Showing papers in "International Journal of Public Health in 2012"

Associations between problematic mobile phone use and psychological parameters in young adults.

Abstract: This study aims to address possible associations between excessive or dysfunctional use of mobile phones and certain psychological variables. Our study focuses on Problematic Mobile Phone Use (PU) in 196 young adults. A survey was arranged to measure PU, daily mobile phone use in minutes, use of short message service (SMS) and also included psychological and health variables (e.g., chronic stress, depression). Statistic analysis indicates that chronic stress, low emotional stability, female gender, young age, depression, and extraversion are associated with PU. Future research needs to clarify the causality of these findings and should also intend to develop concepts for a more meaningful use of mobile phone and related technologies.

Classification and regression trees

Abstract: Public health data are often complex, unbalanced and contain missing values. The relationships between a health outcome and its determinants may not be linear and necessitate higher order interactions. Classification and Regression Trees (CaRTs) are analytical tools that can be used to explore such relationships. They can be used to analyze either categorical (resulting in classification trees) or continuous health outcomes (resulting in regression trees). Figure 1a shows an illustrative example, of a classification tree (CT) result, using a binary health outcome, e.g. being diseased or healthy. The building of a CT begins with a parent node, containing all individuals in a data set, which is then split at a determined value along a range of values for a variable thus producing two child nodes with greater homogeneity (purity) than the parent node. In Fig. 1a, the most homogeneous grouping is reached by first splitting the individuals—denoted by dots—into two groups depending on whether they have a number of years of education less than some specified level c1. The program iterates on all possible values of the independent variables to identify the first splitter as well as the cut-point for the split, c1, aiming, as far as possible, to result in one group with only diseased individuals and another group with healthy individuals. The group of individuals below c1 still contain a mixture of healthy and diseased individuals. Child nodes are recursively treated as parent nodes, thereby continuously splitting the data trying to further sift out diseased from healthy individuals. In our example, the group of individuals with years of education less than c1 is split again according to income, at the level c2. The individuals to the left of the c2 line, and below c1, those with relatively low levels of literacy and income, also have the highest percentage of subjects being sick. Most often it is not possible to reach the ideal result in Fig. 1a, but the program aims to create groups which are as homogeneous as possible. For a binary explanatory variable, only one split is possible, each level defining a group. For categorical variables with k levels, there are 2-1 possible splits. For numeric explanatory variables, a split is defined by values less than, some value, and for h unique values there are h-1 possible splits. From all possible splits of all explanatory variables, called splitters; the program selects the one that maximizes the homogeneity (purity) of the two resulting groups. The final result resembles an inverted tree (see Fig. 1b), structured as a sequence of simple yes/no questions. The tree building process results in a saturated tree with one case or only cases of one type in each terminal node (i.e., a nodes which is not split further) probably greatly overfitting the information contained within the data set. However, as with stepwise linear regression procedures, adding variables will continuously increase the fit of the model to the data, but at the cost of increasing the true fit to an independent data set. Breiman et al. (1993) showed that an optimal tree can be obtained through a process of using a learning data set (e.g. one part of the data) to prune the saturated tree and select among the so obtained sequence of nested trees, an optimal tree with an appropriate fit to a N. Speybroeck (&) Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium e-mail: Niko.Speybroeck@uclouvain.be Int J Public Health (2012) 57:243–246 DOI 10.1007/s00038-011-0315-z

Does parental involvement make a difference in school-based nutrition and physical activity interventions? A systematic review of randomized controlled trials.

Abstract: Objectives Parental involvement is often advocated as important for school-based interventions, however, to date, only inconsistent evidence is available. Therefore, this study aimed at determining the impact of parental involvement in school-based obesity prevention interventions in children and adolescents.

A scoping review of intersectoral action for health equity involving governments.

