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Background: Anaemia continues to be a pressing public health concern in India. Despite the high burden of anaemia among lactating adolescents in the country, research addressing this concern among this population remains scarce. Hence, this study attempted to examine the prevalence and determinants of anaemia among lactating adolescents in India., Methods: We used data from three latest rounds of the National Family Health Survey (NFHS) carried out in 2005-06, 2015-16, and 2019-21 and analysed a pooled sample of 10,689 lactating adolescents aged 15-19 years from these three rounds. Bivariate statistics was used to analyse the prevalence of anaemia according to the background characteristics of lactating adolescents. Further, binary multivariate logistic regression was carried out to examine the factors associated with anaemia in the study population., Results: Three in every five lactating adolescents from the pooled sample were found to have anaemia (66.98% in NFHS-3, 61.08% in NFHS-4 and 66.27% in NFHS-5). Lactating adolescents with a higher education had a 30% lower likelihood [adjusted odds ratio (AOR): 0.70, 95% CI: 0.49-1.01, p = 0.050] of being anaemic compared to those with no education. The likelihood of being anaemic among the poorest quintile was 41% (AOR: 1.41, 1.12-1.77; p = 0.003) higher than those from the richest quintile. Lactating adolescents from the Scheduled Tribe category had higher odds (AOR: 1.29, 95% CI: 1.01-1.46, p = 0.001) of anaemia than those categorised as 'Others'. Those living in rural areas were 22% more likely to suffer from anaemia (AOR: 1.22, 95% CI: 1.00-1.26, p = 0.050) compared to their urban counterparts. Additionally, underweight lactating adolescents were 15% more likely (AOR: 1.15, 95% CI: 1.05-1.26, p = 0.002) to be anaemic than those with normal BMI. Odds of being anaemic were higher among the ones receiving supplementary nutrition during pregnancy (AOR: 1.18, 95% CI: 1.08-1.29, p < 0.001) in contrast to those not receiving., Conclusion: The consistently high prevalence of anemia among lactating adolescents, especially among those with lower education level, rural residence, underweight status, and belonging to ST category and poorest quintile, underscore the urgent need for targeted public health interventions to address and reduce anemia in this population., (© 2024. The Author(s).)

Background: Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are widespread, treatable sexually transmitted infections (STIs) of global significance, affecting millions annually. Left untreated, they pose significant risks, including pelvic inflammatory disease (PID), infertility, and complications during pregnancy. The U.S. Centers for Disease Control recommends annual chlamydial screening for sexually active women to address these risks. Responding to this global challenge, the World Health Organization (WHO) has formulated a global health sector strategy on sexually transmitted infections, outlining priority actions to strengthen STI responses in countries. However, STI epidemiological studies encounter challenges in developing nations like Egypt due to socio-cultural factors, poverty, and limited diagnostic facilities. In Egypt, STI diagnosis primarily relies on clinical presentations, lacking structured screening programs for CT and NG. This study's main objective is to estimate the prevalence of Chlamydial and gonorrheal infections, advocating for supportive STI strategies in Egypt. Additionally, the study aims to provide a foundation for national prevalence estimates of CT and NG infections., Methods: A cross-sectional study encompassed five antenatal clinics in different regions of Egypt. A total of 1040 pregnant women attending these clinics were consecutively sampled. Data collection involved structured questionnaires, and urine samples were subjected to the GeneXpert CT/NG qualitative real-time PCR test., Results: The prevalence of CT infections was 0.29% (95% CI, 0.10-0.86%), with no detected NG infections. The three CT-positive cases were distributed across different recruitment centers, with no statistically significant differences observed between infected and non-infected participants. Notably, 40.3% of recruited women reported gynecological symptoms, primarily discharge. Additionally, 9.6% had undergone previous testing for sexually transmitted infections, with 8.2% receiving positive results., Conclusions: This study provides valuable data on the prevalence of CT and NG infections among pregnant women attending ANC clinics in Egypt. The findings underscore the importance of ongoing surveillance, routine screening, and targeted interventions to ensure the reproductive health and well-being of pregnant women and their infants. Further research is warranted to explore the broader implications of STIs in different populations and to inform evidence-based guidelines for screening and management in diverse settings., Trial Registration: IRB no.: 17,400,017; WHO ERC Protocol Id. A66005., (© 2024. The Author(s).)

Background: Fatal opioid-involved overdose rates increased precipitously from 5.0 per 100,000 population to 33.5 in Massachusetts between 1999 and 2022., Methods: We used spatial rate smoothing techniques to identify persistent opioid overdose-involved fatality clusters at the ZIP Code Tabulation Area (ZCTA) level. Rate smoothing techniques were employed to identify locations of high fatal opioid overdose rates where population counts were low. In Massachusetts, this included areas with both sparse data and low population density. We used Local Indicators of Spatial Association (LISA) cluster analyses with the raw incidence rates, and the Empirical Bayes smoothed rates to identify clusters from 2011 to 2021. We also estimated Empirical Bayes LISA cluster estimates to identify clusters during the same period. We constructed measures of the socio-built environment and potentially inappropriate prescribing using principal components analysis. The resulting measures were used as covariates in Conditional Autoregressive Bayesian models that acknowledge spatial autocorrelation to predict both, if a ZCTA was part of an opioid-involved cluster for fatal overdose rates, as well as the number of times that it was part of a cluster of high incidence rates., Results: LISA clusters for smoothed data were able to identify whether a ZCTA was part of a opioid involved fatality incidence cluster earlier in the study period, when compared to LISA clusters based on raw rates. PCA helped in identifying unique socio-environmental factors, such as minoritized populations and poverty, potentially inappropriate prescribing, access to amenities, and rurality by combining socioeconomic, built environment and prescription variables that were highly correlated with each other. In all models except for those that used raw rates to estimate whether a ZCTA was part of a high fatality cluster, opioid overdose fatality clusters in Massachusetts had high percentages of Black and Hispanic residents, and households experiencing poverty. The models that were fitted on Empirical Bayes LISA identified this phenomenon earlier in the study period than the raw rate LISA. However, all the models identified minoritized populations and poverty as significant factors in predicting the persistence of a ZCTA being part of a high opioid overdose cluster during this time period., Conclusion: Conducting spatially robust analyses may help inform policies to identify community-level risks for opioid-involved overdose deaths sooner than depending on raw incidence rates alone. The results can help inform policy makers and planners about locations of persistent risk., (© 2024. The Author(s).)

Background: Postpartum depression (PPD) affects around 10% of women, or 1 in 7 women, after giving birth. Undiagnosed PPD was observed among 50% of mothers. PPD has an unfavorable relationship with women's functioning, marital and personal relationships, the quality of the mother-infant connection, and the social, behavioral, and cognitive development of children. We aim to determine the frequency of PPD and explore associated determinants or predictors (demographic, obstetric, infant-related, and psychosocial factors) and coping strategies from June to August 2023 in six countries., Methods: An analytical cross-sectional study included a total of 674 mothers who visited primary health care centers (PHCs) in Egypt, Yemen, Iraq, India, Ghana, and Syria. They were asked to complete self-administered assessments using the Edinburgh Postnatal Depression Scale (EPDS). The data underwent logistic regression analysis using SPSS-IBM 27 to list potential factors that could predict PPD., Results: The overall frequency of PPD in the total sample was 92(13.6%). It ranged from 2.3% in Syria to 26% in Ghana. Only 42 (6.2%) were diagnosed. Multiple logistic regression analysis revealed there were significant predictors of PPD. These factors included having unhealthy baby adjusted odds ratio (aOR) of 11.685, 95% CI: 1.405-97.139, p = 0.023), having a precious baby (aOR 7.717, 95% CI: 1.822-32.689, p = 0.006), who don't receive support (aOR 9.784, 95% CI: 5.373-17.816, p = 0.001), and those who are suffering from PPD. However, being married and comfortable discussing mental health with family relatives are significant protective factors (aOR = 0.141 (95% CI: 0.04-0.494; p = 0.002) and (aOR = 0.369, 95% CI: 0.146-0.933, p = 0.035), respectively., Conclusion: The frequency of PPD among the mothers varied significantly across different countries. PPD has many protective and potential factors. We recommend further research and screenings of PPD for all mothers to promote the well-being of the mothers and create a favorable environment for the newborn and all family members., (© 2024. The Author(s).)

Background: Menstruation is a natural occurrence that women experience during their reproductive years and may encounter many years throughout their lifespan. Many adolescent females lack accurate knowledge about menstruation, so they may face issues from receiving incorrect information from unreliable sources. Our study aimed to investigate the practices and beliefs surrounding menstruation among Iranian adolescent females., Methods: This qualitative study was conducted using conventional content analysis. A purposeful sampling method was used to select 18 adolescent females from secondary and high schools located in the three regions of Neyshabur City-Iran. Data were collected through in-depth, semi-structured interviews., Results: Three main themes were extracted, consisting of lifestyle and related beliefs, lake of support, and awareness and information., Conclusions: misconceptions and wrong behaviors during menstruation indicate that the lake of knowledge an traditional factors influence adolescent girls' health. The study provides the basis for intervention planning in this regard and different levels (individual, intrapersonal, health systems, and community)., (© 2024. The Author(s).)

