, and James M. Stuart Copyright © 2015 Germaine Hanquet et al. All rights reserved. Interventional Tools to Improve Prescription and Adherence to Medical Plans Tue, 24 Nov 2015 11:56:50 +0000 Elísio Costa, Anna Giardini, Alexandra Prados-Torres, Caitriona Cahir, and Alessandra Marengoni Copyright © 2015 Elísio Costa et al. All rights reserved. Using Theory of Planned Behavior to Predict the Physical Activity of Children: Probing Gender Differences Mon, 16 Nov 2015 13:52:47 +0000 Objectives. The primary objective of this study was to use the theory of planned behavior (TPB) to examine the association between TPB variables and the moderate-to-vigorous physical activity (MVPA) of children in Shanghai, China. Gender differences were also explored. Methods. The participants were 353 children (180 boys and 173 girls) aged 9 to 13 years from three primary schools in Shanghai. Accelerometers were used to measure the MVPA duration of the children. Questionnaires that focused on attitude, subjective norms, and perceived behavioral control (PBC) related to MVPA engagement were completed by the participants. Results. Regression analyses revealed that intention, and not PBC, accounted for 9% of the variance in MVPA. Meanwhile, attitude and PBC explained 33% of the variance in intentions to engage in MVPA. In terms of gender differences, TPB performed better in the physical activity (PA) domain for boys than for girls. Furthermore, attitude and PBC were significantly associated with intention among boys, whereas only PBC was significantly related to intention among girls. Conclusion. Practitioners should consider tailoring intervention to address gender differences to increase leisure-time PA participation of children. Lijuan Wang and Lin Wang Copyright © 2015 Lijuan Wang and Lin Wang. All rights reserved. Psychosocial Factors and Workers’ Health and Safety Sun, 08 Nov 2015 12:37:33 +0000 Sergio Iavicoli, Giancarlo Cesana, Maureen Dollard, Stavroula Leka, and Steven L. Sauter Copyright © 2015 Sergio Iavicoli et al. All rights reserved. Some Biochemical and Hematological Parameters among Petrol Station Attendants: A Comparative Study Sun, 08 Nov 2015 09:44:38 +0000 Objective. To describe selected biochemical and hematological parameters (blood picture, liver enzymes, and kidney functions) in petrol station attendants in Mansoura city. Methods. This is a comparative cross-sectional study. The exposed group included 102 petrol station attendants. They were compared to a matched group of healthy 102 male service and office workers at the Faculty of Medicine, Mansoura University. The results of blood picture, liver enzymes, and kidney functions were compared between both groups. Results. Mean Red Blood Cells (RBCs) count, hemoglobin level, and Hematocrit (HCT) level were significantly lower in petrol station attendants than the comparison group. All other blood picture parameters showed nonsignificant difference between both groups. Liver enzymes, renal functions, serum albumin, and total protein showed statistically nonsignificant difference between both groups except for alanine aminotransferase (ALT) which was significantly higher in petrol station attendants. Conclusions. Some laboratory parameters among petrol station attendants showed changes that could be attributed to workplace exposure and should be given attention at preemployment and periodic medical examination. Hala Samir Abou-ElWafa, Ahmed A. Albadry, Abdel-Hady El-Gilany, and Fagr B. Bazeed Copyright © 2015 Hala Samir Abou-ElWafa et al. All rights reserved. Comment on “HIV/AIDS Awareness among VCT Clients: A Cross-Sectional Study from Delhi, India” Tue, 27 Oct 2015 08:37:02 +0000 Siddharudha Shivalli and Soujanya Kaup Copyright © 2015 Siddharudha Shivalli and Soujanya Kaup. All rights reserved. Childhood Lead Exposure from Battery Recycling in Vietnam Mon, 26 Oct 2015 08:41:18 +0000 Background. Battery recycling facilities in developing countries can cause community lead exposure. Objective. To evaluate child lead exposure in a Vietnam battery recycling craft village after efforts to shift home-based recycling outside the village. Methods. This cross-sectional study evaluated 109 children in Dong Mai village, using blood lead level (BLL) measurement, parent interview, and household observation. Blood samples were analyzed with a LeadCare II field instrument; highest BLLs (≥45 μg/dL) were retested by laboratory analysis. Surface and soil lead were measured at 11 households and a school with X-ray fluorescence analyzer. Results. All children had high BLLs; 28% had BLL ≥45 μg/dL. Younger age, family recycling, and outside brick surfaces were associated with higher BLL. Surface and soil lead levels were high at all tested homes, even with no recycling history. Laboratory BLLs were lower than LeadCare BLLs, in 24 retested children. Discussion. In spite of improvements, lead exposure was still substantial and probably associated with continued home-based recycling, legacy contamination, and workplace take-home exposure pathways. There is a need for effective strategies to manage lead exposure from battery recycling in craft villages. These reported BLL values should be interpreted cautiously, although the observed field-laboratory discordance may reflect bias in laboratory results. William E. Daniell, Lo Van Tung, Ryan M. Wallace, Deborah J. Havens, Catherine J. Karr, Nguyen Bich Diep, Gerry A. Croteau, Nancy J. Beaudet, and Nguyen Duy Bao Copyright © 2015 William E. Daniell et al. All rights reserved. Comment on “Second-Hand Smoking among Intermediate and Secondary School Students in Madinah, Saudi Arabia” Mon, 26 Oct 2015 08:28:18 +0000 Siddharudha Shivalli Copyright © 2015 Siddharudha Shivalli. All rights reserved. Intervention Mapping to Adapt Evidence-Based Interventions for Use in Practice: Increasing Mammography among African American Women Mon, 26 Oct 2015 07:30:59 +0000 This paper describes and demonstrates the use of the systematic planning process, Intervention Mapping, to adapt an evidence-based public health intervention (EBI). We used a simplified version of Intervention Mapping (IM Adapt) to increase an intervention’s fit with a new setting and population. IM Adapt guides researchers and practitioners in selecting an EBI, making decisions about whether and what to adapt, and executing the adaptation while guarding the EBI’s essential elements (those responsible for effectiveness). We present a case study of a project in which we used IM Adapt to find, adapt, implement, and evaluate an EBI to improve mammography adherence for African American women in a new practice setting in Houston, Texas. IM Adapt includes the following (1) assess needs and organizational capacity; (2) find EBIs; (3) plan adaptations based on fit assessments; (4) make adaptations; (5) plan for implementation; and (6) plan for evaluation of the adapted EBI. The case study shows an example of how public health researchers and practitioners can use the tool to make it easier to find and use EBIs, thus encouraging greater uptake. IM Adapt adds to existing dissemination and adaptation models by providing detailed guidance on how to decide on effective adaptation, while maintaining the essential elements of the EBI. Linda Highfield, Marieke A. Hartman, Patricia Dolan Mullen, Serena A. Rodriguez, Maria E. Fernandez, and L. Kay Bartholomew Copyright © 2015 Linda Highfield et al. All rights reserved. A Cross-Sectional Study of Pesticide Use and Knowledge of Smallholder Potato Farmers in Uganda Sun, 25 Oct 2015 11:39:40 +0000 In response to increased pest and disease problems, potato farmers use pesticides, which could raise environmental and health concerns. This study sought to promote proper and safe pesticide-handling practices by providing data needed to guide pesticide regulation policy and training for extension staff and farmers. A household survey was conducted in three major potato-growing agroecological zones of Uganda. Two hundred and four potato farmers were interviewed about the type and source of pesticides they use in potato cultivation, the frequency of applications, the use of protective clothing, and cases of pesticide poisoning. The types of pesticides used in potato were fungicides (72%), insecticides (62%), and herbicides (3%). Overall, use of personal protective equipment was low, that is, gumboots (73%), gloves (7%), face masks (16%), and long sleeve shirts (42%). Forty-three percent of farmers who applied pesticides reported having experienced skin itching, 25% skin burning sensation, 43% coughing, 60% a runny nose, 27% teary eyes, and 42% dizziness. An IPM approach involving only moderately to slightly hazardous pesticides when pest and disease incidence has reached economic injury levels and by considering all safety measures during application and storage would be environmentally recommendable and result in reduced health risks. Joshua Sikhu Okonya and Jürgen Kroschel Copyright © 2015 Joshua Sikhu Okonya and Jürgen Kroschel. All rights reserved. Exercise and BMI in Overweight and Obese Children and Adolescents: A Systematic Review and Trial Sequential Meta-Analysis Thu, 22 Oct 2015 13:46:24 +0000 Objective. Determine the effects of exercise on body mass index (BMI in kg·m−2) among overweight and obese children and adolescents. Methods. Trial sequential meta-analysis of randomized controlled exercise intervention trials ≥ 4 weeks and published up to November 11, 2014. Results. Of the 5,436 citations screened, 20 studies representing 971 boys and girls were included. Average length, frequency, and duration of training were 13 weeks, 3 times per week, for 46 minutes per session. Overall, random-effects models showed that exercise decreased BMI by 3.6% (mean: −1.08; 95% CI: −0.52 to −1.64; ; ; %; 95% CI: 87.6% to 93.4%; %). Trial sequential meta-analysis showed that changes in BMI crossed the monitoring boundary for a type 1 error in 2010, remaining stable thereafter. The number needed to treat was 5 while the percentile improvement was 26.9. It was estimated that approximately 2.5 million overweight and obese children in the US and 22.0 million overweight and obese children worldwide could reduce their BMI by participating in a regular exercise program. Overall quality of evidence was rated as moderate. Conclusions. Exercise is associated with improvements in BMI among overweight and obese children and adolescents. This trial is registered with PROSPERO Trial Registration #CRD42015017586. George A. Kelley, Kristi S. Kelley, and Russell R. Pate Copyright © 2015 George A. Kelley et al. All rights reserved. Quercetin Increases Hepatic Homocysteine Remethylation and Transsulfuration in Rats Fed a Methionine-Enriched Diet Mon, 19 Oct 2015 13:14:27 +0000 This study was aimed at investigating the effects of quercetin on mRNA expression and activity of critical enzymes in homocysteine metabolism in rats fed a methionine-enriched diet. Rats were fed for 6 weeks the following diets, that is, control, 0.5% quercetin, 1.0% methionine, and 1.0% methionine plus 0.5% quercetin diets. Serum homocysteine was significantly increased after methionine treatment and decreased after the addition of quercetin. The mRNA expression of methionine synthase was significantly increased after methionine or methionine plus quercetin supplementation, while its enzymatic activity was significantly increased after methionine plus quercetin supplementation. The mRNA expression and enzymatic activity of cystathionine β-synthase and cystathionine γ-lyase were upregulated after quercetin, methionine, or quercetin plus methionine treatment and a more significant increase was observed for hepatic cystathionine β-synthase in the methionine plus quercetin treated rats, suggesting an interaction between methionine and quercetin. Meanwhile, hepatic ratio of S-adenosylmethionine to S-adenosylhomocysteine was significantly decreased in response to methionine supplementation and normalized after the addition of quercetin. It is concluded that quercetin reduces serum homocysteine by increasing remethylation and transsulfuration of homocysteine in rats exposed to a methionine-enriched diet. Bin Meng, Weina Gao, Jingyu Wei, Lingling Pu, Zhenchuang Tang, and Changjiang Guo Copyright © 2015 Bin Meng et al. All rights reserved. Verbal Aggression from Care Recipients as a Risk Factor among Nursing Staff: A Study on Burnout in the JD-R Model Perspective Mon, 19 Oct 2015 12:59:54 +0000 Among nursing staff, the risk of experiencing violence, especially verbal aggression, is particularly relevant. The present study, developed in the theoretical framework of the Job Demands-Resources model (JD-R), has two main aims: (a) to examine the association between verbal aggression and job burnout in both nurses and nurse’s aides and (b) to assess whether job content, social resources, and organizational resources lessen the negative impact of verbal aggression on burnout in the two professional groups. The cross-sectional study uses a dataset that consists of 630 workers (522 nurses and 108 nurse’s aides) employed in emergency and medical units. High associations were found between verbal aggression and job burnout in both professional groups. Moderated hierarchical regressions showed that, among nurses, only the job content level resources moderated the effects of the verbal aggression on job burnout. Among nurse’s aides, the opposite was found. Some resources on the social and organizational levels but none of the job content level resources buffered the effects of verbal aggression on workers burnout. The study highlights the crucial role of different types of resources in protecting nursing staff from the detrimental effects of verbal aggression on job burnout. Sara Viotti, Silvia Gilardi, Chiara Guglielmetti, and Daniela Converso Copyright © 2015 Sara Viotti et al. All rights reserved. The Relationship of On-Call Work with Fatigue, Work-Home Interference, and Perceived Performance Difficulties Mon, 19 Oct 2015 10:03:10 +0000 Objectives. This study examined the relationship between on-call duty exposure (active and total on-call hours a month, number of calls per duty) and employees’ experiences of being on-call (stress due to unpredictability, ability to relax during inactive on-call periods, restrictions during on-call duties, on-call work demands, and satisfaction with compensation for on-call duties) on the one hand and fatigue, strain-based and time-based work-home interference (WHI), and perceived on-call performance difficulties (PPD) on the other hand. Methods. Cross-sectional survey data were collected among a large heterogeneous sample of Dutch employees (). The final sample consisted of 157 on-call workers (23–69 years, 71% males). Data were analyzed by means of hierarchical regression analyses (controlling for age and job characteristics). Results. Differences in on-call work exposure were not systematically related to fatigue, WHI, and PPD (all p’s ). The experience of being on-call explained a medium proportion of the variation in fatigue and strain-based WHI and a medium to large proportion of the variation in time-based WHI and PPD over and above the control variables. Conclusions. Our results suggest that it is employees’ experience of being on-call, especially the experience of stress due to the unpredictability, rather than the amount of exposure, that is related to fatigue, WHI, and perceived on-call performance difficulties. Carla M. Ziebertz, Madelon L. M. van Hooff, Debby G. J. Beckers, Wendela E. Hooftman, Michiel A. J. Kompier, and Sabine A. E. Geurts Copyright © 2015 Carla M. Ziebertz et al. All rights reserved. Psychosocial Work Factors and Musculoskeletal Pain: A Cross-Sectional Study among Swedish Flight Baggage Handlers Mon, 19 Oct 2015 08:09:54 +0000 Objective. Flight baggage handlers sort and load luggage to airplanes. This study aimed at investigating associations between psychosocial exposures and low back and shoulder musculoskeletal disorders (MSDs) among Swedish flight baggage handlers. Methods. A questionnaire addressing MSDs (Standardized Nordic Questionnaire) and psychosocial factors (Copenhagen Psychosocial Questionnaire, COPSOQ) was answered by 525 baggage handlers in six Swedish airports. Results. Low back (LBP) and shoulder pain (SP) were reported by 70% and 60%, respectively. Pain was reported to interfere with work (PIW) by 30% (low back) and 18% (shoulders), and intense pain (PINT) occurred in 34% and 28% of the population. Quality of leadership was the most dissatisfying psychosocial factor, while the most positive was social community at work. Low ratings in the combined domain Work organization and job content were significantly associated with PIW in both low back and shoulders (Adjusted Hazard Ratios 3.65 (95% CI 1.67–7.99) and 2.68 (1.09–6.61)) while lower ratings in the domain Interpersonal relations and leadership were associated with PIW LBP (HR 2.18 (1.06–4.49)) and PINT LBP and SP (HRs 1.95 (1.05–3.65) and 2.11 (1.08–4.12)). Conclusion. Severity of pain among flight baggage handlers was associated with psychosocial factors at work, suggesting that they may be a relevant target for intervention in this occupation. Eva L. Bergsten, S. E. Mathiassen, and E. Vingård Copyright © 2015 Eva L. Bergsten et al. All rights reserved. Job Strain and Self-Reported Insomnia Symptoms among Nurses: What about the Influence of Emotional Demands and Social Support? Sun, 18 Oct 2015 12:50:16 +0000 Job strain, derived from high psychological demands and low job control, is associated with insomnia, but information on the role of emotional demands and social support in this relationship is scarce. The aims of this study were (i) to test the association between job strain and self-reported insomnia symptoms, (ii) to evaluate the combination of emotional demands and job control regarding insomnia symptoms, and (iii) to analyze the influence of social support in these relationships. This cross-sectional study refers to a sample of nurses (N = 3,013 and N = 3,035 for Job Strain and Emotional demand-control model, resp.) working at public hospitals in Rio de Janeiro, Brazil. Data were collected through a self-report questionnaire. The prevalence of insomnia symptoms was 34.3%. Job strain was associated with increased odds for insomnia symptoms (OR: 2.20); the same result was observed with the combination of emotional demands and low job control (OR: 1.99). In both models, the inclusion of low social support combined with high demands and low job control led to increased odds for insomnia symptoms, compared to groups with high social support from coworkers and supervisors. Besides job strain, the study of emotional demands and social support are promising with regards to insomnia symptoms, particularly among nurses. Luciana Fernandes Portela, Caroline