Abstract: We carried out a scoping review to identify and describe scholarly and grey literature referring to global cases of intersectoral action for health equity featuring a central role for governments. The scoping review process systematically identified articles describing one or more cases of intersectoral action. Each article was then described in terms of the context of initiation, as well as the strategies, actors, tools and structures used to implement these initiatives. 128 unique articles were found describing intersectoral action across 43 countries. A majority of the cases appear to have initiated in the last decade. A variety of approaches were used to carry out intersectoral action, but articles varied in the richness of information included to describe different aspects of these initiatives. With this examination of cases across multiple countries and contexts, we can begin to clarify how intersectoral approaches to health equity have been used; however, the description of these complex, multi-actor processes in the published documents was generally superficial and sometimes entirely absent and improvements in such documentation in future publications is warranted. Richer sources of information such as interviews may facilitate a more comprehensive understanding from the perspective of multiple sectors involved.

Air pollution interventions and their impact on public health

Abstract: INTRODUCTION: Numerous epidemiological studies have found a link between air pollution and health. We are reviewing a collection of published intervention studies with particular focus on studies a ...

Education and physical health trajectories in old age. Evidence from the Survey of Health, Ageing and Retirement in Europe (SHARE)

Abstract: The model of cumulative inequality predicts that health differences between educational levels increase with age. Using a variety of analytical approaches and measures of health, studies have, however, reported increasing as well as decreasing and constant patterns of educational health inequality. The aim of this study is use a standardized research design to compare different dimensions of health inequality trajectories across educational levels. We used data from two waves (2004/2005 and 2006/2007) of SHARE. The sample consisted of respondents aged 50–80 (n = 14,818). Using OLS regression models, we analyzed trajectories of health inequality in self-reported measures (ADL, IADL, mobility, chronic diseases, and self-rated health) as well as non-invasive objective measures (grip strength) of physical health. Inequality between higher and lower educated individuals increased significantly in limitations of physical functioning and grip strength. In chronic diseases and self-rated health, the gap between these two groups remained constant. Although our results mainly supported the model of cumulative inequality, they also showed that the trajectory of the education-health gradient is not uniform but varies across different dimensions of physical health.

Socioeconomic position, resilience, and health behaviour among elderly people.

Abstract: Healthy psychological functioning, the ability to respond rapidly to environmental changes, has been associated with better health outcomes. Less work has examined the association with health behaviour. This study explores whether resilience (a specific expression of healthy psychological functioning) is positively associated with health behaviour in an elderly population aged ≥65 years and whether this association differs in different socioeconomic groups. Resilience was measured in 3,942 elderly participating in a population-based cohort study (KORA-Age study) in Germany through a short version of the Resilience Scale developed by Wagnild and Young. Regression analyses were performed by socioeconomic position (low/high educational level or income) for two outcome variables, i.e. high consumption of fruit and vegetables and high/moderate physical activity. Resilient people were more likely to consume ≥5 servings of fruit and vegetables a day and to perform high/moderate physical activity as compared to non-resilient people (ORs ranging from 1.5 to 2.2), irrespective of socioeconomic position. Resilience could provide an important starting point for health promotion strategies, addressing resources rather than deficits and risk factors.

Prevalence of self-reported cardiovascular risk factors in Portuguese women: a survey after delivery.

Abstract: To estimate the pre-pregnancy prevalence of overweight/obesity, smoking, hypertension, dyslipidemia and diabetes mellitus, in women who delivered a live born. In a birth cohort study, puerperae were consecutively recruited at five public maternities of Porto, Portugal (2005–2006). We included 7,381 women with complete data for the current analysis. Socioeconomic characteristics, smoking habits, pre-pregnancy weight and chronic diseases diagnosis were self-reported and height was measured. Before pregnancy, 21.3% of women were overweight and 8.8% were obese, 26.6% smoked and 11.2% were former smokers. The prevalence of hypertension, dyslipidemia and diabetes mellitus was 1.7, 1.7 and 0.6%, respectively, with an evident tendency to cluster. The prevalence of all cardiovascular risk factors, except smoking, increased with age and body mass index. Education and income were inversely associated with excessive weight. Current smokers were younger, thinner and in a lower socioeconomic position, whereas former smokers were older and in a higher socioeconomic position. Despite the low prevalence of hypertension, dyslipidemia and diabetes, their tendency to cluster and the increased prevalence among overweight/obese women highlight the high level of risk of this young female population.

