Showing papers in "Public Health Research in 2016"

Implications for public health research of models and theories of disability: A scoping study and evidence synthesis

Abstract: Background: Public health interventions that are effective in the general population are often assumed to apply to people with impairments. However, the evidence to support this is limited and hence there is a need for public health research to take a more explicit account of disability and the perspectives of people with impairments. Objectives: (1) To examine the literature on theories and models of disability; (2) to assess whether or not, and how, intervention studies of effectiveness could incorporate more inclusive approaches that are consistent with these theories and models; and (3) to use the findings to draw out implications for improving evaluative study designs and evidence-based practice. Review methods: The project is a scoping review of the literature. The first stage examines theories and models of disability and reflects on possible connections between theories of disability and public health paradigms. This discussion is used to develop an ethical–empirical decision aid/checklist, informed by a human rights approach to disability and ecological approaches to public health. We apply this decision aid in the second stage of the review to evaluate the extent to which the 30 generic public health reviews of interventions and the 30 disability-specific public health interventions include the diverse experiences of disability. Five deliberation panels were also organised to further refine the decision aid: one with health-care professionals and four with politically and socially active disabled people. Results: The evidence from the review indicated that there has been limited public health engagement with theories and models of disability. Outcome measures were often insensitive to the experiences of disability. Even when disabled people were included, studies rarely engaged with their experiences in any meaningful way. More inclusive research should reflect how people live and ‘flourish’ with disability. Limitations: The scoping review provides a broad appraisal of a particular field. It generates ideas for future practice rather than a definite framework for action. Conclusions: Our ethical–empirical decision aid offers a critical framework with which to evaluate current research practice. It also offers a resource for promoting more ethical and evidence-based public health research that is methodologically robust while being sensitive to the experiences of disability. Future work: Developing more inclusive research and interventions that avoid conceptualising disability as either a ‘burden’ or ‘problem’ is an important starting point. This includes exploring ways of refining and validating current common outcome measures to ensure that they capture a diverse range of disabling experiences, as well as generating evidence on meaningful ways of engaging a broad range of disabled children and adults in the research process.

IMPRoving Outcomes for children exposed to domestic ViolencE (IMPROVE): an evidence synthesis