Kröning Luna, Lúcia Rotenberg, Aline Silva-Costa, Susanna Toivanen, Tania Araújo, and Rosane Härter Griep Copyright © 2015 Luciana Fernandes Portela et al. All rights reserved. Consequences of Job Insecurity on the Psychological and Physical Health of Greek Civil Servants Sun, 18 Oct 2015 12:49:37 +0000 The aim of this study was to estimate the short term consequences of job insecurity associated with a newly introduced mobility framework in Greece. In specific, the study examined the impact of job insecurity on anxiety, depression, and psychosomatic and musculoskeletal symptoms, two months after the announcement of the mobility framework. In addition the study also examined the “spill over” effects of job insecurity on employees not directly affected by the mobility framework. Personal interviews using a structured questionnaire were conducted for 36 university administrative employees awaiting repositioning, 36 coworkers not at risk, and 28 administrative employees of a local hospital not at risk. Compared to both control groups the employees in the anticipation phase of labor mobility had significantly worse scores for perceived stress, anxiety, depression, positive affect, negative affect, social support, marital discord, common somatic symptoms, and frequency of musculoskeletal pain. This study highlights the immediate detrimental effects of job insecurity on the physical, psychological, and social functioning of employees. There is a need for the development of front line interventions to prevent these effects from developing into chronic conditions with considerable cost for the individual and society in general. Dimitra Nella, Efharis Panagopoulou, Nikiforos Galanis, Anthony Montgomery, and Alexis Benos Copyright © 2015 Dimitra Nella et al. All rights reserved. Towards a Job Demands-Resources Health Model: Empirical Testing with Generalizable Indicators of Job Demands, Job Resources, and Comprehensive Health Outcomes Sun, 18 Oct 2015 12:48:16 +0000 Studies using the Job Demands-Resources (JD-R) model commonly have a heterogeneous focus concerning the variables they investigate—selective job demands and resources as well as burnout and work engagement. The present study applies the rationale of the JD-R model to expand the relevant outcomes of job demands and job resources by linking the JD-R model to the logic of a generic health development framework predicting more broadly positive and negative health. The resulting JD-R health model was operationalized and tested with a generalizable set of job characteristics and positive and negative health outcomes among a heterogeneous sample of 2,159 employees. Applying a theory-driven and a data-driven approach, measures which were generally relevant for all employees were selected. Results from structural equation modeling indicated that the model fitted the data. Multiple group analyses indicated invariance across six organizations, gender, job positions, and three times of measurement. Initial evidence was found for the validity of an expanded JD-R health model. Thereby this study contributes to the current research on job characteristics and health by combining the core idea of the JD-R model with the broader concepts of salutogenic and pathogenic health development processes as well as both positive and negative health outcomes. Rebecca Brauchli, Gregor J. Jenny, Désirée Füllemann, and Georg F. Bauer Copyright © 2015 Rebecca Brauchli et al. All rights reserved. The Context, Process, and Outcome Evaluation Model for Organisational Health Interventions Sun, 18 Oct 2015 12:47:43 +0000 To facilitate evaluation of complex, organisational health interventions (OHIs), this paper aims at developing a context, process, and outcome (CPO) evaluation model. It builds on previous model developments in the field and advances them by clearly defining and relating generic evaluation categories for OHIs. Context is defined as the underlying frame that influences and is influenced by an OHI. It is further differentiated into the omnibus and discrete contexts. Process is differentiated into the implementation process, as the time-limited enactment of the original intervention plan, and the change process of individual and collective dynamics triggered by the implementation process. These processes lead to proximate, intermediate, and distal outcomes, as all results of the change process that are meaningful for various stakeholders. Research questions that might guide the evaluation of an OHI according to the CPO categories and a list of concrete themes/indicators and methods/sources applied within the evaluation of an OHI project at a hospital in Switzerland illustrate the model’s applicability in structuring evaluations of complex OHIs. In conclusion, the model supplies a common language and a shared mental model for improving communication between researchers and company members and will improve the comparability and aggregation of evaluation study results. Annemarie Fridrich, Gregor J. Jenny, and Georg F. Bauer Copyright © 2015 Annemarie Fridrich et al. All rights reserved. The Association between Job Strain and Atrial Fibrillation: Results from the Swedish WOLF Study Sun, 18 Oct 2015 12:15:33 +0000 Introduction. Atrial fibrillation (AF) is a common heart rhythm disorder. Several life-style factors have been identified as risk factors for AF, but less is known about the impact of work-related stress. This study aims to evaluate the association between work-related stress, defined as job strain, and risk of AF. Methods. Data from the Swedish WOLF study was used, comprising 10,121 working men and women. Job strain was measured by the demand-control model. Information on incident AF was derived from national registers. Cox proportional hazard regression was used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for the association between job strain and AF risk. Results. In total, 253 incident AF cases were identified during a total follow-up time of 132,387 person-years. Job strain was associated with AF risk in a time-dependent manner, with stronger association after 10.7 years of follow-up (HR 1.93, 95% CI 1.10–3.36 after 10.7 years, versus HR 1.11, 95% CI 0.67–1.83 before 10.7 years). The results pointed towards a dose-response relationship when taking accumulated exposure to job strain over time into account. Conclusion. This study provides support to the hypothesis that work-related stress defined as job strain is linked to an increased risk of AF. Eleonor I. Fransson, Magdalena Stadin, Maria Nordin, Dan Malm, Anders Knutsson, Lars Alfredsson, and Peter J. M. Westerholm Copyright © 2015 Eleonor I. Fransson et al. All rights reserved. Burnout Is Associated with Reduced Parasympathetic Activity and Reduced HPA Axis Responsiveness, Predominantly in Males Sun, 18 Oct 2015 12:11:58 +0000 There is mounting evidence that burnout is a risk factor for cardiovascular disease (CVD). Stress-related dysregulation of the sympathetic and parasympathetic system and the hypothalamic pituitary adrenal (HPA) axis may explain the enhanced risk for CVD. To test this hypothesis, 55 patients (34 males and 21 females) with burnout on sickness absence and 40 healthy participants (16 males and 24 females) were exposed to a psychosocial stressor consisting of mental arithmetic and public speech. Physiological variables (i.e., blood pressure, heart rate, cardiac output, vascular resistance, cortisol, and alpha-amylase) were measured. Basal levels, reactivity, and recovery were compared between groups. In male patients, baseline systolic blood pressure was higher, whereas basal alpha-amylase and cortisol reactivity were lower than in healthy males. In female patients, a tendency for lower basal cortisol was found as compared to healthy females. Furthermore, reduced basal heart rate variability and a trend for elevated basal cardiac output were observed in both male and female patients. Burnout is characterised by dysregulation of the sympathetic and parasympathetic system and the HPA axis, which was more pronounced in males than in females. This study further supports burnout as being a risk factor for CVD through dysregulation of the sympathetic and parasympathetic system and the HPA axis. Wieke de Vente, Jan G. C. van Amsterdam, Miranda Olff, Jan H. Kamphuis, and Paul M. G. Emmelkamp Copyright © 2015 Wieke de Vente et al. All rights reserved. Models of Workplace Incivility: The Relationships to Instigated Incivility and Negative Outcomes Sun, 18 Oct 2015 12:01:16 +0000 The aim of the study was to investigate workplace incivility as a social process, examining its components and relationships to both instigated incivility and negative outcomes in the form of well-being, job satisfaction, turnover intentions, and sleeping problems. The different components of incivility that were examined were experienced and witnessed incivility from coworkers as well as supervisors. In addition, the organizational factors, social support, control, and job demands, were included in the models. A total of 2871 (2058 women and 813 men) employees who were connected to the Swedish Hotel and Restaurant Workers Union completed an online questionnaire. Overall, the results from structural equation modelling indicate that whereas instigated incivility to a large extent was explained by witnessing coworker incivility, negative outcomes were to a high degree explained by experienced supervisor incivility via mediation through perceived low social support, low control, and high job demands. Unexpectedly, the relationships between incivility (experienced coworker and supervisor incivility, as well as witnessed supervisor incivility) and instigated incivility were moderated by perceived high control and high social support. The results highlight the importance of including different components of workplace incivility and organizational factors in future studies of the area. Kristoffer Holm, Eva Torkelson, and Martin Bäckström Copyright © 2015 Kristoffer Holm et al. All rights reserved. Associations between Distal Upper Extremity Job Physical Factors and Psychosocial Measures in a Pooled Study Sun, 18 Oct 2015 11:55:16 +0000 Introduction. There is an increasing body of literature relating musculoskeletal diseases to both job physical exposures and psychosocial outcomes. Relationships between job physical exposure measures and psychosocial factors have not been well examined or quantified. These exploratory analyses evaluate relationships between quantified exposures and psychosocial outcomes. Methods. Individualized quantification of duration, repetition, and force and composite scores of the Strain Index (SI) and the Threshold Limit Value for Hand Activity Level (TLV for HAL) were compared to 10 psychosocial measures. Relationships and predicted probabilities were assessed using ordered logistic regression. Analyses were adjusted for age, BMI, and gender. Results and Discussion. Among 1834 study participants there were multiple statistically significant relationships. In general, as duration, repetition, and force increased, psychosocial factors worsened. However, general health and mental exhaustion improved with increasing job exposures. Depression was most strongly associated with increased repetition, while physical exhaustion was most strongly associated with increased force. SI and TLV for HAL were significantly related to multiple psychosocial factors. These relationships persisted after adjustment for strong confounders. Conclusion. This study quantified multiple associations between job physical exposures and occupational and nonoccupational psychosocial factors. Further research is needed to quantify the impacts on occupational health outcomes. Matthew S. Thiese, Kurt T. Hegmann, Jay Kapellusch, Andrew Merryweather, Stephen Bao, Barbara Silverstein, and Arun Garg Copyright © 2015 Matthew S. Thiese et al. All rights reserved. Effects of a Workplace Intervention Targeting Psychosocial Risk Factors on Safety and Health Outcomes Sun, 18 Oct 2015 11:32:14 +0000 The goal of this study was to test the effectiveness of a workplace intervention targeting work-life stress and safety-related psychosocial risk factors on health and safety outcomes. Data were collected over time using a randomized control trial design with 264 construction workers employed in an urban municipal department. The intervention involved family- and safety-supportive supervisor behavior training (computer-based), followed by two weeks of behavior tracking and a four-hour, facilitated team effectiveness session including supervisors and employees. A significant positive intervention effect was found for an objective measure of blood pressure at the 12-month follow-up. However, no significant intervention results were found for self-reported general health, safety participation, or safety compliance. These findings suggest that an intervention focused on supervisor support training and a team effectiveness process for planning and problem solving should be further refined and utilized in order to improve employee health with additional research on the beneficial effects on worker safety. Leslie B. Hammer, Donald M. Truxillo, Todd Bodner, Jennifer Rineer, Amy C. Pytlovany, and Amy Richman Copyright © 2015 Leslie B. Hammer et al. All rights reserved. An Evaluation of the Policy Context on Psychosocial Risks and Mental Health in the Workplace in the European Union: Achievements, Challenges, and the Future Sun, 18 Oct 2015 11:31:52 +0000 Despite the developments both in hard and soft law policies in the European Union in relation to mental health and psychosocial risks in the workplace, a review of these policies at EU level has not been conducted to identify strengths, weaknesses, and gaps to be addressed in the future. Keeping in mind that the aim should be to engage employers in good practice, ideally such policies should include key definitions and elements of the psychosocial risk management process, covering risk factors, mental health outcomes, risk assessment and preventive actions, or interventions. The current paper aims to fill this gap by reviewing hard and soft law policies on mental health in the workplace and psychosocial risks applicable at EU level and conducting a gap analysis according to a set of dimensions identified in models of good practice in this area. Our review of ninety-four policies in total revealed several gaps, especially in relation to binding in comparison to nonbinding policies. These are discussed in light of the context of policy-making in the EU, and recommendations are offered for future actions in this area. Stavroula Leka, Aditya Jain, Sergio Iavicoli, and Cristina Di Tecco Copyright © 2015 Stavroula Leka et al. All rights reserved. Workplace Bullying as a Risk Factor for Musculoskeletal Disorders: The Mediating Role of Job-Related Psychological Strain Sun, 18 Oct 2015 09:23:59 +0000 Workplace bullying is considered by the European Agency for Safety and Health at Work one of the emerging psychosocial risk factors that could negatively affect workers’ health. Thus, the aim of this study was to analyze the process that leads from bullying to negative health (such as musculoskeletal disorders (MSDs)), testing the mediating role of job-related strain. Data were collected on 512 workers (62.9% female; mean age = 43.6 years) of a retail chain who filled in a self-report questionnaire after a one-hour training session on work-related stress. Data analyses were performed controlling for potentially confounding variables (i.e., gender, age, organizational role, type of contract, and perceived physical job demands). Preacher and Hayes analytical approach was used to test the indirect relationship between bullying and MSDs. Results showed that work-related strain mediates the relationship between bullying and MSDs considered (low back, upper back, and neck) except for MSDs of the shoulders. Our study confirms the role played by bullying and job-related strain in determining workers’ MSDs. Michela Vignoli, Dina Guglielmi, Cristian Balducci, and Roberta Bonfiglioli Copyright © 2015 Michela Vignoli et al. All rights reserved. Estimating the Impact of Workplace Bullying: Humanistic and Economic Burden among Workers with Chronic Medical Conditions Sun, 18 Oct 2015 09:18:40 +0000 Background. Although the prevalence of work-limiting diseases is increasing, the interplay between occupational exposures and chronic medical conditions remains largely uncharacterized. Research has shown the detrimental effects of workplace bullying but very little is known about the humanistic and productivity cost in victims with chronic illnesses. We sought to assess work productivity losses and health disutility associated with bullying among subjects with chronic medical conditions. Methods. Participants () with chronic diseases answered a self-administered survey including sociodemographic and clinical data, workplace bullying experience, the SF-12 questionnaire, and the Work Productivity Activity Impairment questionnaire. Results. The prevalence of significant impairment was higher among victims of workplace bullying as compared to nonvictims (SF-12 PCS: 55.5% versus 67.9%, ; SF-12 MCS: 59.4% versus 74.3%, ). The adjusted marginal overall productivity cost of workplace bullying ranged from 13.9% to 17.4%, corresponding to Italian Purchase Power Parity (PPP) 2010 US$ 4182–5236 yearly. Association estimates were independent and not moderated by concurrent medical conditions. Conclusions. Our findings demonstrate that the burden on workers’ quality of life and productivity associated with workplace bullying is substantial. This study provides key data to inform policy-making and prioritize occupational health interventions. A. Fattori, L. Neri, E. Aguglia, A. Bellomo, A. Bisogno, D. Camerino, B. Carpiniello, A. Cassin, G. Costa, P. De Fazio, G. Di Sciascio, G. Favaretto, C. Fraticelli, R. Giannelli, S. Leone, T. Maniscalco, C. Marchesi, M. Mauri, C. Mencacci, G. Polselli, R. Quartesan, F. Risso, A. Sciaretta, M. Vaggi, S. Vender, and U. Viora Copyright © 2015 A. Fattori et al. All rights reserved. Prognostic Factors of Returning to Work after Sick Leave due to Work-Related Common Mental Disorders: A One- and Three-Year Follow-Up Study Sun, 18 Oct 2015 09:08:00 +0000 The aim of this paper was to assess the prognostic factors of return to work (RTW) after one and three years among people on sick leave due to occupational stress. Methods. The study population comprised 223 completers on sick leave, who participated in a stress treatment program. Self-reported psychosocial work environment, life events during the past year, severity of the condition, occupational position, employment sector, marital status, and medication were assessed at baseline. RTW was assessed with data from a national compensation