Background: Self-medication (SM) is a rising public health issue, especially in developing countries. It can be associated with various problems such as the delayed seeking of medical advice, drug interactions, and serious events such as antimicrobial drug resistance. We aimed to evaluate the Egyptian general population's knowledge, attitudes, and practices of SM., Methods: We employed a cross-sectional design between February 7th and March 8th, 2023 using a self-administered questionnaire available in Arabic. The questionnaire was developed based on previous studies and included four domains: sociodemographic data, knowledge, attitude, and practice of SM. We utilized both online (Google Forms) and paper surveys, utilizing convenience and snowball sampling methods. Data were analyzed using R Statistical Software (v4.1.3; R Core Team 2022)., Results: 1630 Egyptian individuals (838 females and 792 males) from the seven provinces were enrolled, with a median age of 25 years (IQR: 22-40). Around 55.97% and 48.28% of the participants had good knowledge and favorable attitudes regarding SM respectively, while 62.8% had practiced SM in the previous three months. The most frequently used medications were painkillers (60.74%) followed by antibiotics (32.13%) and antipyretics (28.61%). The pharmacist's recommendation was the source of SM for 53.61% while 31.53% used old medications at home. Most participants (59.08%) practiced SM because they thought they had simple or minor symptoms. The multivariate regression analysis revealed that females had significantly higher knowledge of SM than males (aOR: 2.10; 95%CI: 1.64-2.71; p-value < 0.001), with no significant differences in practice (aOR: 1.24; 95%CI: 0.99 - 1.56; p-value = 0.065). Individuals working or studying in the medical field were significantly more knowledgeable about SM (aOR: 4.30; 95%CI: 3.27-5.69; p-value < 0.001) and more likely to practice SM (aOR: 1.65; 95%CI: 1.26-2.17; p-value < 0.001). The odds of SM decreased with favorable attitudes (aOR: 0.44; 95%CI: 0.36-0.55; p-value < 0.001) while surprisingly, knowledge level was not significantly contributing to SM practice (aOR: 1.15; 95%CI: 0.90-1.48; p-value = 0.268)., Conclusions: SM is prevalent in Egypt, highlighting the importance of raising awareness and encouraging physician consultation as a priority. Governments, healthcare organizations, and educational institutions need to collaborate to provide the necessary support and resources., (© 2024. The Author(s).)

Background: Upon arrival, the prevalence of overweight and obesity is lower in new immigrants than their native counterparts in the U.S. With longer residency in the U.S., these differences converge over time, followed by higher prevalence among immigrants than native U.S. residents. Results from the Live Well project in the Greater Boston area demonstrate the viability of utilizing a culturally adapted, community-based participatory research (CBPR) approach to reduce weight gain among newly immigrated mother-child dyads., Methods: Haitian, Latina, and Brazilian mother-child dyads (n = 390), new to the U.S. (fewer than 10 years) were enrolled in a one- to two-year long CBPR lifestyle intervention that targeted dietary and physical activity behaviors. Attendance was recorded to establish dose. Demographics, anthropometrics, and relevant covariates were collected from participants at baseline, 6, 12, 18, and 24 months. Body Mass Index (BMI) was calculated using objectively measured height and weight. Linear mixed regression models were used to assess change in BMI and BMI z-score of mothers and children respectively., Results: At baseline, nearly 75% of mothers and 50% of children were either overweight or obese (BMI ≥ 25.0 and BMI z-score ≥ 85 th percentile, respectively). Only 20% of mothers attended all 12 intervention sessions in year 1. Using intent-to-treat analyses, no significant time, intervention, or time × intervention effects were observed for weight change of mothers or children at follow-up. Mothers in the highest quantile (those who attended all 12 intervention sessions) had significant reductions in BMI at 18 months (1.76 units lower, 95%CI: -3.14, -0.37) and 24 months (2.61 units, 95%CI -3.92, -1.29) compared to mothers in the lower quantiles, including those with no exposure. Such dose effects on BMI z-scores were not noted for children., Conclusions: Findings from Live Well demonstrate the viability of utilizing a CBPR approach to address overweight and obesity among immigrant mothers. Given the higher-than-expected prevalence of overweight and obesity among mother-child dyads by ~ 6 years of U.S. residency, and lower maternal participation rates in the intervention, additional research is necessary to identify the optimal intervention length, retention strategies, and approach to jointly support healthy maternal and child weight., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: It is crucial to study the public's perceptions and behaviour during a pandemic as this will be the driving force for practicing recommended precautions. The current study aimed to identify perceptions of a group of Egyptian adults to COVID-19 using the Health Belief Model (HBM), to measure self-reported practice of preventive behaviours and to identify influencing factors., Methods: Cross sectional study was used, including Egyptian adults aged 18 + years. A structured anonymous online questionnaire was used including: a demographic section, the modified MERS- CoV Health Belief Model scale after addition of questions related to COVID-19 and questions on preventive behaviours to COVID-19., Results: Of the 532 study participants, 28.6% were males, age ranges (18 to 74 years). There was a statistically significant positive correlation between total practice score and all COVID-19 Health Belief Model constructs total scores except for perceived barriers score showing negative correlation (P value < 0.05). Linear regression analysis showed that older age, male gender and living inside Cairo were associated with lower practice score (P value < 0.01)., Conclusions: Increased perceived susceptibility, perceived benefits, cues to action and perceived self-efficacy scores were associated with higher practice score in the current study. Additionally, results revealed that social media and websites can play an important role in shaping risk perception in the community. Stressing risk perception and efficacy beliefs prevention message can drive people to practice preventive behaviors., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Knowing what to eat and realizing the significance of healthful eating habits are among the important steps to promoting eating behavior. The current study aims to assess the nutrition knowledge (NK) among a convenient sample in four different countries, determine the association between different demographic factors and NK, and investigate the need for future interventions on nutrition in the four selected countries., Methods: A cross-sectional multi-national survey study among a convenient sample of 8,191 subjects from Egypt, Syria, Saudi Arabia, and Jordan who undertook surveys between January 2019 and January 2020. A pre-tested interview questionnaire was utilized for data collection from study participants. It included three sections: i) Sociodemographic characteristics:. ii). Section two included twenty-one questions related to NK.. iii). Section three included one question about NK sources., Results: About three-quarters showed inadequate nutrition knowledge (73.1%). Youth (15-24 yrs.) were more dependent on social media, with 87% using it as a primary source of NK, while adults (≥ 25 yrs.) demonstrated that 43% of them used social media. In contrast, TV was more prominent among them, with participants' characteristics such as living with parents, body mass index, and country of residence showing no association with NK. However, female sex, education, and reading nutrition articles are significantly correlated with adequate knowledge (p < 0.001). Significant predictors of satisfactory knowledge were age, sex, education, living with parents, and reading nutrition articles., Conclusion: The study revealed low levels of NK indicating an urgent need to implement educational programs to promote nutrition knowledge. As NK is a modifiable determinant of diet intake and can positively impact the need for developing strategies in counselling and raising awareness among the general population to improve their health status., (© 2023. The Author(s).)

Background: Peer support programs are promising approaches to diabetes prevention. However, there is still limited evidence on the health benefits of peer support programs for lay peer leaders., Purpose: To examine whether a peer support program designed for diabetes prevention resulted in greater improvements in health behaviors and outcomes for peer leaders as compared to other participants., Methods: 51 lay peer leaders and 437 participants from the Kerala Diabetes Prevention Program were included. Data were collected at baseline, 12 months, and 24 months. We compared behavioral, clinical, biochemical, and health-related quality of life parameters between peer leaders and their peers at the three time-points., Results: After 12 months, peer leaders showed significant improvements in leisure time physical activity (+ 17.7% vs. + 3.4%, P = 0.001) and health-related quality of life (0.0 vs. + 0.1, P = 0.004); and a significant reduction in alcohol use (-13.6% vs. -6.6%, P = 0.012) and 2-hour plasma glucose (-4.1 vs. + 9.9, P = 0.006), as compared to participants. After 24 months, relative to baseline, peer leaders had significant improvements in fruit and vegetable intake (+ 34.5% vs. + 26.5%, P = 0.017) and leisure time physical activity (+ 7.9% vs. -0.9%, P = 0.009); and a greater reduction in alcohol use (-13.6% vs. -4.9%, P = 0.008), and waist-to-hip ratio (-0.04 vs. -0.02, P = 0.014), as compared to participants. However, only the changes in fruit and vegetable intake and waist-to-hip ratio were maintained between 12 and 24 months., Conclusion: Being a peer leader in a diabetes prevention program was associated with greater health benefits during and after the intervention period. Further studies are needed to examine the long-term sustainability of these benefits., (© 2023. The Author(s).)