Measuring population mental health and social well-being.

Abstract: This paper examines the relationships between indicators of positive and negative dimensions of mental health, social well-being and physical health. The paper reports on data collected in the third National Survey of Lifestyle, Attitudes and Nutrition (SLAN 2007), a cross-sectional survey conducted with a representative sample of 10,364 Irish adults. The survey included measures of positive mental health and non-specific psychological distress from the SF-36 questionnaire, together with measures of social well-being, subjective health, and selected health behaviours. Positive mental health is predicted by lower levels of loneliness and higher levels of social support. Better self-rated health, positive health behaviours and lower GP consultation rates are associated with higher levels of positive mental health. Lower levels of social well-being, were found to be the strongest predictors of negative mental health. Social well-being and health behaviours correlate with both positive and negative mental health. These findings highlight the need to endorse comprehensive approaches to population mental health promotion. The inclusion of both positive and negative mental health indicators in future population health surveys is supported by the findings.

Research on Roma health and access to healthcare: state of the art and future challenges

Abstract: Health inequalities experienced by Roma people living in Europe presents a persisting challenge for health research and practice. Available literature on Roma and health agrees that: (1) Roma people suffer from poorer health and unhealthier living conditions compared to majority populations, (2) better data are needed to explain the Roma health gap and design better interventions to reduce this gap and (3) the poor health of Roma is closely linked to the social determinants of health. This editorial discusses the lessons to be learnt from recent research findings and outlines a number of challenges in exploring and addressing the various mechanisms that contribute to the health gap between Roma and majority populations.

Socio-economic disparities in mortality due to pandemic influenza in England

Abstract: Objectives This study examines variations in mortality between socio-economic groups due to the pandemic Influenza (H1N1) 2009 virus in England.

Early substance use initiation and suicide ideation and attempts among students in France and the United States.

Abstract: In response to recent research documenting a link between early substance use and suicidal behaviors among youth, the current study sought to examine the associations between ages of substance use initiation and suicidal behavior among students in France and the USA. Cross-sectional logistic regression analyses based on the 2003 European School Survey Project on Alcohol and Other Drugs (ESPAD) survey (France; n = 13,187) and the 2003 Youth Risk Behavior Survey (YRBS) (United States; n = 15,136) assessed associations between early substance use initiation (i.e., alcohol, cigarette and cannabis/marijuana) and suicide ideation and attempts while controlling for potential confounders. Early alcohol use initiation (ORadj = 1.52; 95% CI 1.17–1.97) and early cannabis/marijuana use initiation (ORadj = 2.90; 95% CI 2.20–3.83) were associated with suicide attempt in France. Early smoking was associated with suicide attempt in both France (ORadj = 1.92; 95% CI 1.55–2.37) and the USA (ORadj = 1.53; 95% CI 1.02–2.28). Sex differences were also noted. The associations between substance use initiation and suicidal behaviors differed in the United States and France. These findings, placed into context, can assist the development and implementation of prevention strategies that seek to reduce the harmful consequences of early substance use among youth.

Prevalence, awareness, treatment, control and risk factors for hypertension in a rural population in South India

Abstract: Hypertension is a major public health problem with prevalence ranging 22–30% in urban India. There are few data on hypertension epidemiology in rural India. We conducted a survey to estimate prevalence, awareness, treatment, control and risk factors for hypertension in a rural population in south India. We did cross-sectional survey in 11 villages in Tamil Nadu. We collected data on behavioral risk factors, anthropometric and blood pressure measurements. We defined hypertension according to WHO criteria. Study population included 10,463 subjects aged 25–64 years. Among them, 4,900 (46.8%) were males. Hypertension was present for 2,247 (21.4%) subjects and 1,682 (74.9%) among hypertensives were newly detected. Overall 20% were on treatment and 6.6% had blood pressure control. Age ≥35 years, BMI ≥ 23 kg/m2 and central obesity were risk factors significantly associated with hypertension (p < 0.05). In addition, alcohol consumption, higher education level were risk factor among males and family history of hypertension was risk factor among females (p < 0.05). Hypertension is an emerging challenge in rural India. We need health promotion programs and reorientation of primary health care to improve hypertension detection and management.