database (DREAM). Results. Self-reported high demands, low decision authority, low reward, low support from leaders and colleagues, bullying, high global symptom index, length of sick leave at baseline, and stressful negative life events during the year before baseline were associated with no RTW after one year. Low work ability and full-time sick leave at inclusion were predictors after three years too. Being single was associated with no RTW after three years. The type of treatment, occupational position, gender, age, and degree of depression were not associated with RTW after one or three years. Conclusion. The impact of the psychosocial work environment as predictor for RTW disappeared over time and only the severity of the condition was a predictor for RTW in the long run. Bo Netterstrøm, Nanna Hurwitz Eller, and Marianne Borritz Copyright © 2015 Bo Netterstrøm et al. All rights reserved. Issues around the Prescription of Half Tablets in Northern Switzerland: The Irrational Case of Quetiapine Sun, 11 Oct 2015 13:53:51 +0000 Background. Prescription of fragmented tablets is useful for individualisation of dose but includes several drawbacks. Although without score lines, the antipsychotic drug quetiapine was in 2011 the most often prescribed 1/2 tablet in discharge prescriptions at the University Hospital in Basel (USB, 671 beds). We aimed at analysing the prescription patterns of split tablets in general and of quetiapine in particular in Switzerland. Methods. All orders of community pharmacies for unit-of-use soft pouch blisters placed at Medifilm AG, the leader company in Switzerland for repackaging into pouch blisters, were analysed. Results. Out of 4,784,999 tablets that were repacked in 2012 in unit-of-use pouch blisters, 8.5% were fragmented, mostly in half (87.6%), and were predominantly psycholeptics (pipamperone 15.8%). Prescription of half quetiapine appears to be a Basel specificity (highest rates of fragments and half quetiapine). Conclusions. Prescription of fragmented tablet is frequent. It represents a safety issue for the patient, and a pharmaceutical care issue for the pharmacist. In ambulatory care, the patient’s cognitive and physical capacities must be clarified, suitability of the splitting of the tablet must be checked, appropriate aids must be offered, like a pill-splitting device in order to improve accuracy, and safe use of the drug must be ensured. Samuel S. Allemann, Delia Bornand, Balthasar Hug, Kurt E. Hersberger, and Isabelle Arnet Copyright © 2015 Samuel S. Allemann et al. All rights reserved. Medication Lists and Brown Bag Reviews: Potential Positive and Negative Impacts on Patients Beliefs about Their Medicine Sun, 11 Oct 2015 09:48:35 +0000 Introduction. Medication lists and structured medication counselling (SMC) including “brown bag reviews” (BBR) are important instruments for medication safety. The aim of this study was to explore whether patients’ use of a medication list is associated with their beliefs about their medicine and their memory of SMC. Methods. Baseline data of 344 patients enrolled into the “Polypharmacy in Multimorbid Patients study” were analysed. Linear regression models were calculated for the “specific necessity subscale” (SNS) and the “specific concerns subscale” (SCS) of the German “Beliefs About Medicine Questionnaire,” including self-developed variables assessing patients’ use of a medication list, their memory of SMC, and sociodemographic data. Results. 62.8% () remembered an appointment for SMC and 32.0% () BBR. The SNS correlated positively with regular receipt of a medication list (, ) and negatively with memory of a BBR (; ). The SCS correlated positively with memory of a BBR (, ) and negatively with the comprehensiveness of the mediation list (; ). Conclusions. A comprehensive medication list may reduce patients’ concerns and increase the perceived necessity of their medication. A potential negative impact of BBR on patients’ beliefs about their medicine should be considered and quality standards for SMC developed. Cornelia Jäger, Jost Steinhaeuser, Tobias Freund, Joachim Szecsenyi, and Katja Goetz Copyright © 2015 Cornelia Jäger et al. All rights reserved. Interdisciplinary Medication Adherence Program: The Example of a University Community Pharmacy in Switzerland Sun, 11 Oct 2015 09:35:04 +0000 The Community Pharmacy of the Department of Ambulatory Care and Community Medicine (Policlinique Médicale Universitaire, PMU), University of Lausanne, developed and implemented an interdisciplinary medication adherence program. The program aims to support and reinforce medication adherence through a multifactorial and interdisciplinary intervention. Motivational interviewing is combined with medication adherence electronic monitors (MEMS, Aardex MWV) and a report to patient, physician, nurse, and other pharmacists. This program has become a routine activity and was extended for use with all chronic diseases. From 2004 to 2014, there were 819 patient inclusions, and 268 patients were in follow-up in 2014. This paper aims to present the organization and program’s context, statistical data, published research, and future perspectives. Mélanie Lelubre, Susan Kamal, Noëllie Genre, Jennifer Celio, Séverine Gorgerat, Denise Hugentobler Hampai, Aline Bourdin, Jerôme Berger, Olivier Bugnon, and Marie Schneider Copyright © 2015 Mélanie Lelubre et al. All rights reserved. Medication Adherence Measures: An Overview Sun, 11 Oct 2015 08:32:50 +0000 WHO reported that adherence among patients with chronic diseases averages only 50% in developed countries. This is recognized as a significant public health issue, since medication nonadherence leads to poor health outcomes and increased healthcare costs. Improving medication adherence is, therefore, crucial and revealed on many studies, suggesting interventions can improve medication adherence. One significant aspect of the strategies to improve medication adherence is to understand its magnitude. However, there is a lack of general guidance for researchers and healthcare professionals to choose the appropriate tools that can explore the extent of medication adherence and the reasons behind this problem in order to orchestrate subsequent interventions. This paper reviews both subjective and objective medication adherence measures, including direct measures, those involving secondary database analysis, electronic medication packaging (EMP) devices, pill count, and clinician assessments and self-report. Subjective measures generally provide explanations for patient’s nonadherence whereas objective measures contribute to a more precise record of patient’s medication-taking behavior. While choosing a suitable approach, researchers and healthcare professionals should balance the reliability and practicality, especially cost effectiveness, for their purpose. Meanwhile, because a perfect measure does not exist, a multimeasure approach seems to be the best solution currently. Wai Yin Lam and Paula Fresco Copyright © 2015 Wai Yin Lam and Paula Fresco. All rights reserved. Effects of Adherence to Statin Therapy on Health Care Outcomes and Utilizations in Taiwan: A Population-Based Study Sun, 11 Oct 2015 08:02:31 +0000 Aim. Good medication adherence may decrease the probability of worse outcomes and reduce unnecessary medical care costs. This study aims to evaluate medication adherence for people on statin therapy. Methods. National health insurance databases were analyzed from January 1, 2001, to December 31, 2007. Study samples were patients of 45 years and older adults who took statin for the first time during the study period. Medication possession ratio (MPR) was measured until the patients had hospitalization or reached the three-year follow-up period. We identified a good (MPR ≥ 80%) and a poor (MPR < 80%) medication adherence group to conduct statistical analyses. Results. 40.8% of patients were of good medication adherence and 59.2% were of poor medication adherence. Multivariate logistic regression model indicated that the MPR ≥ 80% group had significantly less probability of hospitalization (). Being men, increasing age, higher Charlson Comorbidity Index (CCI) scores, seeking care mostly in the medical center or teaching hospitals, and living in the suburban or rural areas had higher probability of hospitalization ( or ). The MPR ≥ 80% group spent less hospitalization expenditures (). Conclusion. Effective interventions may be applied to the poor medication adherence group in order to improve their health care outcomes. Ying-Chun Li and Wei-Ling Huang Copyright © 2015 Ying-Chun Li and Wei-Ling Huang. All rights reserved. The Construct and Measurement of Perceived Risk of Nonremunerated Blood Donation: Evidence from the Chinese Public Wed, 07 Oct 2015 09:27:03 +0000 The perceived risk of nonremunerated blood donation (NRBD) is one of the most important factors which hinder the Chinese public from donating blood. To understand deeply and measure scientifically the public’s perceived risk of NRBD, in this paper the qualitative and quantitative methods were used to explore the construct of perceived risk of NRBD in Chinese context. Firstly, the preliminary construct of perceived risk of NRBD was developed based on the grounded theory. Then, a measurement scale of perceived risk of NRBD was designed. Finally, the exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were adopted for testing and verifying the construct. The results show that the construct of perceived risk of NRBD has three core dimensions, namely, trust risk, psychological risk, and health risk, which provides a clear construct and concise scale to better capture the Chinese public’s perceived risk of NRBD. Blood collection agencies can strategically make polices about perceived risk reduction to maximize the public’s NRBD behavior. Liangyong Chen and Zujun Ma Copyright © 2015 Liangyong Chen and Zujun Ma. All rights reserved. The Prevalence of Skilled Birth Attendant Utilization and Its Correlates in North West Ethiopia Sun, 04 Oct 2015 13:23:52 +0000 The low utilization of skilled birth attendants sustained high maternal mortality. The aim of this study was to assess its magnitude and correlates in Northwest Ethiopia. A study was conducted on 373 randomly selected women who gave birth in the 12 months preceding the survey. Correlates were identified using binary logistic regression. Skilled birth attendance was 18.8%. Inability to perform cultural practices in health facilities (65.5%), expecting smooth delivery (63.4%), and far distance (62%) were the main barriers. Women with urban residence (AOR = 5.46: 95% CI ), primary (AOR = 2.10: 95% CI ) and secondary-plus (AOR = 6.12: ) educational level, four-plus ANC visits (AOR = 17.33: 95% CI ), and proximity to health centers (AOR = 5.67: 95% CI ) had higher odds of using skilled birth attendants though women with no labor complications had lower odds (AOR = 0.02: 95% CI ). Skilled birth attendance use was low. Urban residence, primary-plus level of education, frequent ANC visits, living nearby the health centers, and a problem during labor were positively correlated with skilled birth attendance utilization. Stakeholders should enhance girls’ education beyond primary level and ANC services and shorten distances to health facilities. Mulunesh Alemayehu and Wubegzier Mekonnen Copyright © 2015 Mulunesh Alemayehu and Wubegzier Mekonnen. All rights reserved. Working Atmosphere and Job Satisfaction of Health Care Staff in Kenya: An Exploratory Study Sun, 04 Oct 2015 13:21:06 +0000 Background. Job satisfaction and working atmosphere are important for optimal health care delivery. The study aimed to document working atmosphere and job satisfaction of health care professionals in Kenya and to explore associations between job satisfaction, staff characteristics, and working atmosphere. Methods. Data from the integrated quality management system (IQMS) for the health sector in Kenya were used. Job satisfaction was measured with 10 items and with additional 5 items adapted to job situation in Kenya. Working atmosphere was measured with 13 item questionnaire. A stepwise linear regression analysis was performed with overall job satisfaction and working atmosphere, aspects of job satisfaction, and individual characteristics. Results. Out of 832 questionnaires handed out, 435 questionnaires were completed (response rate: 52.3%). Health care staff indicated high commitment to provide quality services and low levels regarding the adequacy and functionality of equipment at their work station. The aspect “support of the ministry of health” (β = 0.577) showed the highest score of explained variance (32.9%) regarding overall job satisfaction. Conclusions. IQMS which also evaluates job satisfaction and working atmosphere of health care staff provides a good opportunity for strengthening the recruitment and retention of health care staff as well as improving the provision of good quality of care. Katja Goetz, Michael Marx, Irmgard Marx, Marc Brodowski, Maureen Nafula, Helen Prytherch, Irene K. E. Omogi Awour, and Joachim Szecsenyi Copyright © 2015 Katja Goetz et al. All rights reserved. Public Concern about the Sale of High-Caffeine Drinks to Children 12 Years or Younger: An Australian Regulatory Perspective Sun, 04 Oct 2015 13:01:28 +0000 Background. Dietary exposure to high caffeine is a health risk for children. Governments are considering measures to restrict the sale of formulated caffeinated beverages (FCB) to children. Objectives. To investigate community concern about sales of high-caffeine drinks to children among Western Australian adults and describe Australian and New Zealand regulatory processes regarding FCB. Methods. Data from the 2009 and 2012 Department of Health’s Nutrition Monitoring Survey Series of 2,832 Western Australians aged 18–64 years was pooled with descriptive and ordinal logistic regression analysis performed. Current regulatory processes for FCB are reported. Results. Most (85%) participants were concerned about the sale of high-caffeine drinks to children; 77.4% were very concerned in 2012 compared to 66.5% in 2009, p < .008. Females and those living with children had higher concern (odds ratio (OR) 2.11; 95% confidence interval (CI) 1.44–3.10; OR 2.16; 95% CI 1.51–3.09, resp., p < .001). Concern increased with each year of age (OR 1.04; 95% CI 1.02, 1.05, p < .001). Conclusions. Community concern regarding sale of high-caffeine energy drinks to children is high and increasing. Being female and living with children were associated with greater concern. These findings support the Australian and New Zealand regulatory controls of FCB, including labelling, promotion, and advertising to children. Christina Mary Pollard, Catrina Lisa McStay, and Xingqiong Meng Copyright © 2015 Christina Mary Pollard et al. All rights reserved. Do Italian Companies Manage Work-Related Stress Effectively? A Process Evaluation in Implementing the INAIL Methodology Sun, 04 Oct 2015 12:55:58 +0000 Studies on Intervention Process Evaluation are attracting growing attention in the literature on interventions linked to stress and the wellbeing of workers. There is evidence that some elements relating to the process and content of an intervention may have a decisive role in implementing it by facilitating or hindering the effectiveness of the results. This study aimed to provide a process evaluation on interventions to assess and manage risks related to work-related stress using a methodological path offered by INAIL. The final sample is composed of 124 companies participating to an interview on aspects relating to each phase of the INAIL methodological path put in place to implement the intervention. INAIL methodology has been defined as useful in the process of assessing and managing the risks related to work-related stress. Some factors related to the process (e.g., implementation of a preliminary phase, workers’ involvement, and use of external consultants) showed a role in significant differences that emerged in the levels of risk, particularly in relation to findings from the preliminary assessment. Main findings provide information on the key aspects of process and content that are useful in implementing an intervention for assessing and managing risks related to work-related stress. Cristina Di Tecco, Matteo Ronchetti, Monica Ghelli, Simone Russo, Benedetta Persechino, and Sergio Iavicoli Copyright © 2015 Cristina Di Tecco et al. All rights reserved. Health Impacts of Increased Physical Activity from Changes in Transportation Infrastructure: Quantitative Estimates for Three Communities Sun, 04 Oct 2015 12:24:04 +0000 Recently, two quantitative tools have emerged for predicting the health impacts of projects that change population physical activity: the Health Economic Assessment Tool (HEAT) and Dynamic Modeling for Health Impact Assessment (DYNAMO-HIA). HEAT has been used to support health impact assessments of transportation infrastructure projects, but DYNAMO-HIA has not been previously employed for this purpose nor have the two tools been compared. To demonstrate the use of DYNAMO-HIA for supporting health impact assessments of transportation infrastructure projects, we employed the model in three communities (urban, suburban, and rural) in North Carolina. We also compared DYNAMO-HIA and HEAT predictions in the urban community. Using DYNAMO-HIA, we estimated benefit-cost ratios of 20.2 (95% C.I.: 8.7–30.6), 0.6 (0.3–0.9), and 4.7 (2.1–7.1) for the urban, suburban, and rural projects, respectively. For a 40-year time period, the HEAT predictions of deaths avoided by the urban infrastructure project were three times as high as DYNAMO-HIA’s predictions due to HEAT’s inability to account for changing population health characteristics over time. Quantitative health impact assessment coupled with economic valuation is a powerful tool for integrating health considerations into transportation decision-making. However, to avoid overestimating benefits, such quantitative HIAs should use dynamic, rather than static, approaches. Theodore J. Mansfield and Jacqueline MacDonald Gibson Copyright © 2015 Theodore J. Mansfield and Jacqueline MacDonald Gibson. All rights reserved. Smoke-Free Workplaces Are Associated with Protection from Second-Hand Smoke at Homes in Nigeria: Evidence for Population-Level Decisions Sun, 04 Oct 2015 12:20:05 +0000 The evidence suggests that smoke-free workplace policies may change social norms towards exposing others to second-hand smoke at home. The aim of the study was to assess whether being employed in a smoke-free workplace (SFWP) is associated with living in a smoke-free home (SFH). We used the data from the Global Adult Tobacco Survey conducted in Nigeria in 2012, in which 9,765 individuals were interviewed including 1,856 persons who worked