Background: Lead (Pb) and cadmium (Cd) heavy metals are considered potentially hazardous toxins which cause serious health problems. Many studies reported that the water of Qaroun Lake in Fayoum, Egypt with its fish farms was contaminated with Pb and Cd above permissible levels. However, there is a lack of studies addressing levels of these toxic metals among inhabitants., Objectives: We aimed to evaluate blood levels of Pb and Cd and their potential health risk among inhabitants around Qaroun Lake., Materials and Methods: This case-control study estimated Pb and Cd blood levels among 190 individuals from two destinations (near and far away) of Qaroun Lack using an atomic absorption spectrometer after full history taking and routine checkup investigations; Full blood count, serum ferritin, liver enzyme (ALT), and creatinine levels., Results: There was a significant difference between blood levels of Pb and Cd heavy metals of inhabitants from near and far away Qaroun Lake destinations (p-value < 0.001). The majority of inhabitants around Qaroun Lake had Pb and Cd blood levels above permissible levels (100% and 60% respectively). Critical levels out of them were 12.1% and 30.3% respectively. In comparison to inhabitants faraway Qaroun Lake, three individuals (2.4%) had Cd above the permissible level, while all of them (100%) had Pb level within the permissible level. There were no statistically significant differences between the two sampled populations as regards hemoglobin level, ALT, creatinine, and ferritin serum levels (p-value > 0.05). The difference between studied populations regarding types of anemia was not statistically significant. Subclinical leucopenia was higher in the population near Qaroun Lake when compare to inhabitants far from the lake (13.6% vs. 4.8%, p-value 0.032)., Conclusion: Bio-monitoring of populations exposed to Pb and Cd hazardous substances could help in generating an early warning system to reduce the disease burden associated with their toxicity., (© 2023. The Author(s).)

Background: We investigate the relationships among political preferences, risk for COVID-19 complications, and complying with preventative behaviors, such as social distancing, quarantine, and vaccination, as they remain incompletely understood. Since those with underlying health conditions have the highest mortality risk, prevention strategies targeting them and their caretakers effectively can save lives. Understanding caretakers' adherence is also crucial as their behavior affects the probability of transmission and quality of care, but is understudied. Examining the degree to which adherence to prevention measures within these populations is affected by their health status vs. voting preference, a key predictor of preventative behavior in the U. S, is imperative to improve targeted public health messaging. Knowledge of these associations could inform targeted COVID-19 campaigns to improve adherence for those at risk for severe consequences., Methods: We conducted a nationally-representative online survey of U.S. adults between May-June 2020 assessing: 1) attempts to socially-distance; 2) willingness/ability to self-quarantine; and 3) intention of COVID-19 vaccination. We estimated the relationships between 1) political preferences 2) underlying health status, and 3) being a caretaker to someone with high-risk conditions and each dependent variable. Sensitivity analyses examined the associations between political preference and dependent variables among participants with high-risk conditions and/or obesity., Results: Among 908 participants, 75.2% engaged in social-distancing, 94.4% were willing/able to self-quarantine, and 60.1% intended to get vaccinated. Compared to participants intending to vote for Biden, participants who intended to vote for Trump were significantly less likely to have tried to socially-distance, self-quarantine, or intend to be vaccinated. We observed the same trends in analyses restricted to participants with underlying health conditions and their caretakers Underlying health status was independently associated with social distancing among individuals with obesity and another high-risk condition, but not other outcomes., Conclusion: Engagement in preventative behavior is associated with political voting preference and not individual risk of severe COVID-19 or being a caretaker of a high-risk individual. Community based strategies and public health messaging should be tailored to individuals based on political preferences especially for those with obesity and other high-risk conditions. Efforts must be accompanied by broader public policy., (© 2022. The Author(s).)

Background: Late-life self-harm (SH) is often linked to depression. However, very few studies have explored the role of other factors and their interaction with depression in the occurrence of late-life SH. The objective of this research was to examine sociodemographic and gender factors associated with non-fatal SH, in older adults with and without antidepressant therapy., Methods: We used national longitudinal register data from a total cohort of all Swedish residents aged ≥75 years between 2006 and 2014 (N = 1,413,806). Using personal identity numbers, we linked individuals' data from numerous national registers. We identified all those with at least one episode of non-fatal self-harm (regardless of level of intent to die) and matched 50 controls to each case. A nested case-control design was used to investigate sociodemographic factors associated with non-fatal SH in the total cohort and among antidepressant users and non-users. Risk factors were analysed in adjusted conditional logistic regression models for the entire cohort and by gender., Results: In all, 2242 individuals had at least one episode of a non-fatal SH (980 men and 1262 women). Being unmarried was a risk factor for non-fatal SH in men but not in women. Among users of antidepressants, higher non-fatal SH risk was observed in those born outside the Nordic countries (IRR: 1.44; 95% CI: 1.11-1.86), whereas in AD non-users increased risk was seen in those from Nordic countries other than Sweden (IRR: 1.58; 95% CI: 1.08-2.29). Antidepressant users with higher education had an increased risk of non-fatal SH (IRR: 1.34; 95% CI: 1.12-1.61), in both men and women., Conclusions: Foreign country of birth was associated with increased risk for non-fatal SH in older adults with and without AD therapies. Being married was a protective factor for non-fatal SH in men. The complex association between sociodemographic factors and use of antidepressants in the occurrence of self-harm in older men and women indicates the need for multifaceted tailored preventive strategies including healthcare and social services alike.

Background: Uptake and completion of the HPV vaccine is suboptimal. This study assessed the feasibility of implementing a one-month Twitter campaign to promote knowledge about the human papillomavirus (HPV) vaccine among low-income women living in public housing., Methods: We recruited a convenience sample (n = 35) of women ages 18-26 years residing in low-come, public housing in Massachusetts. We assessed the feasibility and acceptability of a communication campaign that consisted of daily Twitter messages. Online surveys assessed changes in HPV knowledge, attitudes, and vaccine intentions before and after the campaign., Results: Most believed that Twitter was an acceptable educational strategy and remained engaged with the campaign throughout the intervention. We observed no changes in HPV knowledge, perceived benefits of or barriers to vaccination, decision self-efficacy, or vaccine intentions after the campaign, although perceived risk for cervical cancer decreased., Conclusions: Twitter may be a feasible and acceptable method for promoting knowledge about the HPV vaccine, but more research is needed to understand how best to reach low-income women with low levels of vaccine uptake., Trial Registration: Clinicaltrials.gov 1,603,045, retrospectively registered 0610/19.

Background: Control of blood pressure among hypertensives is a major challenge around the world. Interventions for improving hypertension control in India are very limited. This paper describes the protocol for a cluster randomized controlled trial of efficacy of behavioural intervention on control of hypertension among school teachers in Kerala., Methods: A total of 92 schools are randomised to intervention and control group in Kerala. A baseline survey was conducted in all schools to assess the prevalence of hypertension and its risk factors among school teachers in Thiruvananthapuram district of Kerala state, India. Teachers in both sets of schools will receive a leaflet containing details on the importance of controlling hypertension. With the objective of improving control of hypertension, the intervention schools will additionally receive self-management education and behavioural intervention programs delivered by trained intervention managers along with measurement of weight, waist circumference and blood pressure. This intervention program will be developed based on the findings of the baseline survey and selected components of successful models of hypertension control from previous research done in similar settings. The intervention will be given for 3 months after which a post-survey will be conducted among teachers of both control and intervention schools. The primary outcome is change in control of hypertension and secondary outcome is the change in behavioural risk factors of hypertension both in the control and intervention groups., Discussion: This is the first comprehensive study looking at the efficacy of behavioural intervention on hypertension control among school teachers in Kerala, India. This study is likely to provide an upper estimate of behavioural intervention on hypertension control since teachers are reported to have one of the highest compliance rates of behavioural intervention., Trial Registration: This trial was prospectively registered with the Clinical Trials Registry of India [CTRI/2018/01/011402] on 18 January 2018.

Background: Chronic musculoskeletal pain is common in adolescents, and it has been shown that adolescents with pain may become young adults with pain. Pain often coincides with psychosomatic symptoms in adults, but little is known about longitudinal associations and predictors of pain in adolescents. The aim was to investigate chronic musculoskeletal pain and its associations with health status, sleeping problems, stress, anxiety, depression, and physical activity in 16-year-old students at baseline, and to identify risk factors using a three-year follow-up., Methods: This was a longitudinal study of 256 students attending a Swedish upper secondary school. Questionnaires regarding chronic musculoskeletal pain and distribution of pain (mannequin), health status (EQ-5D-3 L), sleeping problems (Uppsala Sleep Inventory), stress symptoms (single-item question), anxiety and depression (Hospital Anxiety and Depression Scale), and physical activity (International Physical Activity Questionnaire) were issued at baseline and follow-up. Student's t-test and chi 2 test were used for descriptive statistics and logistic regression analyses were used to study associations between chronic pain and independent variables., Results: Fifty-two out of 221 students at baseline (23.5%) and 39 out of 154 students at follow-up (25.3%) were categorized as having chronic musculoskeletal pain. Chronic musculoskeletal pain at follow-up was separately associated with reporting of an EQ-5D value below median (OR 4.06, 95% CI 1.83-9.01), severe sleeping problems (OR 3.63, 95% CI 1.69-7.82), and possible anxiety (OR 4.19, 95% CI 1.74-10.11) or probable anxiety (OR 3.82, 95% CI 1.17-12.48) at baseline. Similar results were found for associations between chronic musculoskeletal pain and independent variables at baseline. In multiple logistic regression analysis, chronic musculoskeletal pain at baseline was a predictor of chronic musculoskeletal pain at follow-up (OR 2.99, 95% CI 1.09-8.24, R 2  = 0.240)., Conclusion: Chronic musculoskeletal pain at baseline was the most important predictor for reporting chronic musculoskeletal pain at the three-year follow-up, but a worse health status, severe sleeping problems, and anxiety also predicted persistence or development of chronic musculoskeletal pain over time. Interventions should be introduced early on by the school health services to promote student health.