Abstract: Background Exposure to domestic violence and abuse (DVA) during childhood and adolescence increases the risk of negative outcomes across the lifespan. Objectives To synthesise evidence on the clinical effectiveness, cost-effectiveness and acceptability of interventions for children exposed to DVA, with the aim of making recommendations for further research. Design (1) A systematic review of controlled trials of interventions; (2) a systematic review of qualitative studies of participant and professional experience of interventions; (3) a network meta-analysis (NMA) of controlled trials and cost-effectiveness analysis; (4) an overview of current UK provision of interventions; and (5) consultations with young people, parents, service providers and commissioners. Settings North America (11), the Netherlands (1) and Israel (1) for the systematic review of controlled trials of interventions; the USA (4) and the UK (1) for the systematic review of qualitative studies of participant and professional experience of interventions; and the UK for the overview of current UK provision of interventions and consultations with young people, parents, service providers and commissioners. Participants A total of 1345 children for the systematic review of controlled trials of interventions; 100 children, 202 parents and 39 professionals for the systematic review of qualitative studies of participant and professional experience of interventions; and 16 young people, six parents and 20 service providers and commissioners for the consultation with young people, parents, service providers and commissioners. Interventions Psychotherapeutic, advocacy, parenting skills and advocacy, psychoeducation, psychoeducation and advocacy, guided self-help. Main outcome measures Internalising symptoms and externalising behaviour, mood, depression symptoms and diagnosis, post-traumatic stress disorder symptoms and self-esteem for the systematic review of controlled trials of interventions and NMA; views about and experience of interventions for the systematic review of qualitative studies of participant and professional experience of interventions and consultations. Data sources MEDLINE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, EMBASE, Cochrane Central Register of Controlled Trials, Science Citation Index, Applied Social Sciences Index and Abstracts, International Bibliography of the Social Sciences, Social Services Abstracts, Social Care Online, Sociological Abstracts, Social Science Citation Index, World Health Organization trials portal and clinicaltrials.gov. Review methods A narrative review; a NMA and incremental cost-effectiveness analysis; and a qualitative synthesis. Results The evidence base on targeted interventions was small, with limited settings and types of interventions; children were mostly < 14 years of age, and there was an absence of comparative studies. The interventions evaluated in trials were mostly psychotherapeutic and psychoeducational interventions delivered to the non-abusive parent and child, usually based on the child’s exposure to DVA (not specific clinical or broader social needs). Qualitative studies largely focused on psychoeducational interventions, some of which included the abusive parent. The evidence for clinical effectiveness was as follows: 11 trials reported improvements in behavioural or mental health outcomes, with modest effect sizes but significant heterogeneity and high or unclear risk of bias. Psychoeducational group-based interventions delivered to the child were found to be more effective for improving mental health outcomes than other types of intervention. Interventions delivered to (non-abusive) parents and to children were most likely to be effective for improving behavioural outcomes. However, there is a large degree of uncertainty around comparisons, particularly with regard to mental health outcomes. In terms of evidence of cost-effectiveness, there were no economic studies of interventions. Cost-effectiveness was modelled on the basis of the NMA, estimating differences between types of interventions. The outcomes measured in trials were largely confined to children’s mental health and behavioural symptoms and disorders, although stakeholders’ concepts of success were broader, suggesting that a broader range of outcomes should be measured in trials. Group-based psychoeducational interventions delivered to children and non-abusive parents in parallel were largely acceptable to all stakeholders. There is limited evidence for the acceptability of other types of intervention. In terms of the UK evidence base and service delivery landscape, there were no UK-based trials, few qualitative studies and little widespread service evaluation. Most programmes are group-based psychoeducational interventions. However, the funding crisis in the DVA sector is significantly undermining programme delivery. Conclusions The evidence base regarding the acceptability, clinical effectiveness and cost-effectiveness of interventions to improve outcomes for children exposed to DVA is underdeveloped. There is an urgent need for more high-quality studies, particularly trials, that are designed to produce actionable, generalisable findings that can be implemented in real-world settings and that can inform decisions about which interventions to commission and scale. We suggest that there is a need to pause the development of new interventions and to focus on the systematic evaluation of existing programmes. With regard to the UK, we have identified three types of programme that could be justifiably prioritised for further study: psycho-education delivered to mothers and children, or children alone; parent skills training in combination with advocacy: and interventions involving the abusive parent/caregiver. We also suggest that there is need for key stakeholders to come together to explicitly identify and address the structural, practical and cultural barriers that may have hampered the development of the UK evidence base to date. Future work recommendations There is a need for well-designed, well-conducted and well-reported UK-based randomised controlled trials with cost-effectiveness analyses and nested qualitative studies. Development of consensus in the field about core outcome data sets is required. There is a need for further exploration of the acceptability and effectiveness of interventions for specific groups of children and young people (i.e. based on ethnicity, age, trauma exposure and clinical profile). There is also a need for an investigation of the context in which interventions are delivered, including organisational setting and the broader community context, and the evaluation of qualities, qualifications and disciplines of personnel delivering interventions. We recommend prioritisation of psychoeducational interventions and parent skills training delivered in combination with advocacy in the next phase of trials, and exploratory trials of interventions that engage both the abusive and the non-abusive parent. Study registration This study is registered as PROSPERO CRD42013004348 and PROSPERO CRD420130043489. Funding The National Institute for Health Research Public Health Research programme.

Change in alcohol outlet density and alcohol-related harm to population health (CHALICE): a comprehensive record-linked database study in Wales