indoors. The percentage of Nigerians employed in SFWP that reported living in a SFH was higher compared to those employed in a workplace where smoking occurred (95% versus 73%). Working in a SFWP was associated with a significantly higher likelihood of living in a SFH (OR = 5.3; ). Urban inhabitants indicated more frequently that they lived in SFH compared to rural residents (OR = 2.0; ). The odds of living in a SFH were significantly higher among nonsmokers and nonsmokeless tobacco users compared to smokers and smokeless tobacco users (OR = 28.8; ; OR = 7.0; ). These findings support the need for implementation of comprehensive smoke-free policies in Nigeria that result in substantial health benefits. Dorota Kaleta, Kinga Polanska, and Bukola Usidame Copyright © 2015 Dorota Kaleta et al. All rights reserved. Challenges and Opportunities for Exploring Patient-Level Data Sun, 04 Oct 2015 12:14:17 +0000 The proper exploration of patient-level data will pave the way towards personalised medicine. To better assess the state of the art in this field we identify the challenges and uncover the opportunities for the exploration of patient-level data through the review of well-known initiatives and projects focusing on the exploration of patient-level data. These cover a broad array of topics, from genomics to patient registries up to rare diseases research, among others. For each, we identified basic goals, involved partners, defined strategies and key technological and scientific outcomes, establishing the foundation for our analysis framework with four pillars: control, sustainability, technology, and science. Substantial research outcomes have been produced towards the exploration of patient-level data. The potential behind these data will be essential to realise the personalised medicine premise in upcoming years. Hence, relevant stakeholders continually push forward new developments in this domain, bringing novel opportunities that are ripe for exploration. Despite last decade’s translational research advances, personalised medicine is still far from being a reality. Patients’ data underlying potential goes beyond daily clinical practice. There are miscellaneous challenges and opportunities open for the exploration of these data by academia and business stakeholders. Pedro Lopes, Luis Bastião Silva, and José Luis Oliveira Copyright © 2015 Pedro Lopes et al. All rights reserved. Evaluation of the Effectiveness and Implementation of an Adapted Evidence-Based Mammography Intervention for African American Women Sun, 04 Oct 2015 11:10:41 +0000 Breast cancer mortality disparities continue, particularly for uninsured and minority women. A number of effective evidence-based interventions (EBIs) exist for addressing barriers to mammography screening; however, their uptake and use in community has been limited. Few cancer-specific studies have evaluated adapted EBIs in new contexts, and fewer still have considered implementation. This study sought to (1) evaluate the effectiveness of an adapted mammography EBI in improving appointment keeping in African American women and (2) describe processes of implementation in a new practice setting. We used the type 1 hybrid design to test effectiveness and implementation using a quasi-experimental design. Logistic regression and intent-to-treat analysis were used to evaluate mammography appointment attendance. The no-show rate was 44% (comparison) versus 19% (intervention). The adjusted odds of a woman in the intervention group attending her appointment were 3.88 . The adjusted odds of a woman attending her appointment in the intent-to-treat analysis were 2.31 . Adapted EBI effectiveness was 3.88 (adjusted OR) versus 2.10 (OR) for the original program, indicating enhanced program effect. A number of implementation barriers and facilitators were identified. Our findings support previous studies noting that sequentially measuring EBI efficacy and effectiveness, followed by implementation, may be missing important contextual information. Linda Highfield, Marieke A. Hartman, L. Kay Bartholomew, Philomene Balihe, and Valerie A. Ausborn Copyright © 2015 Linda Highfield et al. All rights reserved. Worksite Tobacco Prevention: A Randomized, Controlled Trial of Adoption, Dissemination Strategies, and Aggregated Health-Related Outcomes across Companies Sun, 04 Oct 2015 11:02:36 +0000 Evidence based public health requires knowledge about successful dissemination of public health measures. This study analyses (a) the changes in worksite tobacco prevention (TP) in the Canton of Zurich, Switzerland, between 2007 and 2009; (b1) the results of a multistep versus a “brochure only” dissemination strategy; (b2) the results of a monothematic versus a comprehensive dissemination strategy that aim to get companies to adopt TP measures; and (c) whether worksite TP is associated with health-related outcomes. A longitudinal design with randomized control groups was applied. Data on worksite TP and health-related outcomes were gathered by a written questionnaire (baseline 627; follow-up 452) and analysed using descriptive statistics, nonparametric procedures, and ordinal regression models. TP measures at worksites improved slightly between 2007 and 2009. The multistep dissemination was superior to the “brochure only” condition. No significant differences between the monothematic and the comprehensive dissemination strategies were observed. However, improvements in TP measures at worksites were associated with improvements in health-related outcomes. Although dissemination was approached at a mass scale, little change in the advocated adoption of TP measures was observed, suggesting the need for even more aggressive outreach or an acceptance that these channels do not seem to be sufficiently effective. Verena Friedrich, Adrian Brügger, and Georg F. Bauer Copyright © 2015 Verena Friedrich et al. All rights reserved. Medicine Sellers for Prevention and Control of Sexually Transmitted Infections: Effect of a Quasi-Experimental Training Intervention in Bangladesh Sun, 27 Sep 2015 14:16:26 +0000 This study used a quasi-experimental pre-post design to test whether short training can improve medicine sellers’ (MSs) practices and skills for prevention and control of sexually transmitted infections (STIs) in Bangladesh. The training included lectures, printed materials, and identification of referral sites. Difference-in-differences estimation was used to determine the effects of intervention on key primary and secondary outcomes. Advice given by the MSs in intervention group for partner treatment and condoms use increased significantly by 11% and 9%, respectively, after adjusting for baseline differences in education, religion, age, duration of training, and study site. Referral of clients to qualified service providers increased by 5% in the intervention group compared to the comparison group, but this change was not found to be statistically significant. Significantly higher proportion of MSs in the intervention group recognized the recommended medications as per the national syndromic management guidelines in Bangladesh for treatment of urethral discharge and genital ulcer symptoms. Short training intervention was found to be effective in improving MSs’ practice of promoting condom use and partner treatment to the clients. We anticipate the need for broad based training programs of MSs to improve their skills for the prevention and control of STI/HIV in Bangladesh. Nazmul Alam, Anadil Alam, and Pierre Fournier Copyright © 2015 Nazmul Alam et al. All rights reserved. Comment on “Maternal Satisfaction on Delivery Service and Its Associated Factors among Mothers Who Gave Birth in Public Health Facilities of Debre Markos Town, Northwest Ethiopia” Sun, 06 Sep 2015 13:51:36 +0000 Siddharudha Shivalli Copyright © 2015 Siddharudha Shivalli. All rights reserved. Behaviour Change in Public Health: Evidence and Implications Wed, 26 Aug 2015 10:12:50 +0000 Subhash Pokhrel, Nana K. Anokye, Daniel D. Reidpath, and Pascale Allotey Copyright © 2015 Subhash Pokhrel et al. All rights reserved. Secular Changes of Adiposity and Motor Development in Czech Preschool Children: Lifestyle Changes in Fifty-Five Year Retrospective Study Tue, 25 Aug 2015 14:06:52 +0000 Secular trends of adiposity and motor development in preschool children since the fifties of the last century up to the beginning of this millennium were analyzed so as to reveal possible changes due to continuously differentiating lifestyle. In preschool children () height, weight, skinfold thickness over triceps, subscapular, and suprailiac were measured by Harpenden caliper in 1957, 1977, 1980, 1985, 1990, and 2012. Simultaneously, motor performance was tested by evaluating the achievements in broad jump and throwing a ball, as a marker of adaptation to changing level of physical activity, free games, and exercise. Along the period of five decades the values of skinfold thickness increased significantly until 2012, mainly on the trunk. Simultaneously, the level of motor performance significantly decreased. Modifications of the way of life during the mentioned five decades characterized by sedentarism and inadequate food intake as related to energy output influenced negatively both adiposity and motor performance already in preschool children. Mostly increased deposition of fat on the trunk which is considered as a marker of possible development of metabolic syndrome was apparent already in preschool age, indicating the importance of early intervention concerning also physical activity and availability for exercise since early life. Petr Sedlak, Jana Pařízková, Robert Daniš, Hana Dvořáková, and Jana Vignerová Copyright © 2015 Petr Sedlak et al. All rights reserved. Estimating Measurement Error of the Patient Activation Measure for Respondents with Partially Missing Data Tue, 25 Aug 2015 14:01:27 +0000 The patient activation measure (PAM) is an increasingly popular instrument used as the basis for interventions to improve patient engagement and as an outcome measure to assess intervention effect. However, a PAM score may be calculated when there are missing responses, which could lead to substantial measurement error. In this paper, measurement error is systematically estimated across the full possible range of missing items (one to twelve), using simulation in which populated items were randomly replaced with missing data for each of 1,138 complete surveys obtained in a randomized controlled trial. The PAM score was then calculated, followed by comparisons of overall simulated average mean, minimum, and maximum PAM scores to the true PAM score in order to assess the absolute percentage error (APE) for each comparison. With only one missing item, the average APE was 2.5% comparing the true PAM score to the simulated minimum score and 4.3% compared to the simulated maximum score. APEs increased with additional missing items, such that surveys with 12 missing items had average APEs of 29.7% (minimum) and 44.4% (maximum). Several suggestions and alternative approaches are offered that could be pursued to improve measurement accuracy when responses are missing. Ariel Linden Copyright © 2015 Ariel Linden. All rights reserved. Facilitators and Barriers to Health-Seeking Behaviours among Filipino Migrants: Inductive Analysis to Inform Health Promotion Tue, 25 Aug 2015 10:58:02 +0000 Understanding factors that influence health-seeking behaviour of migrants is necessary to intervene for behaviour change. This paper explores Filipino migrants’ perceptions of facilitators and barriers to maintaining health in Australia. Open-ended survey item responses reflecting factors that assisted and hindered health following migration to Australia were inductively analysed. Three hundred and thirty-seven of the 552 survey respondents (61%) provided open-ended responses. Responses were grouped into two major categories: individual factors, including personal resources and cultural influences, and environmental factors encompassing both the physical conditions in the host country and health service access. Awareness of practices that enhance health was a major personal facilitator of health-seeking behaviour; however, competing priorities of daily living were perceived as barriers. Cultural beliefs and practices influenced health-seeking behaviour. Despite high self-rated English language skills in this population, new migrants and the elderly cited communication difficulties as barriers to accessing health services. Insight into facilitators and barriers to health-seeking behaviour in this less researched migrant population revealed tools for enhancing engagement in health promotion programs addressing healthy lifestyle. D. Maneze, M. DiGiacomo, Y. Salamonson, J. Descallar, and P. M. Davidson Copyright © 2015 D. Maneze et al. All rights reserved. PE Teacher and Classmate Support in Level of Physical Activity: The Role of Sex and BMI Status in Adolescents from Kosovo Tue, 25 Aug 2015 08:43:52 +0000 The aim of this paper is to examine the role of physical education (PE) teacher and classmate support in relation to sex and BMI status in adolescents’ physical activity (PA) in Kosovo. A Classmate and Teacher Support Scale (with additional questions) was used on a cross-sectional sample of 608 girls and 620 boys aged 15–18, randomly selected from secondary schools of seven major municipalities in Kosovo. PA level was determined with a Physical Activity Screening Measure questionnaire. Descriptive statistics and a three-way ANOVA, along with Tukey’s HSD post hoc test, were employed. The findings showed the levels of teacher and classmate support to be important factors in stimulating adolescents’ PA. It was found that boys with normal weight, high support from teachers, and medium or high support from classmates were more physically active, compared with girls. Michal Bronikowski, Malgorzata Bronikowska, Ida Laudańska-Krzemińska, Adam Kantanista, Besnik Morina, and Shemsedin Vehapi Copyright © 2015 Michal Bronikowski et al. All rights reserved. Perspectives of Fijian Policymakers on the Obesity Prevention Policy Landscape Tue, 25 Aug 2015 08:38:15 +0000 In Fiji and other Pacific Island countries, obesity has rapidly increased in the past decade. Therefore, several obesity prevention policies have been developed. Studies show that their development has been hampered by factors within Fiji’s policy landscape such as pressure from industry. Since policymakers in the Fijian national government are primarily responsible for the development of obesity policies, it is important to understand their perspectives; we therefore interviewed 15 policymakers from nine Fijian ministries. By applying the “attractor landscape” metaphor from dynamic systems theory, we captured perceived barriers and facilitators in the policy landscape. A poor economic situation, low food self-sufficiency, power inequalities, inappropriate framing of obesity, limited policy evidence, and limited resource sharing hamper obesity policy developments in Fiji. Facilitators include policy entrepreneurs and policy brokers who were active when a window of opportunity opened and who strengthened intersectoral collaboration. Fiji’s policy landscape can become more conducive to obesity policies if power inequalities are reduced. In Fiji and other Pacific Island countries, this may be achievable through increased food self-sufficiency, strengthened intersectoral collaboration, and the establishment of an explicit functional focal unit within government to monitor and forecast the health impact of policy changes in non-health sectors. Anna-Marie Hendriks, Mere Y. Delai, Anne-Marie Thow, Jessica S. Gubbels, Nanne K. De Vries, Stef P. J. Kremers, and Maria W. J. Jansen Copyright © 2015 Anna-Marie Hendriks et al. All rights reserved. Promotion and Prevention Focused Feeding Strategies: Exploring the Effects on Healthy and Unhealthy Child Eating Tue, 25 Aug 2015 08:37:14 +0000 There is a general lack of research addressing the motivations behind parental use of various feeding practices. Therefore, the present work aims to extend the current literature on parent-child feeding interactions by integrating the traditional developmental psychological perspective on feeding practices with elements of Regulatory Focus Theory (RFT) derived from the field of motivational psychology. In this paper, we seek to explain associations between parental feeding practices and child (un)healthy eating behaviors by categorizing parental feeding practices into promotion and prevention focused strategies, thus exploring parent-child feeding interactions within the framework of RFT. Our analyses partly supported the idea that (1) child healthy eating is positively associated with feeding practices characterized as promotion focused, and (2) child unhealthy eating is negatively associated with feeding practices characterized as prevention focused. However, a general observation following from our results suggests that parents’ major driving forces behind reducing children’s consumption of unhealthy food items and increasing their consumption of healthy food items are strategies that motivate rather than restrict. In particular, parents’ provision of a healthy home food environment seems to be essential for child eating. Elisabeth L. Melbye and Håvard Hansen Copyright © 2015 Elisabeth L. Melbye and Håvard Hansen. All rights reserved. Using a Smartphone Application to Promote Healthy Dietary Behaviours and Local Food Consumption Tue, 25 Aug 2015 08:05:24 +0000 Smartphone “apps” are a powerful tool for public health promotion, but unidimensional interventions have been ineffective at sustaining behavioural change. Various logistical issues exist in successful app development for health intervention programs and for sustaining behavioural change. This study reports on a smartphone application and messaging service, called “SmartAPPetite,” which uses validated behaviour change techniques and a behavioural economic approach to “nudge” users into healthy dietary behaviours. To help gauge participation in and influence of the program, data were collected using an upfront food survey, message uptake tracking, experience sampling interviews, and a follow-up survey. Logistical and content-based issues in the deployment of the messaging service were subsequently addressed to strengthen the effectiveness of the app in changing dietary behaviours. Challenges included creating relevant food goal categories for participants, providing messaging appropriate to self-reported food literacy and ensuring continued participation in the program. SmartAPPetite was effective at creating a sense of improved awareness and consumption of healthy foods, as well as drawing people to local food vendors with greater frequency. This work serves as a storehouse