Background: Maternal exposure to air pollution is related to fetal dysplasia. However, the association between maternal exposure to air pollution and the risk of congenital hypothyroidism (CH) in the offspring is largely unknown., Methods: We conducted a national database based study in China to explore the association between these two parameters. The incidence of CH was collected from October 1, 2014 to October 1, 2015 from the Chinese Maternal and Child Health Surveillance Network. Considering that total period of pregnancy and consequently the total period of particle exposure is approximately 10 months, average exposure levels of PM 2.5 , PM 10 and Air Quality Index (AQI) were collected from January 1, 2014 to January 1, 2015. Generalized additive model was used to evaluate the association between air pollution and the incidence of CH, and constructing receiver operating characteristic (ROC) curve was used to calculate the cut-off value., Results: The overall incidence of CH was 4.31 per 10,000 screened newborns in China from October 1, 2014 to October 1, 2015. For every increase of 1 μg/m 3 in the PM 2.5 exposure during gestation could increase the risk of CH (adjusted OR = 1.016 per 1 μg/m 3 change, 95% CI, 1.001-1.031). But no significant associations were found with regard to PM 10 (adjusted OR = 1.009, 95% CI, 0.996-1.018) or AQI (adjusted OR = 1.012, 95% CI,0.998-1.026) and the risk of CH in the offspring. The cut-off value of prenatal PM 2.5 exposure for predicting the risk of CH in the offspring was 61.165 μg/m 3 ., Conclusions: The present study suggested that maternal exposure to PM 2.5 may exhibit a positive association with increased risk of CH in the offspring. We also proposed a cut-off value of PM 2.5 exposure that might determine reduction in the risk of CH in the offspring in highly polluted areas.

Background: Experiencing work-related stress constitutes an obvious risk for becoming sick-listed. In primary health care, no established method to early identify, advise and treat people with work-related stress exists. The aim was to evaluate if the use of the Work Stress Questionnaire (WSQ) brief intervention, including feedback from the general practitioner (GP), had an impact on the level of sickness absence., Method/design: In total 271 (intervention group, n = 132, control group, n = 139) non-sick-listed employed women and men, aged 18 to 64 years, who had mental and physical health complaints and sought care at primary health care centers participated in this two-armed randomized controlled trial. The main outcomes were the number of registered sick leave days and episodes, and time to first sick leave during the 12-months follow-up. The intervention included early identification of work-related stress by the WSQ, GP awareness supported by a brief training session, patients' self-reflection by WSQ completion, GP feedback at consultation, and initiation of preventive measures., Results: The mean days registered for the WSQ intervention group and the control group were 39 and 45 gross days respectively, and 31 and 39 net days respectively (ns). No statistical significant difference for the number of sick leave episodes or time to first day of sick leave episode were found between the groups., Conclusions: The WSQ brief intervention combined with feedback and suggestions of measures at patient-GP-consultation was not proven effective in preventing sick leave in the following 12 months compared to treatment as usual. More research is needed on methods to early identify, advise and treat people with work-related stress in primary health care, and on how and when GPs and other professionals in primary health care can be trained to understand this risk of sick leave due to work-related stress, on how to prevent it, and on how to advise and treat employees at risk., Trial Registration: ClinicalTrials.gov. Identifier: NCT02480855 . Registered 20 May 2015.

Background: Ethiopia was among the 15 countries that, together accounted for 64% of the world's severe episodes of pneumonia among children below the age of 5 in 2011. To reduce this burden, the 10-valent pneumococcal conjugate vaccine (PCV 10) was introduced into the general childhood national immunization program in Ethiopia in 2011. However, there is little evidence on its cost-effectiveness, and the aim of this study was to estimate the cost-effectiveness of the introduction of PCV 10 vaccination in the Ethiopian setting., Methods: The cost-effectiveness analysis was carried out based on a quasi-experimental evaluation of implementing PCV 10 at the Butajira rural health program site in Ethiopia. The intervention and the control groups consisted 876 and 1010 children, respectively. Using data from program site's surveillance system database as a framework, health outcome and vaccination data were collected from medical records, immunization registration books and reports. Disability- Adjusted Life Year (DALY) was a main health outcome metric complimented by incidence of acute lower respiratory infection/1000-person years. Vaccination and treatment costs were collected by document review and cross-sectional household survey., Results: In the intervention cohort, 626 of 876 (71.5%) children received PCV 10 vaccination. Until the first year of life, the incidence of acute lower respiratory infection was higher in the intervention group. After the first year of life, the incidence rate was 35.2 per 1000-person years in the intervention group compared to 60.4 per 1000-person years in the control group. The incremental cost-effectiveness ratio (ICER) per averted DALY for the intervention group during the total follow-up period was (2013 US$) 394.3 (undiscounted) and 413.8 (discounted). The ICER per averted DALY excluding the first year of life was (2013 US$) 225 (undiscounted) and 292.7 (discounted)., Conclusion: Compared to the WHO's suggested cost-effectiveness threshold value, the results indicate that the general childhood PCV 10 vaccination was a cost-effective intervention in the Butajira rural health program site.

Background: Increasing children's physical activity (PA) at school is critical to obesity prevention and health promotion. Implementing novel, low-cost PA programs offers potential to contribute to children's in-school PA, particularly in resource-constrained schools. This evaluation describes implementation fidelity, reach, and dose of two PA programs in the Fueling Learning through Exercise (FLEX) Study., Methods: Thirteen diverse, low-income Massachusetts elementary schools were recruited and randomized to the 100 Mile Club walking/running program (n = 7) or CHALK/Just Move classroom activity break PA program (n = 6). Intervention programs were delivered across two school years. Surveys with program champions/teachers and children, in-session measurement of children's PA by accelerometry (Actigraph GT3X) in a subset of schools, and key informant interviews were used to collect information on implementation, including fidelity, dose, reach, and sustainability, and to calculate an implementation score., Results: Six CHALK/Just Move schools implemented the program in both years. Two schools randomized to 100 Mile Club did not implement at all, and only three schools implemented both years. Implementing schools had similar implementation scores (range = 0-3; 100 Mile Club = 2.0 vs. CHALK/Just Move = 1.9) but fidelity to core and enhanced elements differed between programs. In 100 Mile Club schools, dose of program delivered was greater than in CHALK/Just Move schools (34.9 vs. 19.7 min per week). Dose of PA received per session was also greater in 100 Mile Club schools (n = 55, 2 schools) compared with CHALK/Just Move schools (n = 160, 2 schools) (13.6 min vs. 2.7 min per session). A slightly higher proportion of eligible children participated in CHALK/Just Move compared to 100 Mile Club (54.0% vs. 31.2%). Both programs were well received by champions/teachers and students., Conclusions: Program implementation varied across programs and schools, and erosion in delivery was seen over the two years. However, among implementing schools, additional PA was delivered and received, and the programs were generally well-received. Although school resource issues remain barriers to implemention, this evaluation demonstrates that low-cost programs may enhance PA opportunities. Future research should evaluate how multiple programs can be implemented to increase children's PA at school., Trial Registration: ClinicalTrials.gov Identifier: NCT02810834 . Registered May 11, 2015.

Background: Undocumented migrants (UMs) in Europe constitute a heterogeneous group. They are typically in a vulnerable and marginalised situation, since most of them have exhausted their options for gaining asylum and protection from war and persecution, many are traumatised and fear disclosure and deportation, and they typically lack basic social security. The present study investigates living conditions, access to human rights and mental health of UMs living in Sweden., Methods: A cross-sectional study with adult UMs was performed in the three largest cities in Sweden in 2014-2016. Sampling was done via informal networks. A socioeconomic questionnaire was constructed, and psychiatric symptoms were screened for using Beck's Depression Inventory II, Beck's Anxiety Inventory and the PTSD Checklist (PCL) for civilians. Trained field workers conducted the interviews. Descriptive statistics, chi-square tests and logistic regression models were used., Results: A total number of 104 individuals participated. Preliminary findings show that 68% of respondents were suffering from either moderate or severe anxiety, 71% from either moderate or severe depression and 58% from PTSD. No statistically significant gender differences occurred, but age was statistically significant in relation to anxiety and depression. The majority feared returning to their country of origin, for political reasons, due to war in progress there and/or because they belonged to a minority and feared harassment. Almost all had an unstable housing situation and were often forced to move. Fifty-seven percent experienced food insecurity., Conclusion: The psychosocial situation among UMs in Sweden, in addition to insecure living conditions without a guarantee of basic needs being met is stressful, and many UMs live in constant fear of disclosure and deportation, all of which has a detrimental effect of the mental health. It is important to understand both associated risk factors for ill-health and coping strategies in this vulnerable population in order try to reduce ongoing stress.