Migration and depressive symptoms in migrant-sending areas: findings from the survey of internal migration and health in China

Abstract: Objectives China has experienced large-scale internal migration and growing mental health disorders. Limited research has examined the relationship between the two processes. We examined the association between labor out-migration and depressive symptoms of family members left behind in migrant-sending areas.

Socioeconomic position, gender, and inequalities in self-rated health between Roma and non-Roma in Serbia

Abstract: Roma experience high levels of discrimination and social exclusion. Our objective was to examine differences in self-rated health (SRH) between Roma and non-Roma in Serbia. Using data from the 2007 Living Standards Measurement Survey in Serbia (n = 14,313), we used binomial regression to estimate the relative risk (RR) of poor (SRH) among Roma (n = 267) relative to non-Roma. We additionally conducted group comparisons of combinations of Romani ethnicity, poverty, and gender, relative to the baseline group of non-Roma males not in poverty. Adjusting for age, Roma were more than twice as likely as non-Roma to report poor SRH (RR = 2.3, 95% Confidence Interval (CI) = 1.8, 2.8). After adjustment for household consumption, employment, and education, the RR was reduced to 1.6 (95% CI = 1.3, 2.0). Romani women, regardless of whether they were living in poverty or not, experienced the greatest risk of poor SRH, with risks relative to non-Roma males not in poverty of 3.2 (95% CI = 2.3, 4.2) and 3.1 (95% CI = 2.4, 4.0), respectively. Roma in Serbia are at increased risk of poor SRH; Romani women experience the greatest burden of poor SRH.

Son preference and sex-selective abortion in China: informing policy options.

Abstract: Objectives There is growing evidence in China that son preference is on the decline, but the sex ratio at birth is still the highest in the world at around 120 male births to 100 females. The aim of the study was to explore attitudes towards gender preference among people of reproductive age, to determine the reasons why the sex ratio is persistently high, and to inform policy options.

Perceptions of the food environment are associated with fast-food (not fruit-and-vegetable) consumption: findings from multi-level models.

Abstract: Diets low in fruits and vegetables and/or high in fast foods are associated with obesity and chronic diseases. Such diets may relate to different aspects of neighborhood food environments. We sought to evaluate if people’s perceptions of their neighborhood food environment are associated with reported fruit-and-vegetable and fast-food consumption. Cross-sectional analysis of a community health survey from Philadelphia, PA and four surrounding suburban counties (n = 10,450 individuals). We used mixed-effects multi-level Poisson models, nesting individuals within neighborhoods—i.e. census tracts (n = 991). Negative perceptions of the food environment (perceived difficulty finding fruits and vegetables, having to travel outside of one’s neighborhood to get to a supermarket, and perceived poor grocery quality) were each directly associated with fast-food consumption (incident rate ratios [IRRs] 1.31, 1.06, 1.20; p < 0.001, 0.04, < 0.001 respectively), but not significantly associated with fruit-and-vegetable consumption. Perceived difficulty finding or accessing produce and high-quality groceries may support the eating of more fast food. Neighborhoods where food-environment perceptions are worst might benefit from interventions to improve availability, accessibility, and quality of healthy foods, towards shifting consumption away from fast foods.

The influence of social status on pre-school children’s eating habits, caries experience and caries prevention behavior

Abstract: Objectives To assess the prevalence of Early Childhood Caries (ECC) in a county in Northern Hesse and to correlate this parameter to various independent variables. Additionally to investigate the relationship between preventive measures and the socioeconomic status (SES).