of methods and best practices for multidimensional local food-based smartphone interventions aimed at improving the “triple bottom line” of health, economy, and environment. Jason Gilliland, Richard Sadler, Andrew Clark, Colleen O’Connor, Malgorzata Milczarek, and Sean Doherty Copyright © 2015 Jason Gilliland et al. All rights reserved. Using Photovoice as a Community Based Participatory Research Tool for Changing Water, Sanitation, and Hygiene Behaviours in Usoma, Kenya Tue, 25 Aug 2015 08:01:21 +0000 Recent years have witnessed an increase in the use of community based participatory research (CBPR) tools for understanding environment and health issues and facilitating social action. This paper explores the application and utility of photovoice for understanding water, sanitation, and hygiene (WASH) behaviours and catalysing community led solutions to change behaviours. Between June and August 2013, photovoice was conducted with eight (8) women in Usoma, a lakeshore community in Western Kenya with a follow-up community meeting (baraza) in May 2014 to discuss findings with the community members and government officials. In the first part of the study, photovoice one-on-one interviews were used to explore local perceptions and practices around water-health linkages and how the ecological and socio-political environment shapes these perceptions and practices. This paper, which is the second component of the study, uses photovoice group discussions to explore participants’ experiences with and (re)action to the photographs and the photovoice project. The findings illustrate that photovoice was an effective CBPR methodology for understanding behaviours, creating awareness, facilitating collective action, and engaging with local government and local health officials at the water-health nexus. Elijah Bisung, Susan J. Elliott, Bernard Abudho, Diana M. Karanja, and Corinne J. Schuster-Wallace Copyright © 2015 Elijah Bisung et al. All rights reserved. Adolescents Perceptions of Pro- and Antitobacco Imagery and Marketing: Qualitative Study of Students from Suva, Fiji Tue, 25 Aug 2015 07:53:25 +0000 Background. Many studies examining smoking uptake among young people in the Pacific have not included their exposure to tobacco control promotions in the media in their assessment. This study examines how Fijian students view tobacco and tobacco-related media depictions to gain insight into both drivers of smoking uptake and potential directions for prevention interventions. Methods. A sample of thirty Fijian students (15 male and 15 female) aged 14–17 years, was recruited from a Suva school between September and October 2013 and participated in a one-to-one in-depth interview about their views on tobacco use, media consumption patterns and preferences and awareness of tobacco use in media. Results. Despite radical developments in access to media, television remains the most popular. Yet, the majority of participants were unaware of any protobacco imagery on television or other entertainment media. Tobacco-related imagery was more likely to be seen in connection with point of sale advertising and branding. The advertising potential of the shop counter was acutely apparent to some participants and this space was considered highly influential. Conclusions. Despite the fact that the recently introduced graphic health warnings were generally well received, more can be done to extend the use of media for tobacco control benefits in Fiji. Gade Waqa, Judith McCool, Wendy Snowdon, and Becky Freeman Copyright © 2015 Gade Waqa et al. All rights reserved. Examining the Relationship between Heavy Alcohol Use and Assaults: With Adjustment for the Effects of Unmeasured Confounders Tue, 25 Aug 2015 07:34:40 +0000 Background. Experimental studies suggest that alcohol can lead to aggression in laboratory settings; however, it is impossible to test the causal relationship between alcohol use and real-life violence among humans in randomized clinical trials. Objectives. (i) To examine the relationship between heavy alcohol use and assaults in a population based study; (ii) to demonstrate the proxy outcome method, as a means of controlling the effects of unknown/unmeasured confounders in observational studies. Methods. This study used data collected from three waves of the National Survey on Drug Use and Health (NSDUH). The effects of heavy alcohol use on assault were measured using multivariable logistic regressions in conjunction with the proxy outcome method. Results. Application of the proxy outcome method indicated that effect sizes of heavy alcohol use on the risk of assault were overestimated in the standard models. After adjusting for the effects of unknown/unmeasured confounders, the risk of assault remained 43% and 63% higher among participants who consumed 5+ drinks/day for 5–8 days/month and 9–30 days/month, respectively. Conclusions. Even after adjustment for unknown/unmeasured confounders the association between heavy alcohol use and risk of violence remained significant. These findings support the hypothesis that heavy alcohol use can cause violence. Wenbin Liang and Tanya Chikritzhs Copyright © 2015 Wenbin Liang and Tanya Chikritzhs. All rights reserved. One-Year Results of the BeweegKuur Lifestyle Intervention Implemented in Dutch Primary Healthcare Settings Tue, 25 Aug 2015 07:26:13 +0000 Background. Lifestyle interventions focusing on healthy diet and physical activity (PA) are effective in reducing health risks in controlled research settings. The aim of this study was to investigate the one-year results of the BeweegKuur lifestyle intervention implemented nationwide in Netherlands for people with a weight-related health risk. Materials and Methods. Data were requested from all 160 locations participating in the BeweegKuur. In a one group pretest/posttest study, one-year changes in health outcome variables and time spent on physical activity were tested with dependent t-tests. Associations between one-year changes in weight and waist circumference and sociodemographic factors and uptake of the program were analysed with ANOVA. Results. Data for 517 participants from 47 locations were available for analysis. One year after the intervention, weight reduced by 2.9 kg (95% CI −3.3;, −2.5), waist circumference by 4.3 cm (−4.9; −3.7), and blood glucose by 0.5 mmol/L (−0.8; −0.3). Physical activity increased significantly. Higher uptake of the program was associated with a larger decrease in waist circumference. Conclusion. The results of the study suggest that lifestyle interventions implemented in real-life primary healthcare settings with tailor-made supervision can contribute meaningfully to primary prevention. Bianca A. M. Schutte, Annemien Haveman-Nies, and Liesbeth Preller Copyright © 2015 Bianca A. M. Schutte et al. All rights reserved. Socioeconomic Impact on the Prevalence of Cardiovascular Risk Factors in Wallonia, Belgium: A Population-Based Study Tue, 25 Aug 2015 07:13:14 +0000 Background. Monitoring the epidemiology of cardiovascular risk factors (CRFs) and their determinants is important to develop appropriate recommendations to prevent cardiovascular diseases in specific risk groups. The NESCaV study was designed to collect standardized data to estimate the prevalence of CRFs in relation to socioeconomic parameters among the general adult population in the province of Liège, Wallonia, Belgium. Methods. A representative stratified random sample of 1017 subjects, aged 20–69 years, participated in the NESCaV study (2010–2012). A self-administered questionnaire, a clinical examination, and laboratory tests were performed on participants. CRFs included hypertension, dyslipidemia, global obesity, abdominal obesity, diabetes, current smoking, and physical inactivity. Covariates were education and subjective and objective socioeconomic levels. Data were analyzed by weighted logistic regression. Results. The prevalence of hypertension, abdominal obesity, global obesity, current smoking, and physical inactivity was higher in subjects with low education and who considered themselves “financially in need.” Living below poverty threshold also increased the risk of global and abdominal obesity, current smoking, and physical inactivity. Conclusion. The study shows that socioeconomic factors impact the prevalence of CRFs in the adult population of Wallonia. Current public health policies should be adjusted to reduce health inequalities in specific risk groups. Sylvie Streel, Anne-Françoise Donneau, Axelle Hoge, Sven Majerus, Philippe Kolh, Jean-Paul Chapelle, Adelin Albert, and Michèle Guillaume Copyright © 2015 Sylvie Streel et al. All rights reserved. Adherence, Compliance, and Health Risk Factor Changes following Short-Term Physical Activity Interventions Tue, 25 Aug 2015 07:05:17 +0000 Background. Low physical activity (PA) levels are associated with poor health risk factor profiles. Intervention strategies to increase PA and quantify the rate and magnitude of change in risk factors are important. Methods. Interventions were conducted over 40 days to increase PA in 736 insufficiently active (<150 min/wk PA) participants using either a pedometer or instructor-led group protocol. There were a further 135 active participants as controls. Major cardiovascular and metabolic risk factors, including fitness parameters, were measured before and after intervention. Results. Adherence to the interventions was higher for the group versus pedometer participants (87.1% versus 79.8%) and compliance rates for achieving sufficient levels of PA (≥150 min/wk) were also higher for the group participants (95.8% versus 77.6%). Total weekly PA patterns increased by 300 and 435 minutes, for the pedometer and group participants, respectively. Improvements were found for waist girth, total cholesterol, aerobic fitness, and flexibility relative to controls. The change in vigorous PA, but not moderate PA, was a significant predictor of the change in eight of 11 risk factor variables measured. Conclusions. Rapid and dramatic increases in PA among previously insufficiently active adults can result in important health benefits. Lynda H. Norton, Kevin I. Norton, and Nicole R. Lewis Copyright © 2015 Lynda H. Norton et al. All rights reserved. A Universal Mental Health Promotion Programme for Young People in Italy Tue, 25 Aug 2015 07:01:32 +0000 In Italy, the Mental Health Unit of the National Institute of Public Health has developed a school-based mental health programme based on a structured handbook. The aim of this programme is to promote self-efficacy, psychological well-being, and life satisfaction. In this study, we evaluated the effectiveness of this programme. We used data from 308 students who participated in a study in 9 Italian high schools during the 2011-2012 school year. In order to analyse the school intervention programme, we set up a pre-post test design study involving 18 classrooms (8 of which acting as a control). The schools were selected via a snowball technique, and then the classrooms that agreed to participate were randomly assigned to intervention and control groups. The programme was performed during regular school hours in one-hour a week sessions for a total of 20 hours of classroom time. Assessments before and 2 months after the programme were performed using Regulatory Emotional Self-Efficacy, Satisfaction With Life, and Ryff’s Psychological Well-Being Scales. The results showed an improvement in self-efficacy in regulating negative affect, overall psychological well-being, and satisfaction with life. These results demonstrate that the programme produced significant positive effects on the mental health status of participating students. Antonella Gigantesco, Debora Del Re, Isabella Cascavilla, Gabriella Palumbo, Barbara De Mei, Chiara Cattaneo, Ilaria Giovannelli, and Antonino Bella Copyright © 2015 Antonella Gigantesco et al. All rights reserved. Using mHealth to Improve Usage of Antenatal Care, Postnatal Care, and Immunization: A Systematic Review of the Literature Tue, 25 Aug 2015 06:36:24 +0000 Mobile health (mHealth) technologies have been implemented in many low- and middle-income countries to address challenges in maternal and child health. Many of these technologies attempt to influence patients’, caretakers’, or health workers’ behavior. The purpose of this study was to conduct a systematic review of the literature to determine what evidence exists for the effectiveness of mHealth tools to increase the coverage and use of antenatal care (ANC), postnatal care (PNC), and childhood immunizations through behavior change in low- and middle-income countries. The full text of 53 articles was reviewed and 10 articles were identified that met all inclusion criteria. The majority of studies used text or voice message reminders to influence patient behavior change (80%, ) and most were conducted in African countries (80%, ). All studies showed at least some evidence of effectiveness at changing behavior to improve antenatal care attendance, postnatal care attendance, or childhood immunization rates. However, many of the studies were observational and further rigorous evaluation of mHealth programs is needed in a broader variety of settings. Jessica L. Watterson, Julia Walsh, and Isheeta Madeka Copyright © 2015 Jessica L. Watterson et al. All rights reserved. Effects of a Health Promotion Program Based on a Train-the-Trainer Approach on Quality of Life and Mental Health of Long-Term Unemployed Persons Tue, 25 Aug 2015 06:27:04 +0000 Background. Long-term unemployment is associated with poorer mental health. The aim of this study was to evaluate the effectiveness of a health promotion program using the train-the-trainer approach on health-related quality of life (HRQoL) and mental health of long-term unemployed persons. Methods. A prospective parallel-group study was conducted among 365 long-term unemployed persons. 287 participants (179 members of the intervention group IG and 108 members of the control group) were reassessed after three months. The intervention comprised both individual sessions based on Motivational Interviewing and participatory group sessions; no health promotion program was administered in the control group. The endpoints were HRQoL (SF-12), depression, and anxiety. The effect size of the change across time in the IG and CG was measured by Cohen’s . To assess the significance of group differences in the change across time, a random effects model was used. Results. Within three months HRQoL improved and anxiety and depression decreased significantly in the IG. A significant intervention effect was observed for anxiety (p = 0.012). Effect sizes in the IG were small to moderate in terms of Cohen’s (anxiety: ; SF-12 mental: ; depression: ; SF-12 physical: ). Conclusions. The health promotion program, based on a train-the-trainer approach, showed positive effects on HRQoL and mental health, especially anxiety, of long-term unemployed persons, a highly burdened target group where an improvement in mental health is a crucial prerequisite to social participation and successful reintegration into the job market. Heribert Limm, Mechthild Heinmüller, Harald Gündel, Katrin Liel, Karin Seeger, Ramazan Salman, and Peter Angerer Copyright © 2015 Heribert Limm et al. All rights reserved. Underground Coal Mining: Relationship between Coal Dust Levels and Pneumoconiosis, in Two Regions of Colombia, 2014 Thu, 20 Aug 2015 12:41:47 +0000 In Colombia, coal miner pneumoconiosis is considered a public health problem due to its irreversibility, high cost on diagnosis, and lack of data related to its prevalence in the country. Therefore, a cross-sectional study was carried out in order to determine the prevalence of pneumoconiosis in underground coal mining workers in two regions of Colombia. The results showed a 35.9% prevalence of pneumoconiosis in the study group (42.3% in region 1 and 29.9% in region 2). An association was found between a radiologic diagnosis of pneumoconiosis and a medium risk level of exposure to carbon dust (OR: 2.901, 95% CI: 0.937, 8.982), medium size companies (OR: 2.301, 95% CI: 1.260–4.201), length of mining work greater than 25 years (OR: 3.222, 95% CI: 1.806–5.748), and a history of smoking for more than one year (OR: 1.479, 95% CI: 0.938–2.334). These results establish the need to generate an intervention strategy aimed at preventing the identified factors, as well as a timely identification and effective treatment of pneumoconiosis in coal miners, in which the commitment of the General Health and Social Security System and the workers compensation system is ensured. Carlos Humberto Torres Rey, Milciades Ibañez Pinilla, Leonardo Briceño Ayala, Diana Milena Checa Guerrero, Gloria Morgan Torres, Helena Groot de Restrepo, and Marcela Varona Uribe Copyright © 2015 Carlos Humberto Torres Rey et al. All rights reserved. The Content of the 14 Metals in Cancellous and Cortical Bone of the Hip Joint Affected by Osteoarthritis Tue, 18 Aug 2015 08:36:32 +0000 The aim of the study was to determine the content of particular elements Ca, Mg, P, Na, K, Zn, Cu, Fe, Mo, Cr, Ni, Ba, Sr, and Pb in the proximal femur bone tissue (cancellous and cortical bone) of 96 patients undergoing total hip replacement for osteoarthritis using ICP-AES and FAAS analytical techniques. The interdependencies among these elements and their correlations depended on factors including age, gender, place of residence, tobacco consumption, alcohol consumption, exposure to environmental pollution, physical activity, and type of degenerative change which were examined by statistical and chemometric methods. The factors that exerted the greatest influence on the elements in the femoral head and neck were tobacco smoking (higher Cr and Ni content in smokers), alcohol consumption (higher concentrations of Ni, Cu in people who consume alcohol), and gender (higher Cu, Zn, and Ni concentrations in men). The factors influencing Pb accumulation in bone tissue were tobacco, alcohol, gender, and age. In primary and secondary osteoarthritis of the hip, the content and interactions of elements are different (mainly those of Fe and Pb). There were no significant differences in the concentrations of elements in the femoral head and neck that could be attributed to residence or physical activity. Anetta Zioła-Frankowska, Łukasz Kubaszewski, Mikołaj Dąbrowski, Artur Kowalski, Piotr Rogala, Wojciech Strzyżewski, Wojciech Łabędź, Ryszard Uklejewski, Karel Novotny, Viktor Kanicky, and Marcin Frankowski Copyright © 2015 Anetta Zioła-Frankowska et al. All rights reserved. Maternal Satisfaction on Delivery Service and Its Associated Factors among Mothers Who Gave Birth in Public Health Facilities of Debre Markos Town, Northwest Ethiopia Mon, 10 Aug 2015 07:27:00 +0000 Introduction. The existence of maternal health