Background: Common mental disorders affect about one-third of the European working-age population and are one of the leading causes of sick leave in Sweden and other OECD countries. Besides the individual suffering, the costs for society are high. This paper describes the design of a study to evaluate a work-related, problem-solving intervention provided at primary health care centers for employees on sick leave due to common mental disorders., Methods: The study has a two-armed cluster randomized design in which the participating rehabilitation coordinators are randomized into delivering the intervention or providing care-as-usual. Employees on sick leave due to common mental disorders will be recruited by an independent research assistant. The intervention aims to improve the employee's return-to-work process by identifying problems perceived as hindering return-to-work and finding solutions. The rehabilitation coordinator facilitates a participatory approach, in which the employee and the employer together identify obstacles and solutions in relation to the work situation. The primary outcome is total number of sick leave days during the 18-month follow-up after inclusion. A long-term follow-up at 36 months is planned. Secondary outcomes are short-term sick leave (min. 2 weeks and max. 12 weeks), psychological symptoms, work ability, presenteeism and health related quality of life assessed at baseline, 6 and 12-month follow-up. Intervention fidelity, reach, dose delivered and dose received will be examined in a process evaluation. An economic evaluation will put health-related quality of life and sick leave in relation to costs from the perspectives of society and health care services. A parallel ethical evaluation will focus on the interventions consequences for patient autonomy, privacy, equality, fairness and professional ethos and integrity., Discussion: The study is a pragmatic trial which will include analyses of the intervention's effectiveness, and a process evaluation in primary health care settings. Methodological strengths and challenges are discussed, such as the risk of selection bias, contamination and detection bias. If the intervention shows promising results for return-to-work, the prospects are good for implementing the intervention in routine primary health care., Trial Registration: ClinicalTrials.gov Identifier: NCT03346395 Registered January, 12 2018.

Background: Individuals on probation experience economic disadvantage because their criminal records often prohibit gainful employment, which compromises their ability to access the basic components of wellbeing. Unemployment and underemployment have been studied as distinct phenomenon but no research has examined multiple determinants of health in aggregate or explored how these individuals prioritize each of these factors. This study identified and ranked competing priorities in adults on probation and qualitatively explored how these priorities impact health., Methods: We conducted in-depth interviews in 2016 with 22 adults on probation in Rhode Island to determine priority rankings of basic needs. We used Maslow's hierarchy of needs theory and the literature to guide the priorities we pre-selected for probationers to rank. Within a thematic analysis framework, we used a modified ranking approach to identify the priorities chosen by participants and explored themes related to the top four ranked priorities., Results: We found that probationers ranked substance use recovery, employment, housing, and food intake as the top four priorities. Probationers in recovery reported sobriety as the most important issue, a necessary basis to be able to address other aspects of life. Participants also articulated the interrelatedness of difficulties in securing employment, food, and housing; these represent stressors for themselves and their families, which negatively impact health. Participants ranked healthcare last and many reported underinsurance as an issue to accessing care., Conclusions: Adults on probation are often faced with limited economic potential and support systems that consistently place them in high-risk environments with increased risk for recidivism. These findings emphasize the need for policies that address the barriers to securing gainful employment and safe housing. Interventions that reflect probationer priorities are necessary to begin to mitigate the health disparities in this population.

Background: Type 2 diabetes mellitus (T2DM) is now one of the leading causes of disease-related deaths globally. India has the world's second largest number of individuals living with diabetes. Lifestyle change has been proven to be an effective means by which to reduce risk of T2DM and a number of "real world" diabetes prevention trials have been undertaken in high income countries. However, systematic efforts to adapt such interventions for T2DM prevention in low- and middle-income countries have been very limited to date. This research-to-action gap is now widely recognised as a major challenge to the prevention and control of diabetes. Reducing the gap is associated with reductions in morbidity and mortality and reduced health care costs. The aim of this article is to describe the adaptation, development and refinement of diabetes prevention programs from the USA, Finland and Australia to the State of Kerala, India., Methods: The Kerala Diabetes Prevention Program (K-DPP) was adapted to Kerala, India from evidence-based lifestyle interventions implemented in high income countries, namely, Finland, United States and Australia. The adaptation process was undertaken in five phases: 1) needs assessment; 2) formulation of program objectives; 3) program adaptation and development; 4) piloting of the program and its delivery; and 5) program refinement and active implementation., Results: The resulting program, K-DPP, includes four key components: 1) a group-based peer support program for participants; 2) a peer-leader training and support program for lay people to lead the groups; 3) resource materials; and 4) strategies to stimulate broader community engagement. The systematic approach to adaptation was underpinned by evidence-based behavior change techniques., Conclusion: K-DPP is the first well evaluated community-based, peer-led diabetes prevention program in India. Future refinement and utilization of this approach will promote translation of K-DPP to other contexts and population groups within India as well as other low- and middle-income countries. This same approach could also be applied more broadly to enable the translation of effective non-communicable disease prevention programs developed in high-income settings to create context-specific evidence in rapidly developing low- and middle-income countries., Trial Registration: Australia and New Zealand Clinical Trials Registry: ACTRN12611000262909 . Registered 10 March 2011.

Background: Common mental disorders have a negative impact on work functioning, but less is known about the process when the functioning starts to destabilize. This study explores experiences of work instability in workers with common mental disorders., Methods: A grounded theory study using a theoretical sampling frame, individual in-depth interviews and a constant comparative analysis conducted by a multidisciplinary research team. The sample involved 27 workers with common mental disorders, currently working full or part time, or being on sick leave not more than 6 months. They were women and men of different ages, representing different occupations and illness severity., Results: A general process of work instability was conceptualized by the core category Working in dissonance: captured in a bubble inside the work stream. The workers described that their ordinary fluency at work was disturbed. They distanced themselves from other people at and outside work, which helped them to regain their flow but simultaneously made them feel isolated. Four categories described sub-processes of the dissonance: Working out of rhythm, Working in discomfort, Working disconnected and Working in a no man's land., Conclusions: The experience of work instability in CMDs was conceptualized as "working in dissonance", suggesting a multifaceted dissonance at work, characterized by a sense of being caught up, as if in a bubble. Focusing on how the worker can re-enter their flow at work when experiencing dissonance is a new approach to explore in occupational and clinical settings.

Background: Despite increased risk for cardiovascular disease (CVD) and related conditions, evaluations of health interventions indicate that Black/African American women are less likely to benefit than their white counterparts and are not as likely to engage in behaviors that reduce CVD risk. The purpose of this study was to test the feasibility and effectiveness of civic engagement as an intervention strategy to address heart health in Black/African American women., Methods: Using a quasi-experimental pre-post study design, civic engagement was tested by convening a convenience sample of self-identified Black/African American women, ages 30-70 years, English-speaking, and BMI ≥25.0 (n = 28) into "Change Clubs" in four churches. Feasibility was examined through adherence, satisfaction, retention, and ability of Change Clubs to meet at least 50% of self-identified action steps for community change. Effectiveness data included: dietary intake, measures of physical activity, cardiorespiratory fitness, blood pressure, and anthropometrics. Psychosocial factors hypothesized to serve as the mechanisms by which civic engagement enacts behavior change were also assessed., Results: At baseline, the study sample (n = 28) had a mean age of 50.5 y; 53.6% had an associate degree or higher; 60.7% had an income of $35,000 or higher; and 57.4% were employed full time. At the conclusion of the study, all participants were satisfied with the progress of their Change Club and with the overall experience and Change Clubs met their self-identified action steps for community change. The intervention had a significant effect on finish time on the cardiorespiratory fitness test (p < 0.001) and systolic blood pressure (p < 0.001)., Conclusions: Study results suggest feasibility and evidence of preliminary effectiveness of using a civic engagement approach to address behavior change in a way that is appealing and acceptable to Black/African American women., Trial Registration: NCT02173366.