A multilevel examination of factors of the school environment and time spent in moderate to vigorous physical activity among a sample of secondary school students in grades 9–12 in Ontario, Canada

Abstract: Objective To examine associations between students’ time spent in moderate to vigorous physical activity (MVPA) and the school built environment while also considering features of the schools’ social environment and student-level characteristics.

Estimates of obesity trends in Brazil, 2006–2009

Abstract: Objective This study investigates the prevalence and trends of obesity among Brazilian adults, from 2006 to 2009, according to socio-demographic variables.

How home-smoking habits affect children: a cross-sectional study using urinary cotinine measurement in Italy

Abstract: To assess the impact of different home-smoking rules and smoking habits of cohabitant on environmental tobacco smoke (ETS) exposure of children. Information about 396 Italian children (5–11 years old) and cohabitants’ smoking habits was collected by a questionnaire. Exposure assessment was performed by determination of urinary cotinine (u-cotinine). Median u-cotinine concentrations in children significantly increased in a similar fashion as theoretical ETS exposure increase: cohabitants do not smoke (1.79 μg/g creatinine), cohabitant(s) smoker(s) never smoke at home (2.84), smoke at home only when children are out (3.90), and smoke at home even if children are in (6.02). Median u-cotinine levels of exposed children were associated to the strength of cohabitant’s smoking behaviours when smoker(s) consume daily a high number of cigarettes (≥ 20) respect to light consumption (1–9) (4.52 and 3.24 μg/g creatinine). The magnitude of ETS exposure in children is correlated with smoking habits and home-smoking precautions adopted by their cohabitants. Educational interventions on parents are essential to increase their awareness about ETS exposure and to teach correct behaviours to protect health of kids, especially in household environment.

Using factor analysis to identify dietary patterns in Iranian adults: Isfahan Healthy Heart Program.

Abstract: To identify dietary patterns of a representative sample of Iranian adults using factor analysis. This study was conducted in 2000–2001 as the baseline survey of Isfahan Healthy Heart Program (IHHP). We studied 12,514 participants aged ≥19 years who were randomly selected in three counties of Central Iran. A validated 48-item food frequency questionnaire was completed and factor analysis was used to identify dietary patterns. Four major dietary patterns were identified, namely “Western”, “animal fat”, “traditional” and “Mediterranean”. In both men and women, we found a significant positive relationship between age and Mediterranean diet, and a negative relationship between age and the other three dietary patterns (P < 0.001). The Western and traditional dietary patterns showed a significant negative relationship with education in both genders (P < 0.01). The Western dietary pattern correlated positively with being single, widowed, or a divorced man (P < 0.001). We identified four major dietary patterns. As dietary pattern analysis is useful to identify dietary behaviors in relation to health risks, the results can be practical.

Prostate-specific antigen testing in Tyrol, Austria: prostate cancer mortality reduction was supported by an update with mortality data up to 2008

Abstract: Objectives The objective of this study was to update an in-depth analysis of the time trend for prostate cancer (PCA) mortality in the population of Tyrol by 5 years, namely to 2008. In Tyrol, prostate-specific antigen (PSA) tests were introduced in 1988/89; more than three-quarters of all men in the age group 45‐74 had at least one PSA test in the past decade. Methods We applied the same model as in a previous publication, i.e., an age-period-cohort model using Poisson regression, to the mortality data covering more than three decades from 1970 to 2008. Results For Tyrol from 2004 to 2008 in the age group 60? period terms show a significant reduction in prostate cancer mortality with a risk ratio of 0.70 (95% confidence interval 0.57, 0.87) for Tyrol, and for Austria excluding Tyrol a moderate reduction with a risk ratio of 0.92 (95% confidence interval 0.87, 0.97), each compared to the mortality rate in the period 1989‐1993. Conclusions This update strengthens our previously published results, namely that PSA testing offered to a population at no charge can reduce prostate cancer mortality. The extent of mortality reduction is in line with that reported in the other recent publications. However, our data do not permit us to fully assess the harms associated with PCA screening, and no recommendation for PSA screening can be made without a careful evaluation of overdiagnosis and overtreatment.