Abstract: Excess alcohol consumption has many adverse effects on health, including an increased risk of liver cirrhosis, gastrointestinal tract and breast cancers, high blood pressure and stroke. There is also an increased risk of harm resulting from antisocial behaviour and violence. Binge drinking is a particular problem, with the highest prevalence in the 16- to 24-year age group for women and men. Up to 40% of attendances at accident and emergency (AE men more than four units per day) and 19% of men and 11% of women binge drink (women more than six units per day; men more than eight units per day). Given the wide range of harm resulting from this substantial level of excess consumption, the potential impact on health at the population level from a reduction in consumption is considerable. One of the principal policies recommended by the British Medical Association to reduce alcohol consumption is to reduce easy access to alcohol through controls on hours of sale and outlet density. This uses the availability theory of alcohol-related harm, which states that harmful outcomes are linked directly or indirectly to a greater availability of alcohol, through a higher density of alcohol outlets, leading to higher consumption and hence alcohol-related harm. However, the evidence relating outlet density to alcohol-related harm is not consistent. Many cross-sectional studies have suggested that high outlet densities are associated with a higher rate of a wide range of alcohol-related injuries. Fewer studies have investigated associations between outlet density and non-injury health outcomes, suggesting that high outlet densities are associated with high levels of consumption, sexually transmitted infections and alcohol-related hospital admissions. There have been few longitudinal studies but these have provided limited evidence that an increase in outlet density is associated with increased consumption and interpersonal violence and that a decrease in proximity to outlets is associated with a small decrease in consumption. No longitudinal studies of admissions to hospital have been published for non-violent outcomes. Many methodological questions remain over the best way to measure outlet density and how to model the relationship with alcohol-related harms. Little is known about the effects of a change in outlet density on inequalities in alcohol-related health and the role of population migration.

Health impacts of the Cambridgeshire Guided Busway: a natural experimental study

Abstract: Background Improving transport infrastructure to support walking and cycling on the journey to and from work – active commuting – could help to promote physical activity and improve population health. Aims To assess whether or not investment in new high-quality transport infrastructure was associated with an increase in active commuting; wider health impacts of changes in travel behaviour; determinants of the use and uptake of active commuting; and how changes in travel behaviour were distributed in the population and related to the wider social context. Design The Commuting and Health in Cambridge study, comprising a quasi-experimental cohort study combined with both nested and supplementary in-depth quantitative and qualitative studies. Setting Cambridgeshire, UK. Participants A cohort of 1143 adults living within 30 km of Cambridge, working in the city and recruited in 2009; and a separate sample of 1710 users intercepted on the Cambridgeshire Guided Busway in 2012. Intervention The Cambridgeshire Guided Busway, comprising a new bus network using 22 km of guideway (segregated bus track) accompanied by a traffic-free path for pedestrians and cyclists, opened in 2011. Main outcome measure Change in time spent in active commuting from 2009 to 2012, using a self-reported measure validated using georeferenced combined heart rate and movement sensor data. Methods A delay from 2009 to 2011 in completing the intervention entailed some changes to the original design and attrition of the cohort. A period of methodological and observational research on active commuting preceded the evaluation, which was based on a quasi-experimental cohort analysis together with the intercept and qualitative data. A graded measure of each participant’s exposure to the intervention, based on the proximity of the busway to his or her home, served as the basis for controlled comparisons. Results Commuting practices were complex and shaped by various changeable social and environmental factors. Walking and cycling were often incorporated into longer commuting journeys made predominantly by car or public transport. In multivariable multinomial regression analyses, exposure to the intervention was associated with a greater likelihood of a large increase in the proportion of commuting trips involving any active travel [adjusted relative risk ratio (RRR) 1.80, 95% confidence interval (CI) 1.27 to 2.55], of a large decrease in the proportion of trips made entirely by car (RRR 2.09, 95% CI 1.35 to 3.21), and of an increase in weekly cycle commuting time (RRR 1.34, 95% CI 1.03 to 1.76). There was a mixed pattern of effects at the individual level, with the intervention providing a more supportive environment for active commuting for some and not for others. There was some evidence that the effect was most pronounced among those who reported no active commuting at baseline, and observational evidence suggesting a relationship between active commuting, greater overall physical activity, and improved well-being and weight status. Conclusions These findings provide new empirical support and direction for reconfiguring transport systems to improve population health and reduce health inequalities. They should be combined with evidence from research evaluating related environmental changes in other settings, preferably using longer periods of observation and controlled comparisons, to support more generalisable causal inference. Funding The National Institute for Health Research Public Health Research programme.