service does not guarantee its use by women; neither does the use of maternal health service guarantee optimal outcomes for women. The World Health Organization recommends monitoring and evaluation of maternal satisfaction to improve the quality and efficiency of health care during childbirth. Thus, this study aimed at assessing maternal satisfaction on delivery service and factors associated with it. Methods. Community based cross-sectional study was conducted in Debre Markos town from March to April 2014. Systematic random sampling technique were used to select 398 mothers who gave birth within one year. The satisfaction of mothers was measured using 19 questions which were adopted from Donabedian quality assessment framework. Binary logistic regression was fitted to identify independent predictors. Result. Among mothers, the overall satisfaction on delivery service was found to be 318 (81.7%). Having plan to deliver at health institution (AOR = 3.30, 95% CI: 1.38–7.9) and laboring time of less than six hours (AOR = 4.03, 95% CI: 1.66–9.79) were positively associated with maternal satisfaction on delivery service. Those mothers who gave birth using spontaneous vaginal delivery (AOR = 0.11, 95% CI: 0.023–0.51) were inversely related to maternal satisfaction on delivery service. Conclusion. This study revealed that the overall satisfaction of mothers on delivery service was found to be suboptimal. Reasons for delivery visit, duration of labor, and mode of delivery are independent predictors of maternal satisfaction. Thus, there is a need of an intervention on the independent predictors. Kurabachew Bitew, Mekonnen Ayichiluhm, and Kedir Yimam Copyright © 2015 Kurabachew Bitew et al. All rights reserved. The Association between Charlson Comorbidity Index and the Medical Care Cost of Cancer: A Retrospective Study Tue, 04 Aug 2015 13:46:45 +0000 Background. This study compared comorbidity-related medical care cost associated with different types of cancer, by examining breast (), colon (), stomach (), and lung () cancer patients undergoing surgery. Methods. Using medical benefits claims data, we calculated Charlson Comorbidity Index (CCI) and total medical cost. The effect of comorbidity on the medical care cost was investigated using multiple regression and logistic regression models and controlling for demographic characteristics and cancer stage. Results. The treatment costs incurred by stomach and colon cancer patients were 1.05- and 1.01-fold higher, respectively, in patients with higher CCI determined. For breast cancer, the highest costs were seen in those with chronic obstructive pulmonary disease (COPD), but the increase in cost reduced as CCI increased. Colon cancer patients with diabetes mellitus and a CCI = 1 score had the highest medical costs. The lowest medical costs were incurred by lung cancer patients with COPD and a CCI = 2 score. Conclusion. The comorbidities had a major impact on the use of medical resources, with chronic comorbidities incurring the highest medical costs. The results indicate that comorbidities affect cancer outcomes and that they must be considered strategies mitigating cancer’s economic and social impact. Seok-Jun Yoon, Eun-Jung Kim, Hyun-Ju Seo, and In-Hwan Oh Copyright © 2015 Seok-Jun Yoon et al. All rights reserved. Applications of Environmental Epidemiology in Addressing Public Health Challenges in East Asia Thu, 30 Jul 2015 07:53:14 +0000 Shih-Bin Su, Jamal H. Hashim, and Chong-huai Yan Copyright © 2015 Shih-Bin Su et al. All rights reserved. Neck Circumference as a Predictive Indicator of CKD for High Cardiovascular Risk Patients Wed, 29 Jul 2015 11:26:43 +0000 Background. Neck circumference (NC) is an anthropometric measure of obesity for upper subcutaneous adipose tissue distribution which is associated with cardiometabolic risk. This study investigated whether NC is associated with indicators of chronic kidney disease (CKD) for high cardiometabolic risk patients. Methods. A total of 177 consecutive patients who underwent the outpatient departments of cardiology were prospectively enrolled in the study. The patients were aged >20 years with normal renal function or with stages 1–4 CKD. A linear regression was performed using the Enter method to present an unadjusted , standardized coefficients, and standard error, and the Durbin-Watson test was used to assess residual independence. Results. Most anthropometric measurements from patients aged ≧65 were lower than those from patients aged <65, except for women’s waist circumference (WC) and waist hip ratio. Female NC obtained the highest values for 24 hr CCR, uric acid, microalbuminuria, hsCRP, triglycerides, and HDL compared to BMI, WC, and hip circumference. The significances of female NC with 24 hr CCR and uric acid were improved after adjusted age and serum creatinine. Conclusions. NC is associated with indicators of CKD for high cardiometabolic risk patients and can be routinely measured as easy as WC in the future. Ya-Fang Liu, Shih-Tai Chang, Wei-Shiang Lin, Jen-Te Hsu, Chang-Min Chung, Jung-Jung Chang, Kuo-Chun Hung, Kang-Hua Chen, Chi-Wen Chang, Fu-Chi Chen, Yun-Wen Shih, and Chi-Ming Chu Copyright © 2015 Ya-Fang Liu et al. All rights reserved. Spatial Variation of the Relationship between PM2.5 Concentrations and Meteorological Parameters in China Wed, 29 Jul 2015 08:16:02 +0000 Epidemiological studies around the world have reported that fine particulate matter (PM2.5) is closely associated with human health. The distribution of PM2.5 concentrations is influenced by multiple geographic and socioeconomic factors. Using a remote-sensing-derived PM2.5 dataset, this paper explores the relationship between PM2.5 concentrations and meteorological parameters and their spatial variance in China for the period 2001–2010. The spatial variations of the relationships between the annual average PM2.5, the annual average precipitation (AAP), and the annual average temperature (AAT) were evaluated using the Geographically Weighted Regression (GWR) model. The results indicated that PM2.5 had a strong and stable correlation with meteorological parameters. In particular, PM2.5 had a negative correlation with precipitation and a positive correlation with temperature. In addition, the relationship between the variables changed over space, and the strong negative correlation between PM2.5 and the AAP mainly appeared in the warm temperate semihumid region and northern subtropical humid region in 2001 and 2010, with some localized differences. The strong positive correlation between the PM2.5 and the AAT mainly occurred in the mid-temperate semiarid region, the humid, semihumid, and semiarid warm temperate regions, and the northern subtropical humid region in 2001 and 2010. Gang Lin, Jingying Fu, Dong Jiang, Jianhua Wang, Qiao Wang, and Donglin Dong Copyright © 2015 Gang Lin et al. All rights reserved. Association of Environmental Arsenic Exposure, Genetic Polymorphisms of Susceptible Genes, and Skin Cancers in Taiwan Wed, 29 Jul 2015 08:15:54 +0000 Deficiency in the capability of xenobiotic detoxification and arsenic methylation may be correlated with individual susceptibility to arsenic-related skin cancers. We hypothesized that glutathione S-transferase (GST M1, T1, and P1), reactive oxygen species (ROS) related metabolic genes (NQO1, EPHX1, and HO-1), and DNA repair genes (XRCC1, XPD, hOGG1, and ATM) together may play a role in arsenic-induced skin carcinogenesis. We conducted a case-control study consisting of 70 pathologically confirmed skin cancer patients and 210 age and gender matched participants with genotyping of 12 selected polymorphisms. The skin cancer risks were estimated by odds ratio (OR) and 95% confidence interval (CI) using logistic regression. EPHX1 Tyr113His, XPD C156A, and GSTT1 null genotypes were associated with skin cancer risk (OR = 2.99, 95% CI = 1.01–8.83; OR = 2.04, 95% CI = 0.99–4.27; OR = 1.74, 95% CI = 1.00–3.02, resp.). However, none of these polymorphisms showed significant association after considering arsenic exposure status. Individuals carrying three risk polymorphisms of EPHX1 Tyr113His, XPD C156A, and GSTs presented a 400% increased skin cancer risk when compared to those with less than or equal to one polymorphism. In conclusion, GSTs, EPHX1, and XPD are potential genetic factors for arsenic-induced skin cancers. The roles of these genes for arsenic-induced skin carcinogenesis need to be further evaluated. Ling-I Hsu, Meei-Maan Wu, Yuan-Hung Wang, Cheng-Yeh Lee, Tse-Yen Yang, Bo-Yu Hsiao, and Chien-Jen Chen Copyright © 2015 Ling-I Hsu et al. All rights reserved. A Comparison of Food Supply from 1984 to 2009 and Degree of Dietary Westernization in Taiwan with Asian Countries and World Continents Wed, 29 Jul 2015 06:37:42 +0000 Objective. To compare quality, quantity, and trends of food supply from 1984 to 2009 and degree of food westernization in Taiwan with Asian countries and world continents by using food balance data. Methods. We compiled data from food balance sheets of Taiwan and Food and Agriculture Organization, including five continents and three most populated countries each in Eastern, Southern, and Southeastern Asia over the period 1984–2009. Quantity of food supply per capita was referenced to Taiwan food guides. The population-weighted means of food supply from Europe, North America, South America, and Australia and New Zealand continents in terms of energy and nutrient distributions, animal/plant sources, and sugar/alcohol contribution were used as indicators of westernization. Trends of food supply per capita of six food groups were plotted, and linear regression was applied to evaluate food changes. Findings. Taiwan’s food supply provided sufficient quantity in food energy, with the lowest cereals/roots supply and rice to wheat ratio, but the highest meat and oil supplies per capita among the 10 studied Asian countries. Taiwan food supply showed the most westernization among these countries. Conclusion. Food supply of Taiwan, although currently sufficient, indicated some security problems and high tendency of diet westernization. Cheau-Jane Peng, Cheng-Yao Lin, and How-Ran Guo Copyright © 2015 Cheau-Jane Peng et al. All rights reserved. Increased Standardised Incidence Ratio of Malignant Pleural Mesothelioma in Taiwanese Asbestos Workers: A 29-Year Retrospective Cohort Study Tue, 28 Jul 2015 14:29:52 +0000 Objective. This paper aimed to determine the standardised incidence ratio (SIR) of malignant pleural mesothelioma (MPM) in workers exposed to asbestos in Taiwan. Methods. All workers employed in asbestos-related factories and registered by the Bureau of Labour Insurance between 1 March, 1950, and 31 December, 1989, were included in the study and were followed from 1 January, 1980, through 31 December, 2009. Incident cases of all cancers, including MPM (ICD-9 code: 163), were obtained from the Taiwan Cancer Registry. SIRs were calculated based on comparison with the incidence rate of the general population of Taiwan and adjusted for age, calendar period, sex, and duration of employment. Results. The highest SIR of MPM was found for male workers first employed before 1979, with a time since first employment more than 30 years (SIR 4.52, 95% CI: 2.25–8.09). After consideration of duration of employment, the SIR for male MPM was 5.78 (95% CI: 1.19–16.89) for the workers employed for more than 20 years in asbestos-related factories. Conclusions. This study corroborates the association between occupational asbestos exposure and MPM. The highest risk of MPM was found among male asbestos workers employed before 1979 and working for more than 20 years in asbestos-related factories. Cheng-Kuan Lin, Yu-Ying Chang, Jung-Der Wang, and Lukas Jyuhn-Hsiarn Lee Copyright © 2015 Cheng-Kuan Lin et al. All rights reserved. Effect of Meteorological and Geographical Factors on the Epidemics of Hand, Foot, and Mouth Disease in Island-Type Territory, East Asia Tue, 28 Jul 2015 14:15:45 +0000 Hand, foot, and mouth disease (HFMD) has threatened East Asia for more than three decades and has become an important public health issue owing to its severe sequelae and mortality among children. The lack of effective treatment and vaccine for HFMD highlights the urgent need for efficiently integrated early warning surveillance systems in the region. In this study, we try to integrate the available surveillance and weather data in East Asia to elucidate possible spatiotemporal correlations and weather conditions among different areas from low to high latitude. The general additive model (GAM) was applied to understand the association between HFMD and latitude, as well as meteorological factors for islands in East Asia, namely, Japan, Taiwan, Hong Kong, and Singapore, from 2012 to 2014. The results revealed that latitude was the most important explanatory factor associated with the timing and amplitude of HFMD epidemics (). Meteorological factors including higher dew point, lower visibility, and lower wind speed were significantly associated with the rise of epidemics (). In summary, weather conditions and geographic location could play some role in affecting HFMD epidemics. Regional integrated surveillance of HFMD in East Asia is needed for mitigating the disease risk. Chang-Chun David Lee, Jia-Hong Tang, Jing-Shiang Hwang, Mika Shigematsu, and Ta-Chien Chan Copyright © 2015 Chang-Chun David Lee et al. All rights reserved. Lower Urinary Tract Symptoms Are Associated with Increased Risk of Dementia among the Elderly: A Nationwide Study Tue, 28 Jul 2015 14:06:40 +0000 Studies show a strong association between dementia and lower urinary tract symptoms (LUTS). The aim of this study was to investigate whether LUTS are a risk factor for cognitive impairment. We enrolled 50-year-old and older subjects with LUTS (LUTS[+]) () and controls without LUTS (LUTS[−]) () from Taiwan’s National Health Insurance Research Database. LUTS, dementia, and other confounding factors are defined by International Classification of Diseases, Ninth Revision, Clinical Modification Codes. Participants were recruited from 2000 to 2004 and then followed up until death or the end of 2011. The outcome was the onset of dementia, which was assessed using Poisson regression analysis, Cox hazards models, and Kaplan-Meier survival curves. The incidence of dementia was significantly higher in the LUTS[+] group than in the LUTS[−] group (124.76 versus 77.59/1000 person-years). The increased risk of dementia related to LUTS remained significant after adjustment for potential confounders (adjusted hazard ratio (AHR): 1.61, 95% confidence interval (CI) 1.47–1.76, ) and higher than that related to cerebrovascular disease (AHR: 1.43, 95% CI 1.26–1.61, ). The outcome suggests the need for early screening and appropriate intervention to help prevent cognitive impairment of patients with LUTS. Chi-Hsiang Chiang, Ming-Ping Wu, Chung-Han Ho, Shih-Feng Weng, Chien-Cheng Huang, Wan-Ting Hsieh, Ya-Wen Hsu, and Ping-Jen Chen Copyright © 2015 Chi-Hsiang Chiang et al. All rights reserved. Modification of S. cerevisiae Growth Dynamics Using Low Frequency Electromagnetic Fields in the 1-2 kHz Range Tue, 28 Jul 2015 08:29:00 +0000 This paper details our further experiments pertaining to the influence of low frequency electromagnetic fields (LF EMF) on the growth dynamics of two wild-type Saccharomyces cerevisiae strands. We opted to explore frequencies beyond the usual 50–60 Hz range, motivated by the ion parametric resonance theory and several studies which discovered and recorded endogenous biosignals in various Saccharomyces cerevisiae strands in the 0.4–2.0 kHz frequency range, most probably stemming from microtubules. Both yeast strands used in our experiments have been subjected to continuous 66-hour session of LF EMF exposure (frequencies 1.2, 1.4, 1.6, 1.8, and 2.0 kHz; average magnetic flux density 2.43 mT) under identical ambient conditions. Experiment results indicate a frequency-dependent proliferative response of both yeast strands. Ján Barabáš, Roman Radil, and Ivona Malíková Copyright © 2015 Ján Barabáš et al. All rights reserved. Tobacco and Health Disparities Mon, 27 Jul 2015 13:59:29 +0000 Kamran Siddiqi, Mohammed Jawad, Nasir Mushtaq, Shehzad Ali, and Javaid Ahmed Khan Copyright © 2015 Kamran Siddiqi et al. All rights reserved. Tobacco Usage in Uttarakhand: A Dangerous Combination of High Prevalence, Widespread Ignorance, and Resistance to Quitting Mon, 27 Jul 2015 12:01:09 +0000 Background. Nearly one-third of adults in India use tobacco, resulting in 1.2 million deaths. However, little is known about knowledge, attitudes, and practices (KAP) related to smoking in the impoverished state of Uttarakhand. Methods. A cross-sectional epidemiological prevalence survey was undertaken. Multistage cluster sampling selected 20 villages and 50 households to survey from which 1853 people were interviewed. Tobacco prevalence and KAP were analyzed by income level, occupation, age, and sex. 95% confidence intervals were calculated using standard formulas and incorporating assumptions in relation to the clustering effect. Results. The overall prevalence of tobacco usage, defined using WHO criteria, was 38.9%. 