Preventive youth health care in 11 European countries: an exploratory analysis

Abstract: Objective To systematically identify similarities and differences in the way preventive youth health care (YHC) is organized in 11 European countries. Method Questionnaire survey to EUSUHM (European Union for School and University Health and Medicine) representatives. Results The greatest similarities were found in the age range of the YHC target group and the separation of curative and preventive services. Croatia, Germany and Switzerland show the greatest differences when compared to other European countries, for example, in the access to medical records, YHC professional input and the number of examinations, immunizations and screenings. In eight countries YHC is financed by national insurances or taxation. In Germany, FYR Macedonia, the Netherlands, Russia and Switzerland, different forms of financing exist in parallel. Conclusion The results should be interpreted as a preliminary step in mapping organizational features of YHC in Europe. © Swiss School of Public Health 2011.

Time series analysis of Japanese encephalitis and weather in Linyi City, China.

Abstract: To examine the relationship between meteorological factors and epidemiological pattern of Japanese encephalitis in Linyi City during 1956–2004. Autoregressive integrated moving average (ARIMA) models were used to evaluate the relationship between monthly JE incidence and weather factors. Logarithmic transformation was applied to the JE incidence series to assure the normality and homogeneity of variance of the residuals. The effect of mass vaccination on JE incidence was also evaluated using a transfer function in the time series analysis. The analysis suggested that monthly average temperature [β = 0.0574, 95% confidence interval (CI) = (0.0172, 0.0976)] and relative humidity [β = 0.0082, 95% CI = (0.0004, 0.0158)] were positively associated with the logarithmic incidence of Japanese encephalitis after adjusting for mass vaccination in this area. Weather variables might be treated as possible predictors of Japanese encephalitis incidence for regions with similar geographic, weather, and socio-economic conditions to Linyi, China.

The health of migrant children in Switzerland.

Abstract: Over 22 % of children and adolescents living in Switzerland have a migrant background. The aim of this systematic literature review is to give an overview of health needs of paediatric migrants in Switzerland. Three databases (Embase, Medline, Global health) were systematically searched for quantitative primary research on the health outcomes of migrant minors (<18-year old) in Switzerland, including articles published since 2000 in French, German, Italian or English. Citation chasing and search of non-indexed literature was also performed. Thirty publications were identified. Compared to their Swiss peers, migrant children had higher hospitalisation (+40 %) and intensive care admission rates, more dental cavities, twice the odds of being obese, and migrant adolescents seemed more frequently affected by psychological problems and twice as often requesting abortions. Certain infectious diseases (tuberculosis, intestinal parasites, H. pylori infection, Hepatitis A) were more prevalent. Increased neonatal and infant mortality rates were found in Turkish and African babies. Children of migrants may have distinct health needs. They should benefit from migrant paediatric care and health promotion activities that recognise these.

Projected impact of urbanization on cardiovascular disease in China.

Abstract: Objectives The Coronary Heart Disease (CHD) Policy Model-China, a national scale cardiovascular disease computer simulation model, was used to project future impact of urbanization.

Alcohol-attributable burden of disease and injury in Canada, 2004.

Abstract: This analysis aimed to estimate the burden of disease and injury caused and prevented by alcohol in 2004 for Canadians aged 0–69 years and compare the effects of different magnitudes of adjustment of survey data on these estimates. Alcohol indicators were obtained from the Canadian Alcohol and Drug Use Monitoring Survey 2008 and were corrected to 80% coverage using adult per capita recorded and unrecorded consumption. Risk relations were taken from meta-analyses. Estimates of burden of disease and injury were obtained from the World Health Organization. In 2004, 4,721 (95% CI 1,432–8,150) deaths and 274,663 (95% CI 201,397–352,432) disability-adjusted life years lost (DALYs) of Canadians 0–69 years of age were attributable to alcohol. This represented 7.1% (95% CI 2.1–12.2%) of all deaths and 9.3% (95% CI 6.8–11.9%) of DALYs for this age range. The sensitivity analysis showed that the outcome estimates varied substantially based on the adjusted coverage rate. More attention to burden of disease and injury statistics is required to accurately characterize alcohol-related harms. This burden is preventable and could be reduced by implementation of more effective policies.