Community pharmacy interventions for public health priorities: a systematic review of community pharmacy-delivered smoking, alcohol and weight management interventions

Abstract: Background The Department of Health has identified interventions to manage alcohol misuse, smoking and overweight, delivered by community pharmacists, as public health priorities. Objectives To systematically review the effectiveness of community pharmacy interventions to manage alcohol misuse, smoking cessation and weight loss; to explore if and how age, sex, ethnicity and socioeconomic status moderate effectiveness; and to describe how the interventions have been organised, implemented and delivered. Data sources Ten electronic databases were searched: Applied Social Sciences Index and Abstracts; Cumulative Index to Nursing and Allied Health Literature; EMBASE; International Bibliography of the Social Sciences; MEDLINE; NHS Economic Evaluation Database; PsycINFO; Social Science Citation Index; Scopus; and the Sociological Abstracts from inception to May 2014. There was no restriction on language or country. Supplementary searches included website, grey literature, study registers, bibliographies and contacting experts. Review methods The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Any type of intervention of any duration based in any country and in people of any age was included. The review included interventions set in a community pharmacy and delivered by the pharmacist or the wider pharmacy team. Randomised controlled trials, non-randomised controlled trials, controlled before-and-after studies and interrupted time series studies were included. Data extraction and quality assessment were conducted independently for each study by two reviewers. Meta-analysis and narrative synthesis were also conducted. Results The searches identified over 14,000 records, of which 24 studies were included. There were two alcohol, 12 smoking cessation, five weight loss and five multicomponent interventions that included pharmacotherapy and lifestyle changes in participants with diabetes mellitus, dyslipidaemia or hypertension. Nine of the studies were UK based; seven of the studies were rated ‘strong’ for quality. All studies were of adults. Pharmacy-based smoking cessation interventions including behavioural support and/or nicotine replacement therapy are effective and cost-effective in helping adults to stop smoking, particularly when compared with usual care. The pooled odds ratio of the intervention effects for smoking cessation was 1.85 (95% confidence interval 1.25 to 2.75). It is currently unknown which specific types of smoking cessation interventions are the most effective. There was insufficient evidence for the effectiveness of community pharmacy-based brief alcohol interventions. Evidence suggests that pharmacy-based weight-loss interventions are as effective as similar interventions in other primary care settings, but not as effective or cost-effective as commercially provided weight management services based in community settings. None of the five multicomponent studies demonstrated an improvement compared with control for anthropometric outcomes in participants with comorbidities, but they did show improvement in measures associated with the comorbidities. Very few studies explored if and how sociodemographic or socioeconomic variables moderated the effect of interventions. In two studies based in areas of high deprivation, where participants chose the intervention, the sociodemographic characteristics of participants differed between intervention settings. There were also differences in recruitment, attendance and retention of participants by type of setting. The evidence suggests that a distinct group of people might access pharmacies compared with other settings for alcohol management, smoking cessation and weight loss. There is insufficient evidence to examine the relationship between behaviour change strategies and effectiveness; or evidence of consistent implementation factors or training components that underpin effective interventions. Limitations The information reported in the publications of included studies did not allow us to assess in detail if and how age, sex, ethnicity and socioeconomic status moderate effectiveness, or to describe how the interventions had been organised, implemented and delivered. Conclusions Community pharmacy interventions are effective for smoking cessation. Evaluations of interventions to manage alcohol misuse and obesity, set within the community pharmacy, are needed. The effect of community pharmacy interventions on health inequalities is unclear. Future research in this area is warranted, and trials should include the assessment of age, sex, ethnicity, socioeconomic status and contextual factors, and present analysis of how these factors moderate effectiveness. Study registration This study is registered as PROSPERO CRD42013005943. Funding The National Institute for Health Research Public Health Research programme.

The effects of Positive Youth Development interventions on substance use, violence and inequalities: systematic review of theories of change, processes and outcomes