93% of smokers and 86% of tobacco chewers were male. Prevalence of tobacco use, controlling for other factors, was associated with lower education, older age, and male sex. 97.6% of users and 98.1% of nonusers wanted less tobacco. Except for lung cancer (89% awareness), awareness of diseases caused by tobacco usage was low (cardiac: 67%; infertility: 32.5%; stroke: 40.5%). Conclusion. A dangerous combination of high tobacco usage prevalence, ignorance about its dangers, and few quit attempts being made suggests the need to develop effective and evidence based interventions to prevent a health and development disaster in Uttarakhand. Nathan John Grills, Rajesh Singh, Rajkumari Singh, and Bradley C. Martin Copyright © 2015 Nathan John Grills et al. All rights reserved. Quitline Use and Outcomes among Callers with and without Mental Health Conditions: A 7-Month Follow-Up Evaluation in Three States Sun, 26 Jul 2015 10:01:27 +0000 Objectives. To examine abstinence outcomes among tobacco users with and without a reported mental health condition (MHC) who enrolled in state tobacco quitline programs. Methods. Data were analyzed from a 7-month follow-up survey (response rate: 41% [3,132/7,459]) of three state-funded telephone quitline programs in the United States that assessed seven self-reported MHCs at quitline registration. We examined 30-day point prevalence tobacco quit rates for callers with any MHC versus none. Data were weighted to adjust for response bias and oversampling. Multivariable logistic regression was used to examine cessation outcomes. Results. Overall, 45.8% of respondents reported ≥1 MHC; 57.4% of those reporting a MHC reported ≥2 MHCs. The unadjusted quit rate for callers with any MHC was lower than for callers with no MHC (22.0% versus 31.0%, ). After adjusting for demographics, nicotine dependence, and program engagement, callers reporting ≥1 MHC were less likely to be abstinent at follow-up (adjusted OR = 0.63, 95% CI = 0.51–0.78, ). Conclusions. More intensive or tailored quitline programs may need to be developed among callers with MHCs as their quit rates appear to be lower than callers without MHCs. Katrina A. Vickerman, Gillian L. Schauer, Ann M. Malarcher, Lei Zhang, Paul Mowery, and Chelsea M. Nash Copyright © 2015 Katrina A. Vickerman et al. All rights reserved. The Epidemiology of Tobacco Use among Khat Users: A Systematic Review Sun, 26 Jul 2015 09:34:52 +0000 Khat, an “amphetamine-like green leaf,” may influence the consumption of tobacco. This study reviews the epidemiology of tobacco use among khat users. Electronic database searches using appropriate keywords/terms were conducted to identify observational studies of khat use. Assessment of quality and risk of bias of all included studies was conducted, and the results were synthesised descriptively. Nine eligible cross-sectional studies were identified. All assessed self-reported tobacco among khat users and were carried out in Africa and the Middle East. Eight reported cigarettes and one reported waterpipes as the mode of use. Methods of tobacco use prevalence assessment varied. Prevalence of “current” tobacco use among students and university teachers ranged from 29 to 37%; “lifetime” tobacco use in university teachers was 58% and “undefined” tobacco use in nonspecific adults and students ranged from 17 to 78%. Daily tobacco use among adults was reported as 17% whilst simultaneous tobacco and khat use was reported as between 14 and 30% in students. In conclusion, tobacco prevalence among khat users appears significant. Findings should be interpreted cautiously due to self-reported tobacco use, diversity in questions assessing tobacco use, and type of tobacco consumption. Future research should address the methodological shortcomings identified in this review before appropriate policy interventions can be developed. Saba Kassim, Mohammed Jawad, Ray Croucher, and Elie A. Akl Copyright © 2015 Saba Kassim et al. All rights reserved. Weaker Self-Esteem in Adolescence Predicts Smoking Sun, 26 Jul 2015 08:33:44 +0000 Background. To study whether weaker self-esteem in adolescence is connected with smoking behavior in adulthood. Methods. An age cohort born in 1979 responded to the Lawrence Self-Esteem Questionnaire (LAWSEQ) at the age of 16 . Respondents’ smoking behavior was monitored annually during adolescence and 75.3% of them remained nonsmokers during adolescence. A follow-up questionnaire eliciting smoking behavior was sent to the adolescent nonsmokers at the age of 29 years. Response rate at follow-up was 46.2% . Results. Weaker self-esteem (LAWSEQ score ≥ 3) during the adolescence was not significantly associated with smoking in adulthood. However, those respondents who had weaker self-esteem in adolescence had increased risk of having been smoking regularly (adjusted OR 1.8, 95% CI 1.1–3.0) although not all of them were smokers at the time of the follow-up. Conclusions. Those with weaker self-esteem in adolescence are more likely to smoke regularly in adulthood. Antti J. Saari, Jukka Kentala, and Kari J. Mattila Copyright © 2015 Antti J. Saari et al. All rights reserved. Social Media Use for Public Health Campaigning in a Low Resource Setting: The Case of Waterpipe Tobacco Smoking Sun, 26 Jul 2015 08:27:42 +0000 Introduction. Waterpipe tobacco smoking prevalence is increasing worldwide despite its documented health effects. A general belief that it is less harmful than cigarettes may be fuelled by the lack of media campaigns highlighting its health effects. We aimed to create and assess the impact of a social media campaign about dangers of waterpipe smoking. Methods. The “ShishAware” campaign included three social media (Facebook, Twitter, and YouTube) and a website. Nine months after launch we collected data to assess use of, and reaction to, our media accounts. Results. Requiring limited maintenance resources, Facebook attracted campaign supporters but YouTube attracted opposers. Twitter enabled the most organisation-based contact but Facebook was the most interactive medium. Facebook users were more likely to “like” weekday than weekend statuses and more likely to comment on “shisha fact” than “current affairs” statuses. Follower subscription increased as our posting rate increased. Our YouTube video gained 19,428 views (from all world continents) and 218 comments (86% from pro-waterpipe smokers). Conclusions. Social media campaigns can be created and maintained relatively easily. They are innovative and have the potential for wide and rapid diffusion, especially towards target audiences. There is a need for more rigorous evaluation of their effects, particularly among the youth. Mohammed Jawad, Jooman Abass, Ahmad Hariri, and Elie A. Akl Copyright © 2015 Mohammed Jawad et al. All rights reserved. Social Inequality in Cigarette Consumption, Cigarette Dependence, and Intention to Quit among Norwegian Smokers Sun, 26 Jul 2015 08:20:05 +0000 Background. The study aim was to examine the influence of education and income on multiple measures of risk of smoking continuation. Methods. Three logistic regression models were run on cigarette consumption, dependence, and intention to quit based on nationally representative samples (2007–2012) of approximately 1 200 current smokers aged 30–66 years in Norway. Results. The relative risk ratio for current versus never smokers was RRR 5.37, 95% CI [4.26–6.77] among individuals with low educational level versus high and RRR 1.53, 95% CI [1.14–2.06] in the low-income group versus high (adjusted model). Low educational level was associated with high cigarette consumption, high cigarette dependence, and no intention to quit. The difference in predicted probability for having high cigarette consumption, high cigarette dependence, and no intention to quit were in the range of 10–20 percentage points between smokers with low versus those with high educational level. A significant difference between low- and high-income levels was observed for intention to quit. The effect of education on high consumption and dependence was mainly found in smokers with high income. Conclusion. Increased effort to combat social differences in smoking behaviour is needed. Implementation of smoking cessation programmes with high reach among low socioeconomic groups is recommended. Marianne Lund Copyright © 2015 Marianne Lund. All rights reserved. Impact of Waterpipe Tobacco Pack Health Warnings on Waterpipe Smoking Attitudes: A Qualitative Analysis among Regular Users in London Sun, 26 Jul 2015 08:03:29 +0000 Background. Despite the rise in prevalence of waterpipe tobacco smoking, it has received little legislative enforcement from governing bodies, especially in the area of health warning labels. Methods. Twenty regular waterpipe tobacco smokers from London took part in five focus groups discussing the impact of waterpipe tobacco pack health warnings on their attitudes towards waterpipe smoking. We presented them with existing and mock waterpipe tobacco products, designed to be compliant with current and future UK/EU legislation. Data were analysed using thematic analysis. Results. Participants felt packs were less attractive and health warnings were more impactful as health warnings increased in size and packaging became less branded. However, participants highlighted their lack of exposure to waterpipe tobacco pack health warnings due to the inherent nature of waterpipe smoking, that is, smoking in a café with the apparatus already prepacked by staff. Health warnings at the point of consumption had more reported impact than health warnings at the point of sale. Conclusions. Waterpipe tobacco pack health warnings are likely to be effective if compliant with existing laws and exposed to end-users. Legislations should be reviewed to extend health warning labels to waterpipe accessories, particularly the apparatus, and to waterpipe-serving premises. Mohammed Jawad, Ali Bakir, Mohammed Ali, and Aimee Grant Copyright © 2015 Mohammed Jawad et al. All rights reserved. Socioeconomic Gradients in Different Types of Tobacco Use in India: Evidence from Global Adult Tobacco Survey 2009-10 Sun, 26 Jul 2015 07:49:30 +0000 Socioeconomic differences in tobacco use have been reported, but there is a lack of evidence on how they vary according to types of tobacco use. This study explored socioeconomic differences associated with cigarette, bidi, smokeless tobacco (SLT), and dual use (smoking and smokeless tobacco use) in India and tested whether these differences vary by gender and residential area. Secondary analysis of Global Adult Tobacco Survey (GATS) 2009-10 () was conducted. The primary outcomes were self-reported cigarette, bidi smoking, SLT, and dual use. The main explanatory variables were wealth, education, and occupation. Associations were assessed using multinomial logistic regressions. 69,030 adults participated in the study. Positive association was observed between wealth and prevalence of cigarette smoking while inverse associations were observed for bidi smoking, SLT, and dual use after adjustment for potential confounders. Inverse associations with education were observed for all four types after adjusting for confounders. Significant interactions were observed for gender and area in the association between cigarette, bidi, and smokeless tobacco use with wealth and education. The probability of cigarette smoking was higher for wealthier individuals while the probability of bidi smoking, smokeless tobacco use, and dual use was higher for those with lesser wealth and education. Ankur Singh, Monika Arora, Dallas R. English, and Manu R. Mathur Copyright © 2015 Ankur Singh et al. All rights reserved. Smoking Cessation and Socioeconomic Status: An Update of Existing Evidence from a National Evaluation of English Stop Smoking Services Sun, 26 Jul 2015 07:47:57 +0000 Smokers from lower socioeconomic groups are less likely to be successful in stopping smoking than more affluent smokers, even after accessing cessation programmes. Data were analysed from 3057 clients of nine services. Routine monitoring data were expanded with CO validated smoking status at 52-week follow-up. Backwards logistic regression modelling was used to consider which factors were most important in explaining the relationship between SES and quitting. The odds ratio of stopping smoking among more affluent clients, compared with more disadvantaged clients, after taking into account design variables only, was 1.85 (95% CI 1.44 to 2.37) which declined to 1.44 (1.11 to 1.87) when all controls were included. The factors that explained more than 10% of the decline in the odds ratio were age, proportion of friends and family who smoked, nicotine dependence, and taking varenicline. A range of factors contribute to lower cessation rates for disadvantaged smokers. Some of these can be modified by improved smoking cessation service provision, but others require contributions from wider efforts to improve material, human, and social capital. Rosemary Hiscock, Fiona Dobbie, and Linda Bauld Copyright © 2015 Rosemary Hiscock et al. All rights reserved. Second-Hand Smoking among Intermediate and Secondary School Students in Madinah, Saudi Arabia Sun, 26 Jul 2015 07:38:39 +0000 Background and objectives. Second-hand smoke (SHS) is an important public health problem worldwide. The study aimed to estimate the prevalence of SHS exposure and its associated risk factors among intermediate and secondary school students. Methods. A cross-sectional study was conducted in 2013 among 3400 students from 34 intermediate and secondary schools in Madinah City, Saudi Arabia. Data about sociodemographic and smoking-related factors and SHS exposure were collected using a self-administered questionnaire. Results. Of the 3210 students analyzed, the prevalence of SHS exposure was 32.7% 49.3%, and 25% inside, outside, and both inside and outside the home, respectively. The highest risk of SHS exposure was associated with the adolescent’s smoking status, parental smoking, close friends smoking, and family structure. The risk was markedly increased in association with parental smoking for exposure inside the home (OR = 6.49; 95% CI = 5.44–7.73) and with close friends smoking for exposure outside the home (OR = 4.16; 95% CI = 3.54–4.77). The risk of SHS, however, was lower among adolescents having knowledge about smoking and highly educated parents. Conclusion. The study revealed a considerably high prevalence of SHS both inside and outside the home among adolescents. Knowledge and beliefs about SHS exposure are the main preventable approach. Abdulmohsen H. Al-Zalabani, Soliman M. Amer, Khaled A. Kasim, Reem I. Alqabshawi, and Ayat R. Abdallah Copyright © 2015 Abdulmohsen H. Al-Zalabani et al. All rights reserved. The Adoption of Smoking and Its Effect on the Mortality Gender Gap in Netherlands: A Historical Perspective Sun, 26 Jul 2015 07:32:44 +0000 We examine in depth the effect of differences in the smoking adoption patterns of men and women on the mortality gender gap in Netherlands, employing a historical perspective. Using an indirect estimation technique based on observed lung cancer mortality from 1931 to 2012, we estimated lifetime smoking prevalence and smoking-attributable mortality. We decomposed the sex difference in life expectancy at birth into smoking-related and nonsmoking-related overall and cause-specific mortality. The smoking epidemic in Netherlands, which started among men born around 1850 and among women from birth cohort 1900 onwards, contributed substantially to the increasing sex difference in life expectancy at birth from 1931 (1.3 years) to 1982 (6.7 years), the subsequent decline to 3.7 years in 2012, and the high excess mortality among Dutch men born between 1895 and 1910. Smoking-related cancer mortality contributed most to the increase in the sex difference, whereas smoking-related cardiovascular disease mortality was mainly responsible for the decline from 1983 onwards. Examining nonsmoking-related (cause-specific) mortality shed new light on the mortality gender gap and revealed the important role of smoking-related cancers, the continuation of excess mortality among women aged 40–50, and a smaller role of biological factors in the sex difference than was previously estimated. Fanny Janssen and Frans van Poppel Copyright © 2015 Fanny Janssen and Frans van Poppel. All rights reserved. Characterization and Evaluation of a Commercial WLAN System for Human Provocation Studies Tue, 09 Jun 2015 16:23:36 +0000 This work evaluates the complex exposure characteristics of Wireless Local Area Network (WLAN) technology and describes the design of a WLAN exposure system built using commercially available modular parts for the study of possible biological health effects due to WLAN exposure in a controlled environment. The system consisted of an access point and a client unit (CU) with router board cards types R52 and R52n with 18 dBm and 25 dBm peak power, respectively. Free space radiofrequency field (RF) measurements were performed with a field meter at a distance of 40 cm from the CU in order to evaluate the RF exposure at several signal configurations of the exposure system. Finally, the specific absorption rate (SAR) generated by the CU was estimated computationally in the head of two human models. Results suggest that exposure to RF fields of WLAN systems strongly depends on the sets of the router configuration: the stability of the exposure was more constant and reliable when both antennas were active and vertically positioned, with best signal quality obtained with the R52n router board at channel 9, in UDP mode. The maximum levels of peak SAR were far away from the limits of international guidelines with peak levels found over the skin. Norbert Zentai, Serena Fiocchi, Marta Parazzini, Attila Trunk, Péter Juhász, Paolo Ravazzani, István Hernádi, and György Thuróczy Copyright © 2015 Norbert Zentai et al. All rights reserved. Cortisol Response to Psychosocial Stress in Chinese Early Puberty Girls: Possible Role of Depressive Symptoms Thu, 04 Jun 2015 11:24:07 +0000 Objective. The present study aimed at investigating unique patterns of salivary cortisol reactivity and recovery in response to a social stressor among girls with early puberty and exploring possible role of depressive symptom in this association. Design. Case-control study. Patients. Fifty-six girls with early puberty and age- and body mass index- (BMI-) matched normal puberty controls were selected. Measurements. Salivary cortisol was measured in response to the Groningen Social Stress Test for Children. Results. Girls with early puberty had higher cortisol concentration at the end of the GSST (C3), cortisol concentration 20 min after the end of the GSST (C4), and AUC increment (AUCi) compared to non-early puberty girls. Depressive symptoms correlated with blunted HPA reactivity among girls with early puberty. Conclusion. This study demonstrated the disturbance effect of objectively examined early pubertal timing on HPA axis responses. It also suggested that stress reactivity might be blunted for individuals with depressive symptoms. Ying Sun, Fang Deng, Yang Liu, and Fang-Biao Tao Copyright © 2015 Ying Sun et al. All rights reserved. Male Partners’ Involvement in the Prevention of Mother-to-Child Transmission of HIV and Associated Factors in Arba Minch Town and Arba Minch Zuria Woreda, Southern Ethiopia Wed, 03 Jun 2015 06:50:55 +0000 Background. Male involvement is an important determinant of prevention of mother-to-child transmission of HIV. However, male involvement in prevention of mother-to-child transmission of HIV in Ethiopia is not well known. Objectives. To assess male partners involvement in prevention of mother-to-child transmission of HIV and associated factors in Arba Minch town and Arba Minch Zuria woreda. Methods. Community based study was conducted in Arba Minch town and Arba Minch Zuria district. Multistage sampling technique was used and data were collected using interviewer administered standard questionnaire. Multiple logistic regression analysis was used to determine the presence of statistically significant associations between the outcome variable and the independent variables. Results. The level of male involvement in PMTCT program in Arba Minch town and Zuria district was 53%. Several factors appear to contribute to male involvement in the PMTCT program including age, residence, education level, knowledge on HIV, knowledge on