The single most important intervention to tackle obesity

Abstract: I was asked recently to name the single most important intervention to reduce childhood obesity My weary reply was that the single most important intervention is to understand that there is no single most important intervention This was greeted with predictable dismay, and groans of derision from my colleagues, who chided me for imperious ivory-towered idealism But I stand by my response Obesity is the outcome of a complex web of social, cultural, environmental, biological and psychological influences As has recently been described in this journal (Raine 2012) people’s diets and physical activity exist within an ecological system of human behaviour that requires upstream actions to shift it The system map produced for the UK Government’s Foresight report clearly shows how this complex system acts at all levels of society, with numerous linkages and interactions (Butland et al 2007; Finegood et al 2010) But what do we need to do fully to understand a complex system such as this, and more importantly how do we decide how best to respond to it? The scientific underpinnings of public health have made huge advances in recent years, building to a large extent on the principles of evidence-based medicine (EBM) But many complex questions about the most effective ways to influence behaviour and improve health are simply not amenable to this kind of assessment There is a fundamental epistemological difference between the rigorous EBM methods that can differentiate between two treatments, and the kinds of research that are able to identify effective, sustainable approaches within complex adaptive systems We need to move from evidence to knowledge (Rayner and Lang 2012), but public health remains largely in thrall to the EBM approach In obesity, despite the rhetoric of complexity becoming commonplace, there is still a strong intellectual dependence upon systematic reviews and other forms of putatively robust and defensible evidence The concept of complexity in health care, and in public health, has been around for some years now (Plsek and Greenhalgh 2001), but remains on the margins of the majority of health and policy activity This may be at least partly because of the inherent challenge of the perspective to a discipline grounded in biomedicine Randomised controlled trials and meta analyses are the kinds of tools that have successfully dragged us away from the unhelpful biases of expert opinion and led us to disinterested objectivity But non-linear systems with feedback, interactions, emergence, compensatory behaviours and small effect sizes are not suited to dichotomous hypothesis testing, resulting in few robust studies and often very little to review The job of public health is not the same as the one we started on a few years ago, and now is the time for some new tools, and new skills to use them These tools are commonly used in other fields, such as climate change modelling, defence, and business They involve a significant shift in thinking, from linear cause and effect to non-linear system-wide dynamics, and much greater tolerance of uncertainty and unpredictability These ways of thinking allow us to conceptualise and respond to systems problems such as obesity in far more effective H Rutter (&) London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK e-mail: harryrutter@lshtmacuk Int J Public Health DOI 101007/s00038-012-0385-6

Balcova heart study: rationale and methodology of the Turkish cohort.

Abstract: Turkey is facing increasing rates of cardiovascular disease (CVD). The study is designed to meet the growing need to obtain information about the recent status and trends of CVD risk factors and their impact on mortality. Balcova heart study (BHS) is a prospective cohort study, focusing on reducing the CVD risk factors of people over 30 years old living in Balcova District, Izmir, Turkey. Information about risk factors, anthropometric and biochemical measurements was collected in community centers. Interventions were planned, based on the 10-year coronary heart disease (CHD) risk and lifestyle characteristics with the collaboration of university and municipality. Mean age of the 16,080 participants was 52 years. The percentage of current smoking was 41.6 in men and 31.1 in women. One-third of the men were physically inactive. Hypertension was reported as 25% in men and 33% in women. The project is unique for being the first community-based cohort on CVD risk factors in a Turkish setting. This project will have a valuable contribution on not only determining CVD risks, but also incorporating interventions for prevention.