Background: Physical activity (PA) is critical to preventing childhood obesity and contributes to children's overall physical and cognitive health, yet fewer than half of all children achieve the recommended 60 min per day of moderate-to-vigorous physical activity (MVPA). Schools are an ideal setting to meeting PA guidelines, but competing demands and limited resources have impacted PA opportunities. The Fueling Learning through Exercise (FLEX) Study is a randomized controlled trial that will evaluate the impact of two innovative school-based PA programs on children's MVPA, cognitive function, and academic outcomes., Methods: Twenty-four public elementary schools from low-income, ethnically diverse communities around Massachusetts were recruited and randomized to receive either 100 Mile Club® (walking/running program) or Just Move™ (classroom-based PA program) intervention, or control. Schoolchildren (grades 3-4, approximately 50 per school) were recruited to participate in evaluation. Primary outcome measures include PA via 7-day accelerometry (Actigraph GT3X+ and wGT3X-BT), cognitive assessments, and academic achievement via state standardized test scores. Additional measures include height and weight, surveys assessing psycho-social factors related to PA, and dietary intake. School-level surveys assess PA infrastructure and resources and intervention implementation. Data are collected at baseline, mid-point (5-6 months post-baseline), and post-intervention (approximately 1.5 years post-baseline). Demographic data were collected by parents/caregivers at baseline. Mixed-effect models will test the short- and long-term effects of both programs on minutes spent in MVPA, as well as secondary outcomes including cognitive and academic outcomes., Discussion: The FLEX study will evaluate strategies for increasing children's MVPA through two innovative, low-cost, school-based PA programs as well as their impact on children's cognitive functioning and academic success. Demonstration of a relationship between school-based MVPA with neutral or improved, rather than diminished, academic outcomes in a naturalistic environment has the potential to positively influence investment in school PA programs and initiatives., Trial Registration: ClinicalTrials.gov Identifier: NCT02810834 . Registered May 11, 2015. (Retrospectively registered).

Background: The need for instruments that can assist in detecting the prodromal stages of stress-related exhaustion has been acknowledged. The aim of the present study was to evaluate whether the Lund University Checklist for Incipient Exhaustion (LUCIE) could accurately and prospectively detect the onset of incipient exhaustion and to what extent work stressor exposure and private burdens were associated with increasing LUCIE scores., Methods: Using surveys, 1355 employees were followed for 11 quarters. Participants with prospectively elevated LUCIE scores were targeted by three algorithms entailing 4 quarters: (1) abrupt onset to a sustained Stress Warning (n = 18), (2) gradual onset to a sustained Stress Warning (n = 42), and (3) sustained Exhaustion Warning (n = 36). The targeted participants' survey reports on changes in work situation and private life during the fulfillment of any algorithm criteria were analyzed, together with the interview data. Participants untargeted by the algorithms constituted a control group (n = 745)., Results: Eighty-seven percent of participants fulfilling any LUCIE algorithm criteria (LUCIE indication cases) rated a negative change in their work situation during the 4 quarters, compared to 48 % of controls. Ratings of negative changes in private life were also more common in the LUCIE indication groups than among controls (58 % vs. 29 %), but free-text commentaries revealed that almost half of the ratings in the LUCIE indication groups were due to work-to-family conflicts and health problems caused by excessive workload, assigned more properly to work-related negative changes. When excluding the themes related to work-stress-related private life compromises, negative private life changes in the LUCIE indication groups dropped from 58 to 32 %, while only a negligible drop from 29 to 26 % was observed among controls. In retrospective interviews, 79 % of the LUCIE indication participants confirmed exclusively/predominantly work stressors, while 6 % described a predominance of private life stressors., Conclusions: Negative changes in the work situation were the most prominent change related to a sustained increase in LUCIE scores. The findings seem to confirm that LUCIE is a potentially useful tool for clinical screening of incipient work-related exhaustion.

Background: In temperate regions, influenza epidemics occur in the winter and correlate with certain climatological parameters. In African tropical regions, the effects of climatological parameters on influenza epidemics are not well defined. This study aims to identify and model the effects of climatological parameters on seasonal influenza activity in Abidjan, Cote d'Ivoire., Methods: We studied the effects of weekly rainfall, humidity, and temperature on laboratory-confirmed influenza cases in Abidjan from 2007 to 2010. We used the Box-Jenkins method with the autoregressive integrated moving average (ARIMA) process to create models using data from 2007-2010 and to assess the predictive value of best model on data from 2011 to 2012., Results: The weekly number of influenza cases showed significant cross-correlation with certain prior weeks for both rainfall, and relative humidity. The best fitting multivariate model (ARIMAX (2,0,0) &#95;RF) included the number of influenza cases during 1-week and 2-weeks prior, and the rainfall during the current week and 5-weeks prior. The performance of this model showed an increase of >3 % for Akaike Information Criterion (AIC) and 2.5 % for Bayesian Information Criterion (BIC) compared to the reference univariate ARIMA (2,0,0). The prediction of the weekly number of influenza cases during 2011-2012 with the best fitting multivariate model (ARIMAX (2,0,0) &#95;RF), showed that the observed values were within the 95 % confidence interval of the predicted values during 97 of 104 weeks., Conclusion: Including rainfall increases the performances of fitted and predicted models. The timing of influenza in Abidjan can be partially explained by rainfall influence, in a setting with little change in temperature throughout the year. These findings can help clinicians to anticipate influenza cases during the rainy season by implementing preventive measures.

Background: A number of child/parental factors have been shown to be significant predictors of childhood overweight, although a better understanding of possible contextual influences of neighbourhood-level characteristics might provide new insights leading to tailored, targeted interventions. The aim of this study was to explore the impact of neighbourhood purchasing power and its relationship with other known risk factors related to childhood overweight in a prospective birth cohort., Methods: A prospective, population-based, birth-cohort study was conducted in south-western Sweden, comprising 2,666 infants born in 2007-2008. Childhood overweight was assessed by body mass index (BMI) data from follow-up examinations at four years of age (n = 2,026) and overweight defined according to the International Obesity Task Force. Using logistic regression analysis, the influential child/parental predictors were identified from the candidate predictors, viz. child's gender, as well as birth weight adjusted for gestational age and parental factors at recruitment, including maternal smoking status, maternal BMI (before pregnancy), paternal BMI and parental educational level. The children's residential parishes at follow-up were stratified by parish-level household purchasing power (<10 %, 10-19.9 %, 20-29.9 % and ≥30 % of all resident families with low purchasing power) and the "contextual" influence was analysed. In each such neighbourhood stratum, the adjusted overweight ratio (AOR), i.e. the ratio between the observed number of overweight children and the expected number, taking account of the influential child/parental predictors, was estimated., Results: The prevalence of overweight at four years of age was 11.9 %. In the economically strongest neighbourhoods (i.e. <10 % of resident families with low purchasing power), the AOR was 0.60 (95 % confidence interval (CI): 0.34-0.98). The corresponding empirically Bayes-adjusted AOR was 0.73 (95 % CI: 0.46-1.02; 97 % posterior probability of AOR <1). In the other neighbourhood strata, the statistical evidence of a deviant AOR was weaker., Conclusion: The economically strongest neighbourhoods had a lower prevalence than expected of overweight at four years of age. This finding should prompt studies to acquire more knowledge of potentially modifiable factors that differ between neighbourhoods and are related to childhood overweight, providing a basis for tailored, targeted interventions.

Background: The evidence that inspires and fosters communication skills, teaching programmes and clinical recommendations are often based on national studies which assume, implicitly, that patients' preferences towards doctors' communication style are not significantly affected by their cultural background. The cross-cultural validity of national results has been recognized as a potential limitation on how generally applicable they are in a wider context. Using 35 country-specific focus group discussions from four European countries, the aim of the present study is to test whether or not national cultures influence lay people's preferences towards doctors' style of communication., Methods: Lay people preferences on doctor's communication style have been collected in Belgium, the Netherlands, the United Kingdom and Italy. Each centre organized between eight and nine focus groups, where participants (n = 259) were asked to comment on a video of a simulated medical interview. The discussions were audiotaped, transcribed and coded using a common framework (Guliver Coding System) that allowed for the identification of different themes., Results: The frequency distribution of the topics discussed highlights lay people's generally positive views towards most part of doctors interventions. The regression model applied to the Guliver categories highlighted slight national differences and the existence of a cross-cultural appreciation, in particular, of five types of intervention: Doctors attitudes (both Task-Oriented and Affective/Emotional), Summarizing, Structuring and Providing solution., Conclusion: Lay panels valued doctors' communication style in a similar manner in the countries selected. This highlights the existence of a common background, which in the process of internationalization of heath care, might foster the implementation of cross-national teaching programmes and clinical guidelines.