PMTCT, accessibility of health facility, having weak perception for male involvement in PMTCT, having perception of ANC attendance being females’ responsibility, ever use of khat, and ever use of cigarette. Conclusion. Geographical accessibility of health facility and male’s knowledge on PMTCT should be improved to increase their involvement in PMTCT. Marelign Tilahun and Shikur Mohamed Copyright © 2015 Marelign Tilahun and Shikur Mohamed. All rights reserved. Over-the-Counter Drugs and Complementary Medications Use among Children in Southern Italy Thu, 28 May 2015 07:03:50 +0000 The use of nonprescription medicines (NPDs) for children illnesses without a doctor’s suggestion can lead to unnecessary medication use and is not free of risks. The aim of our study was to examine attitudes and practice of parents towards NPDs use for their children. We also investigated the conditions that may predict NPDs use. A cross-sectional survey was conducted on parents of children attending Community Based Pediatrician (CBP) consultation and data were collected through structured interviews. Positive attitude on NPDs use was reported by 71.4% of parents, and 61.5% of them had administered NPDs in the previous 6 months. Antipyretic drugs were the most frequently used medication class without the supervision of the CBP. A positive attitude towards NPDs was significantly more frequent in parents who did not use the CBP as the sole source of information about drugs. The study demonstrated a widespread use of NPDs in children in our context, supported by a substantial positive attitude towards their safety. However, considering potential harms related to some NPDs and the finding that most parents rely on CBP advice, role of CBP on appropriate use of NPDs by parents should be emphasized. Claudia Pileggi, Valentina Mascaro, Aida Bianco, and Maria Pavia Copyright © 2015 Claudia Pileggi et al. All rights reserved. Effects of Music Aerobic Exercise on Depression and Brain-Derived Neurotrophic Factor Levels in Community Dwelling Women Thu, 14 May 2015 13:18:52 +0000 A randomized clinical trial was utilized to compare the improvement of depression and brain-derived neurotrophic factor (BDNF) levels between community women with and without music aerobic exercise (MAE) for 12 weeks. The MAE group involved 47 eligible participants, whereas the comparison group had 59 participants. No significant differences were recorded in the demographic characteristics between the participants in the MAE group and the comparison group. Forty-one participants in the MAE group and 26 in the comparison group completed a pre- and posttest. The MAE group displayed significant improvement in depression scores (p = 0.016), decreased depression symptoms in crying (p = 0.03), appetite (p = 0.006), and fatigue (p = 0.011). The BDNF levels of the participants significantly increased after the 12-week MAE (p = 0.042). The parallel comparison group revealed no significant changes in depression scores or BDNF levels. In summary, the 12-week MAE had a significant impact on the enhancement of BDNF levels and improvement of depression symptoms. Middle-aged community women are encouraged to exercise moderately to improve their depression symptoms and BDNF levels. Shu-Hui Yeh, Li-Wei Lin, Yu Kuan Chuang, Cheng-Ling Liu, Lu-Jen Tsai, Feng-Shiou Tsuei, Ming-Tsung Lee, Chiu-Yueh Hsiao, and Kuender D. Yang Copyright © 2015 Shu-Hui Yeh et al. All rights reserved. The Effects of Educational Campaigns and Smoking Bans in Public Places on Smokers’ Intention to Quit Smoking: Findings from 17 Cities in China Mon, 04 May 2015 07:01:22 +0000 Despite the perceived success of educational campaigns and smoking bans in public places in China, the actual effects have not been investigated. This study examines the effects of the two policies by major characteristics of smokers and whether the affected smokers have intention to quit smoking. A cross-sectional survey was conducted in 17 cities in China and 16,616 participants were selected using multistage stratified sampling. Logistic regression models were used to examine the effects of educational campaigns and smoking bans in public places on their intention to quit smoking. Results show that the Chinese government should try every means to build its tobacco control publicity and implement various forms of public educational campaigns to enhance smokers’ knowledge of the health consequences of smoking. In addition, China should emphasize the enforcement of the existing smoking prohibitions and regulations by implementing local tobacco control legislation and total prohibitions in all public places and workplaces. Biao Luo, Liang Wan, Liang Liang, and Tieshan Li Copyright © 2015 Biao Luo et al. All rights reserved. Prevalence of Active Trachoma and Its Associated Factors among Rural and Urban Children in Dera Woreda, Northwest Ethiopia: A Comparative Cross-Sectional Study Wed, 25 Mar 2015 13:03:47 +0000 Background. Trachoma is the most common infectious cause of blindness worldwide. Once an epidemic in most parts of the world, it has largely now disappeared from developed countries. However, it continues to be endemic in many developing countries like Ethiopia. Even if several studies were conducted in different parts of Ethiopia, most of them did not show the independent predictors for rural and urban children separately. Therefore, this study aimed at assessing the prevalence and associated factors of active trachoma in urban and rural children. Methods. Community based comparative cross-sectional study was conducted in Dera woreda. Multistage sampling technique was used to select 671 children of one up to nine years of age. Data were collected by face to face interview and observation using a structured and pretested questionnaire. Binary Logistic Regression Model was fitted to consider adding independent predictors of outcome. Results. Out of 671 children, 20 (9.3%) of urban and 85 (18.6%) of rural children were positive for active trachoma. Having discharge on eye (AOR = 6.9, 95% CI: 1.79–27.89), presence of liquid waste around the main house (AOR = 5.6, 95% CI: 1.94–16.18), and living in households without latrine (AOR = 4.39, 95% CI: 1.39–13.89) were significantly associated with active trachoma of urban children. Rural children who had discharge on their eye (AOR = 5.86, 95% CI: 2.78–12.33), those who had unclean face (AOR = 4.68, 95% CI: 2.24–9.81), and those living in households with feces around their main houses (AOR = 1.94, 95% CI: 1.04–3.62) were significantly associated with active trachoma. Conclusion. The result showed that the prevalence of active trachoma in urban areas of the district was below WHO threshold of 10% to determine trachoma as public health problem. However, in rural areas of the district it is far from elimination of trachoma as a public health problem. Thus, in order to improve awareness of the community there is a need of health education programs regarding facial cleanliness, utilization of latrine, and proper solid waste and liquid waste disposal using multidisciplinary approach. Metadel Alemayehu, Digsu N. Koye, Amare Tariku, and Kedir Yimam Copyright © 2015 Metadel Alemayehu et al. All rights reserved. The Role of the Location of Personal Exposimeters on the Human Body in Their Use for Assessing Exposure to the Electromagnetic Field in the Radiofrequency Range 98–2450 MHz and Compliance Analysis: Evaluation by Virtual Measurements Tue, 24 Mar 2015 13:10:28 +0000 The use of radiofrequency (98–2450 MHz range) personal exposimeters to measure the electric field (-field) in far-field exposure conditions was modelled numerically using human body model Gustav and finite integration technique software. Calculations with 256 models of exposure scenarios show that the human body has a significant influence on the results of measurements using a single body-worn exposimeter in various locations near the body ((from −96 to +133)%, measurement errors with respect to the unperturbed -field value). When an exposure assessment involves the exposure limitations provided for the strength of an unperturbed -field. To improve the application of exposimeters in compliance tests, such discrepancies in the results of measurements by a body-worn exposimeter may be compensated by using of a correction factor applied to the measurement results or alternatively to the exposure limit values. The location of a single exposimeter on the waist to the back side of the human body or on the front of the chest reduces the range of exposure assessments uncertainty (covering various exposure conditions). However, still the uncertainty of exposure assessments using a single exposimeter remains significantly higher than the assessment of the unperturbed -field using spot measurements. Krzysztof Gryz, Patryk Zradziński, and Jolanta Karpowicz Copyright © 2015 Krzysztof Gryz et al. All rights reserved. Primary Care Quality among Different Health Care Structures in Tibet, China Sun, 15 Mar 2015 13:43:47 +0000 Objective. To compare the primary care quality among different health care structures in Tibet, China. Methods. A self-administered questionnaire survey including Primary Care Assessment Tool-Tibetan version was used to obtain data from a total of 1386 patients aged over 18 years in the sampling sites in two prefectures in Tibet. Multivariate analysis was performed to assess the association between health care structures and primary care quality while controlling for sociodemographic and health care characteristics. Results. The services provided by township health centers were more often used by a poor, less educated, and healthy population. Compared with prefecture (77.42) and county hospitals (82.01), township health centers achieved highest total score of primary care quality (86.64). Factors that were positively and significantly associated with higher total assessment scores included not receiving inpatient service in the past year, less frequent health care visits, good self-rated health status, lower education level, and marital status. Conclusions. This study showed that township health centers patients reported better primary care quality than patients visiting prefecture and county hospitals. Government health reforms should pay more attention to THC capacity building in Tibet, especially in the area of human resource development. Wenhua Wang, Leiyu Shi, Aitian Yin, Zongfu Mao, Elizabeth Maitland, Stephen Nicholas, and Xiaoyun Liu Copyright © 2015 Wenhua Wang et al. All rights reserved. Prediction of Cardiovascular Disease Risk among Low-Income Urban Dwellers in Metropolitan Kuala Lumpur, Malaysia Mon, 02 Mar 2015 07:34:38 +0000 We aimed to predict the ten-year cardiovascular disease (CVD) risk among low-income urban dwellers of metropolitan Malaysia. Participants were selected from a cross-sectional survey conducted in Kuala Lumpur. To assess the 10-year CVD risk, we employed the Framingham risk scoring (FRS) models. Significant determinants of the ten-year CVD risk were identified using General Linear Model (GLM). Altogether 882 adults (≥30 years old with no CVD history) were randomly selected. The classic FRS model (figures in parentheses are from the modified model) revealed that 20.5% (21.8%) and 38.46% (38.9%) of respondents were at high and moderate risk of CVD. The GLM models identified the importance of education, occupation, and marital status in predicting the future CVD risk. Our study indicated that one out of five low-income urban dwellers has high chance of having CVD within ten years. Health care expenditure, other illness related costs and loss of productivity due to CVD would worsen the current situation of low-income urban population. As such, the public health professionals and policy makers should establish substantial effort to formulate the public health policy and community-based intervention to minimize the upcoming possible high mortality and morbidity due to CVD among the low-income urban dwellers. Tin Tin Su, Mohammadreza Amiri, Farizah Mohd Hairi, Nithiah Thangiah, Awang Bulgiba, and Hazreen Abdul Majid Copyright © 2015 Tin Tin Su et al. All rights reserved. Black Stain and Dental Caries: A Review of the Literature Tue, 24 Feb 2015 12:31:47 +0000 Black stain is characterized as a dark line or an incomplete coalescence of dark dots localized on the cervical third of the tooth. Over the last century, the etiology of black stain has been the subject of much debate. Most of the studies concerning this issue were conducted in pediatric population. According to the reviewed articles published between 2001 and 2014, the prevalence of black stain varies from 2.4% to 18% with equal sex distribution. The majority of the authors confirm the correlation between the presence of black stain and lower caries experience. The microflora of this deposit is dominated by Actinomyces spp. and has lower cariogenic potential than nondiscolored dental plaque. Iron/copper and sulfur complexes are thought to be responsible for the dark color. In patients with black stain saliva has higher calcium concentrations and higher buffering capacity. Factors such as dietary habits, socioeconomic status, and iron supplementation may be contributing to the formation of black stain. Tomasz Żyła, Beata Kawala, Joanna Antoszewska-Smith, and Maciej Kawala Copyright © 2015 Tomasz Żyła et al. All rights reserved. Scenarios Approach to the Electromagnetic Exposure: The Case Study of a Train Compartment Mon, 23 Feb 2015 07:45:39 +0000 Previous studies identified the train compartment as the place where people can experience the highest exposure levels (still below the international guideline limits) to electromagnetic fields in the radiofrequency range. Here a possible scenario of a train compartment has been reproduced and characterized, both numerically and experimentally. A good agreement between the simulated electric field distributions and measurements has been found. Results indicate that the higher values of exposure in specific positions inside the train compartment depend on the number of active cell phones, the bad coverage condition, the cell orientation, and the presence of metallic walls. This study shows that the proposed approach, based on the scenarios characterization, may efficiently support the assessment of the individual electromagnetic exposure. A. Paffi, F. Apollonio, R. Pinto, and M. Liberti Copyright © 2015 A. Paffi et al. All rights reserved. Joint Minimization of Uplink and Downlink Whole-Body Exposure Dose in Indoor Wireless Networks Sun, 22 Feb 2015 15:59:23 +0000 The total whole-body exposure dose in indoor wireless networks is minimized. For the first time, indoor wireless networks are designed and simulated for a minimal exposure dose, where both uplink and downlink are considered. The impact of the minimization is numerically assessed for four scenarios: two WiFi configurations with different throughputs, a Universal Mobile Telecommunications System (UMTS) configuration for phone call traffic, and a Long-Term Evolution (LTE) configuration with a high data rate. Also, the influence of the uplink usage on the total absorbed dose is characterized. Downlink dose reductions of at least 75% are observed when adding more base stations with a lower transmit power. Total dose reductions decrease with increasing uplink usage for WiFi due to the lack of uplink power control but are maintained for LTE and UMTS. Uplink doses become dominant over downlink doses for usages of only a few seconds for WiFi. For UMTS and LTE, an almost continuous uplink usage is required to have a significant effect on the total dose, thanks to the power control mechanism. D. Plets, W. Joseph, K. Vanhecke, G. Vermeeren, J. Wiart, S. Aerts, N. Varsier, and L. Martens Copyright © 2015 D. Plets et al. All rights reserved. Quadruple Burden of HIV/AIDS, Tuberculosis, Chronic Intestinal Parasitoses, and Multiple Micronutrient Deficiency in Ethiopia: A Summary of Available Findings Thu, 12 Feb 2015 06:25:36 +0000 Human immunodeficiency virus (HIV), tuberculosis (TB), and helminthic infections are among the commonest public health problems in the sub-Saharan African countries like Ethiopia. Multiple micronutrient deficiencies also known as the “hidden hunger” are common in people living in these countries either playing a role in their pathogenesis or as consequences. This results in a vicious cycle of multiple micronutrient deficiencies and infection/disease progression. As infection is profoundly associated with nutritional status resulting from decreased nutrient intake, decreased nutrient absorption, and nutrient losses, micronutrient deficiencies affect immune system and impact infection and diseases progression. As a result, micronutrients, immunity, and infection are interrelated. The goal of this review is therefore to provide a summary of available findings regarding the “quadruple burden trouble” of HIV, TB, intestinal parasitic infections, and multiple micronutrient deficiencies to describe immune-modulating effects related to disorders. Bemnet Amare, Beyene Moges, Andargachew Mulu, Sisay Yifru, and Afework Kassu Copyright © 2015 Bemnet Amare et al. All rights reserved. Risk Factors for Reduced Salivary Flow Rate in a Japanese Population: The Hisayama Study Tue, 03 Feb 2015 14:31:28 +0000 The purpose of this study was to determine distinct risk factors causing reduced salivary flow rate in a community-dwelling population using a prospective cohort study design. This was a 5-year follow-up survey of 1,377 community-dwelling Japanese individuals aged ≥40 years. The salivary flow rate was evaluated at baseline and follow-up by collecting stimulated saliva. Data on demographic characteristics, use of medication, and general and oral health status were obtained at baseline. The relationship between reduced salivary flow rate during the follow-up period and its predictors was evaluated after adjustment for confounding factors. In a multivariate logistic regression model, higher age and plaque score and lower serum albumin levels were significantly associated with greater odds of an obvious reduction in salivary flow rate (age per decade, odds ratio [OR] = 1.25, 95% confidence interval [CI] = 1.03–1.51; serum albumin levels <4 g/dL, OR = 1.60, 95% CI = 1.04–2.46; plaque score ≥1, OR = 1.53, 95% CI = 1.04–2.24). In a multivariate linear regression model, age and plaque score remained independently associated with the increased rate of reduced salivary flow. These results suggest that aging and plaque score are important predictors of reduced salivary flow rate in Japanese adults. Kenji Takeuchi, Michiko Furuta, Toru Takeshita, Yukie Shibata, Yoshihiro Shimazaki, Sumio Akifusa, Toshiharu Ninomiya, Yutaka Kiyohara, and Yoshihisa Yamashita Copyright © 2015 Kenji Takeuchi et al. All rights reserved.