Background: Both sleep duration and screen time have been suggested to affect children's diet, although in different directions and presumably through different pathways. The present cross-sectional study aimed to simultaneously investigate the associations between sleep duration, screen time and food consumption frequencies in children., Methods: The analysis was based on 10 453 children aged 6-9 years from five European countries that participated in the World Health Organization European Childhood Obesity Surveillance Initiative. Logistic multilevel models were used to assess associations of parent-reported screen time as well as sleep duration (exposure variables) with consumption frequencies of 16 food items (outcome variables). All models were adjusted for age, sex, outdoor play time, maximum educational level of parents and sleep duration or screen time, depending on the exposure under investigation., Results: One additional hour of screen time was associated with increased consumption frequencies of 'soft drinks containing sugar' (1.28 [1.19;1.39]; odds ratio and 99% confidence interval), 'diet/light soft drinks' (1.21 [1.14;1.29]), 'flavoured milk' (1.18 [1.08;1.28]), 'candy bars or chocolate' (1.31 [1.22;1.40]), 'biscuits, cakes, doughnuts or pies' (1.22 [1.14;1.30]), 'potato chips (crisps), corn chips, popcorn or peanuts' (1.32 [1.20;1.45]), 'pizza, French fries (chips), hamburgers'(1.30 [1.18;1.43]) and with a reduced consumption frequency of 'vegetables (excluding potatoes)' (0.89 [0.83;0.95]) and 'fresh fruits' (0.91 [0.86;0.97]). Conversely, one additional hour of sleep duration was found to be associated with increased consumption frequencies of 'fresh fruits' (1.11 [1.04;1.18]) and 'vegetables (excluding potatoes)' (1.14 [1.07;1.23])., Conclusion: The results suggest a potential relation between high screen time exposure and increased consumption frequencies of foods high in fat, free sugar or salt whereas long sleep duration may favourably be related to children's food choices. Both screen time and sleep duration are modifiable behaviours that may be tackled in childhood obesity prevention efforts.

Background: High physical activity, low sedentary behavior and low consumption of sugar-sweetened beverages can be markers of a healthy lifestyle. We aim to observe longitudinal changes and secular trends in these lifestyle variables as well as in the prevalence of overweight and obesity in 7-to-9-year-old schoolchildren related to gender and socioeconomic position., Methods: Three cross-sectional surveys were carried out on schoolchildren in grades 1 and 2 (7-to-9-year-olds) in 2008 (n = 833), 2010 (n = 1085), and 2013 (n = 1135). Information on children's level of physical activity, sedentary behavior, diet, and parent's education level was collected through parental questionnaires. Children's height and weight were also measured. Longitudinal measurements were carried out on a subsample (n = 678) which was included both in 2008 (7-to-9-year-olds) and 2010 (9-to-11-year-olds). BMI was used to classify children into overweight (including obese) and obese based on the International Obesity Task Force reference. Questionnaire reported maternal education level was used as a proxy for socioeconomic position (SEP)., Results: Longitudinally, consumption of sugar-sweetened beverages ≥ 4 days/week increased from 7% to 16% in children with low SEP. Overall, sedentary behavior > 4 hours/day doubled from 14% to 31% (p < 0.001) and sport participation ≥ 3 days/week increased from 17% to 37% (p < 0.001). No longitudinal changes in overweight or obesity were detected. In the repeated cross-sectional observations sedentary behavior increased (p = 0.001) both in high and low SEP groups, and overweight increased from 13.8% to 20.9% in girls (p < 0.05). Overall, children with high SEP were less-often overweight (p < 0.001) and more physically active (p < 0.001) than children with low SEP., Conclusions: Children's lifestyles changed longitudinally in a relatively short period of two years. Secular trends were also observed, indicating that 7-9-year-olds could be susceptible to actions that promote a healthy lifestyle. Socioeconomic differences were consistent and even increasing when it came to sugar-sweetened beverage consumption. Decreasing the socioeconomic gap in weight status and related lifestyle variables should be prioritized. Primary school is an arena where most children could be reached and where their lifestyle could be influenced by health promoting activities.

Background: The home, the family and the parents represent a context of everyday life that is important for child health and development, with parent-child relationships highlighted as crucial for children's mental health. Time pressure is an emerging feature of modern societies and previous studies indicates that parents with children living at home experience time pressure to a greater extent than people with no children living at home. Previous studies of children's mental health in relation to parents' time pressure are lacking. Hence, the purpose of this study was to examine the association between parents' subjective time pressure and mental health problems among children in the Nordic countries as well as potential disparities between boys and girls in different age groups., Methods: 4592 children, aged 4-16 from Denmark, Finland, Norway and Sweden, participating in the 2011 version of the NordChild study, were included. The Strength and Difficulties Questionnaire was used to measure children's mental health and associations to parents' time pressure were assessed by multiple logistic regression analysis., Results: Among children of parents experiencing time pressure, 18.6% had mental health problems compared to 10.1% among children of parents experiencing time pressure not or sometimes. The odds of mental health problems were higher among both boys (OR 1.80 95% CI 1.32-2.46) and girls (OR 1.95 95% CI 1.42-2.66) if their parents experienced time pressure when adjusted for financial stress. The highest prevalence of mental health problems in the case of parental time pressure was found among girls 13-16 years old (23.6%) and the lowest prevalence was found among boys 13-16 years old (10.7%)., Conclusions: In this study an association between parents' subjective time pressure and increased mental health problems among children was found. Given that time pressure is a growing feature of modern societies, the results might contribute to an explanation as to mental health problems are common among children in the Nordic countries in spite of otherwise favourable conditions. Additional research on the linkage between parents' experienced time pressure and children's and adolescents' mental health problems is needed to confirm the novel findings of this study.

Background: Psychosocial stress at work has been recognised as one of the most important factors behind the increase in sick leave due to stress-related mental disorders. It is therefore important to be able to measure perceived work stress in a way that is both valid and reliable. It has been suggested that the Stress-Energy Questionnaire (SEQ) could be a useful tool for measuring mood (stress and energy) at work and it has been used in many Scandinavian studies. The aim of the study is to examine the internal construct validity of the SEQ in a working population and to address measurement issues, such as the ordering of response categories and potential differences in how women and men use the scale - what is termed differential item functioning (DIF)., Methods: The data used in the present study is baseline data from a longitudinal cohort study aimed at evaluating psychosocial working conditions, stress, health and well-being among employees in two human service organisations in Western Sweden. A modern psychometric approach for scale validations, the Rasch model, was used., Results: Stress items showed a satisfactory fit to the model. Problems related to unidimensionality and local dependence were found when the six stress items were fitted to the model, but these could be resolved by using two testlets. As regards the energy scale, although the final analysis showed an acceptable fit to the model some scale problems were identified. The item dull had disordered thresholds and DIF for gender was detected for the item passive. The items were not well targeted to the persons, with skewness towards high energy. This might explain the scale problems that were detected but these problems need to be investigated in a group where the level of energy is spread across the trait, measured by the SEQ., Conclusion: The stress scale of the SEQ has good psychometric properties and provides a useful tool for assessing work-related stress, on both group and individual levels. However, the limitations of the energy scale make it suitable for group evaluations only. The energy scale needs to be evaluated further in different settings and populations.

Background: Socioeconomic inequalities in smoking habits have stabilized in many Western countries. This study aimed at evaluating whether socioeconomic disparities in smoking habits are still enlarging in Italy and at comparing the impact of education and occupation., Methods: In the frame of the GEIRD study (Gene Environment Interactions in Respiratory Diseases) 10,494 subjects, randomly selected from the general population aged 20-44 years in seven Italian centres, answered a screening questionnaire between 2007 and 2010 (response percentage = 57.2%). In four centres a repeated cross-sectional survey was performed: smoking prevalence recorded in GEIRD was compared with prevalence recorded between 1998 and 2000 in the Italian Study of Asthma in Young Adults (ISAYA)., Results: Current smoking was twice as prevalent in people with a primary/secondary school certificate (40-43%) compared with people with an academic degree (20%), and among unemployed and workmen (39%) compared with managers and clerks (20-22%). In multivariable analysis smoking habits were more affected by education level than by occupation. From the first to the second survey the prevalence of ever smokers markedly decreased among housewives, managers, businessmen and free-lancers, while ever smoking became even more common among unemployed (time-occupation interaction: p = 0.047). At variance, the increasing trend in smoking cessation was not modified by occupation., Conclusion: Smoking prevalence has declined in Italy during the last decade among the higher socioeconomic classes, but not among the lower. This enlarging socioeconomic inequality mainly reflects a different trend in smoking initiation.

Background: Inequity in health is a global concern. Even in Sweden there are considerable health gaps between different social groups, not least concerning life-style related conditions. Interventions drawing on Community-based participatory research (CBPR) have potential to build prerequisites for complex, supportive structures that constitute basis for implementation of sustainable health promoting programs. CBPR rests on principles of empowerment. The researchers are responsible for the scientific quality and that ethical standards are met. Health Equilibrium Initiative (HEI) aims at narrowing the health gap and promoting healthy weight in children; "healthy weight" including both anthropometric criteria and aspects having to do with self-esteem and self-efficacy. Evaluation objectives are to compare outcome between children in intervention and control areas, conduct health economic assessments (HEA) and evaluate the processes of the project., Methods/design: HEI is a repeated cross-sectional and longitudinal study. The Program Logic Model is based on Social Cognitive Theory and Intervention Mapping. Primary contact groups are children in disadvantaged communities. Core efforts are to confirm and convey knowledge, elucidate and facilitate on-going health work and support implementation of continuous health work. Socioeconomic status is assessed on area level by the parameters yearly average income, degree of employment, tertiary education and percent of inhabitants born in countries where violent conflicts recently have taken place or were ongoing. Anthropometry, food patterns, physical activity and belief in ability to affect health; together with learning, memory and attention assessment will be assessed in 350 children (born 2006). Examinations will be repeated after two years, forming the basis of a health economic analysis. The process evaluation procedure will use document analysis (such as structured reports from meetings and dialogues, school/workplaces policies and curriculum, food service menus); key informant interviews and focus groups with parents, children and professionals., Discussion: Inviting, awaiting and including local perspectives create mutual confidence and collaboration. Enhanced self-efficacy and access to relevant knowledge has potential to enable individuals and communities to choose alternatives that are relevant for their health and well-being in a long perspective. The economic of this study may contribute in decision- making processes regarding appropriate public health interventions.

Background: Previous work has found that first-generation immigrants to developed nations tend to have better health than individuals born in the host country. We examined the evidence for the healthy immigrant effect and convergence of health status between Chinese immigrants (n = 147) and U.S. born whites (n = 167) participating in the cross-sectional Community Assessment of Freeway Exposure and Health study and residing in the same neighborhoods., Methods: We used bivariate and multivariate models to compare disease prevalence and clinical biomarkers., Results: Despite an older average age and lower socioeconomic status, Chinese immigrants were less likely to have asthma (OR = 0.20, 95% CI = 0.09-0.48) or cardiovascular disease (OR = 0.44, 95% CI = 0.20-0.94), had lower body mass index (BMI), lower inflammation biomarker levels, lower average sex-adjusted low-density lipoprotein (LDL) cholesterol, and higher average sex-adjusted high-density lipoprotein (HDL) cholesterol. However, there was no significant difference in the prevalence of diabetes or hypertension. Duration of time in the U.S. was related to cardiovascular disease and asthma but was not associated with diabetes, hypertension, BMI, HDL cholesterol, LDL cholesterol, socioeconomic status, or health behaviors., Conclusions: The lower CVD and asthma prevalence among the Chinese immigrants may be partially attributed to healthier diets, more physical activity, lower BMI, and less exposure to cigarette smoke. First generation immigrant status may be protective even after about two decades.

Background: Few population-based studies assessing IPV among randomly selected women and men have been conducted in Sweden. Hence, the aim of the current study was to explore self-reported exposure, associated factors, social and behavioural consequences of and reasons given for using psychological, physical and sexual intimate partner violence (IPV) among women and men residing in Sweden., Methods: Cross-sectional postal survey of women and men aged 18-65 years. Bivariate and multivariate logistic regression analyses were used to identify factors associated with exposure to IPV., Results: Past-year IPV exposure rates were similar in women and men; however, earlier-in-life estimates were higher in women. Poor to moderate social support, growing up with domestic violence and being single, widowed or divorced were associated with exposure to all forms of IPV in men and women. Women and men tended to report different social consequences of IPV., Conclusions: Our finding that women reported greater exposure to IPV earlier-in-life but not during the past year suggests the importance of taking this time frame into account when assessing gender differences in IPV. In-depth, qualitative studies that consider masculinities, femininities power and gender orders would be beneficial for extending and deepening our understanding of the gendered matter of IPV.

Background: Some previous studies have proposed potential explanatory factors for the social gradient in sickness absence. Yet, this research area is still in its infancy and in order to comprise the full range of socioeconomic positions there is a need for studies conducted on random population samples. The main aim of the present study was to investigate if somatic and mental symptoms, mental wellbeing, job strain, and physical work environment could explain the association between low socioeconomic position and belonging to a sample of new cases of sick-listed employees., Methods: This study was conducted on one random working population sample (n = 2763) and one sample of newly sick-listed cases of employees (n = 3044), drawn from the same random general population in western Sweden. Explanatory factors were self-rated 'Somatic and mental symptoms', 'Mental well-being', 'job strain', and 'physical work conditions' (i.e. heavy lifting and awkward work postures). Multiple logistic regression analyses were used., Results: Somatic and mental symptoms, mental well-being, and job strain, could not explain the association between socioeconomic position and sickness absence in both women and men. However, physical work conditions explained the total association in women and much of this association in men. In men the gradient between Non-skilled manual OR 1.76 (1.24;2.48) and Skilled manual OR 1.59 (1.10;2.20), both in relation to Higher non-manual, remained unexplained., Conclusions: The present study strengthens the scientific evidence that social differences in physical work conditions seem to comprise a key element of the social gradient in sickness absence, particularly in women. Future studies should try to identify further predictors for this gradient in men.

Background: Good work ability is very important in young workers, but knowledge of work situations that influence work ability in this group is poor. The aim of this study was to assess whether changes in self-reported work factors are associated with self-reported work ability among young female and male workers., Methods: A sample of 1,311 (718 women and 593 men) was selected from a Swedish cohort of workers aged 21-25 years. At baseline and at 1-year follow-up, participants completed a self-administrated questionnaire including ratings of physical and psychosocial work factors and current work ability. Prevalence ratios were calculated to assess univariate and multivariate associations between changes in work factors and changes in work ability., Results: Decreased job control (PR 1.7, 95% CI 1.49-2.12) and increased negative influence of job demands on private life (PR 1.5, 95% CI 1.25-1.69) were associated with reduced work ability for both female and male workers in the multivariate analyses. Among female workers, an association was found between improved work ability and increased social support at work (PR 2.4, CI 1.43-3.95). For male workers, increased job control (PR 2.3, 95% CI 1.21-4.54) and decreased negative influence of job demands on private life (PR 2.1, 95% CI 1.10-3.87) were associated with improved work ability in the multivariate analyses., Conclusions: Decreased job control and increased negative influence of job demands on private life over time seem to be the most important work factors associated with reduced work ability among young workers of both sexes. Increased social support at work, increased job control, and decreased negative influence of job demands on private life were also found to be the main work factors associated with improved work ability, although with possible gender differences.

Background: Despite advances in surveillance and prevention, pneumonia and influenza (P&I) remain among the leading causes of mortality in the United States. Elderly adults experience the most severe morbidity from influenza-associated diseases, and have the highest rates of seasonal migration within the U.S. compared to other subpopulations. The objective of this study is to assess spatiotemporal patterns in influenza-associated hospitalizations in the elderly, by time, geography, and intensity of P&I. Given the high seasonal migration of individuals to Florida, this state was examined more closely using harmonic regression to assess spatial and temporal patterns of P&I hospitalizations by state of residence., Methods: Data containing all Medicare-eligible hospitalizations in the United States for 1991-2006 with P&I (ICD-9-CM codes 480-487) were abstracted for the 65+ population. Hospitalizations were classified by state of residence, provider state, and date of admissions, specifically comparing those admitted between October and March to those admitted between April and September. We then compared the hospitalization profile data of Florida residents with that of out-of-state residents by state of primary residence and time of year (in-season or out-of-season)., Results: We observed distinct seasonal patterns of nonresident P&I hospitalizations, especially comparing typical winter destination states, such as California, Arizona, Texas, and Florida, to other states. Although most other states generally experienced a higher proportion of non-resident P&I during the summer months (April-September), these states had higher nonresident P&I during the traditional peak influenza season (October-March)., Conclusions: This study is among the first to quantify spatiotemporal P&I hospitalization patterns in the elderly, focusing on the change of patterns that are possibly due to seasonal population migration. Understanding migration and influenza-associated disease patterns in this vulnerable population is critical to prepare for and potentially prevent influenza outbreaks in this vulnerable population.

Background: Because of the quick development and widespread use of mobile phones, and their vast effect on communication and interactions, it is important to study possible negative health effects of mobile phone exposure. The overall aim of this study was to investigate whether there are associations between psychosocial aspects of mobile phone use and mental health symptoms in a prospective cohort of young adults., Methods: The study group consisted of young adults 20-24 years old (n = 4156), who responded to a questionnaire at baseline and 1-year follow-up. Mobile phone exposure variables included frequency of use, but also more qualitative variables: demands on availability, perceived stressfulness of accessibility, being awakened at night by the mobile phone, and personal overuse of the mobile phone. Mental health outcomes included current stress, sleep disorders, and symptoms of depression. Prevalence ratios (PRs) were calculated for cross-sectional and prospective associations between exposure variables and mental health outcomes for men and women separately., Results: There were cross-sectional associations between high compared to low mobile phone use and stress, sleep disturbances, and symptoms of depression for the men and women. When excluding respondents reporting mental health symptoms at baseline, high mobile phone use was associated with sleep disturbances and symptoms of depression for the men and symptoms of depression for the women at 1-year follow-up. All qualitative variables had cross-sectional associations with mental health outcomes. In prospective analysis, overuse was associated with stress and sleep disturbances for women, and high accessibility stress was associated with stress, sleep disturbances, and symptoms of depression for both men and women., Conclusions: High frequency of mobile phone use at baseline was a risk factor for mental health outcomes at 1-year follow-up among the young adults. The risk for reporting mental health symptoms at follow-up was greatest among those who had perceived accessibility via mobile phones to be stressful. Public health prevention strategies focusing on attitudes could include information and advice, helping young adults to set limits for their own and others' accessibility.