Abstract: Background: Positive Youth Development (PYD) delivered outside school aims to enable young people to develop positive assets such as relationships and confidence, rather than to merely address risk. Existing reviews of PYD effects on substance use or violence are old and unsystematic. Objectives: To systematically review evidence to answer the following questions: what theories of change inform PYD interventions addressing substance use and violence? What characteristics of participants and contexts are identified as barriers to and facilitators of implementation and receipt in process evaluations of PYD? What is the effectiveness and cost-effectiveness of PYD in reducing substance use and violence? What characteristics of participants and contexts appear to moderate, or are necessary and sufficient for, PYD effectiveness? Data sources: A total of 21 bibliographic databases; 35 websites and contacting authors. Review methods: We included reports published in English since 1985 and reporting on theories of change, as well as process, outcome and economic evaluations of PYD targeting 11- to 18-year-olds and addressing substance use or violence. References were screened on title/abstract and, where appropriate, on full report. Data extraction and quality assessment used Critical Appraisal Skills Programme, Evidence for Policy and Practice Information and Co-ordinating Centre and Cochrane tools. Theories of change and process evaluations were qualitatively metasynthesised. Outcome evaluations were synthesised narratively and meta-analytically. Results: 32,394 unique references were identified and 48 were included. A total of 16 reports described theories, 13 (10 studies) evaluated processes and 25 (10 studies) evaluated outcomes. Theories of change: PYD interventions aim to offer opportunities for young people to develop positive ‘assets’ such as skills and confidence. These are theorised to promote and be promoted by young people’s ‘intentional self-regulation’, which involves reflecting on behaviour; determining goals; using existing resources to pursue these; and redirecting effort when thwarted. This enables ‘developmental regulation’, namely individuals capitalising on other opportunities to promote personal development. Positive assets thus accrued reduce health risks by reducing the impact on individuals of environmental risk or by ameliorating the impact of such risks. The literature offers limited insights beyond these general ideas. Process evaluations: Community engagement ensured that programmes were accessible and appealing. Staff capacity and continuity were crucial factors but often challenging when programmes could not offer full-time jobs. Tensions arose between a desire to empower participants to choose activities and a requirement for them to undertake a breadth of activities. Outcome evaluations: Meta-analyses of all combined outcomes and of short-term alcohol use, illicit drug use and smoking found no significant effects. There were small, statistically significant, short-term effects for an omnibus measure of substance use and for violence. We could not undertake metaregression to assess sociodemographic moderators but narrative synthesis suggested no clear pattern of effects by sex. We found no economic evaluations. Limitations: Insufficient studies precluded qualitative comparative analyses. Conclusions: How PYD might promote health is currently undertheorised. Implementation can be challenging. We found little evidence that current PYD interventions delivered outside school reduce substance use or violence. However, these may not constitute a test of the effectiveness of the PYD model, as some included interventions that, although meeting our inclusion criteria, were not exemplars of PYD. Future work: Further evaluations should assess interventions employing PYD theory of change. Study registration: This study is registered as PROSPERO CRD42013005439. Funding: The National Institute for Health Research Public Health Research programme.

Prevalence of Drug Abuse Amongst University Students in Benin City, Nigeria

Abstract: Drug Abuse is becoming an increasing problem in Nigeria. This study sought to determine the prevalence of drug abuse among students in a tertiary institution in Benin City, Edo State, Nigeria. The study adopted a descriptive survey design. The sample size for this study was 800 students (n=800). Structured questionnaire was used to collect data. Three research questions and one hypothesis was answered. Descriptive statistics and Pearson product moment correlation were used for data analysis using the statistical package for social sciences (SPSS). Results showed that majority of the respondents were young people within the age group of 20-25 years and a higher proportion of respondents were male students. This study reveals that 46.6% of the sample respondents have taken drugs for non-medical purposes at least once. Coffee and alcohol were the most commonly abused drugs. Majority of the respondents agreed that students take drugs as a result of poor teacher-student relationship, improper parental upbringing, as well as the influence of peer pressure. Results also revealed that the null hypothesis which states that there is no significant relationship between university environment and drug abuse among UNIBEN students is rejected while the alternate hypothesis is upheld. It is therefore recommended that Public health intervention aimed at preventing drug use among students should be designed to raise awareness about the negative effects of drug abuse.

Interventions to promote or maintain physical activity during and after the transition to retirement: an evidence synthesis

Abstract: Background It has been argued that transition points in life, such as the approach towards and early years of retirement, present key opportunities for interventions to improve the health of the population. Interventions that may change or preserve activity levels around the time of retirement have the potential to provide benefits in terms of increased health and well-being for people in later life. Research has highlighted health inequalities in health statuses in the retired population and in response to interventions. Objective We aimed to conduct a systematic review and meta-synthesis of the types and effectiveness of interventions to increase physical activity among people around the time of retirement. We also aimed to identify factors that may underpin the effectiveness or acceptability of interventions, and how issues of health inequalities may be addressed. Data sources The following electronic databases were searched: (1) MEDLINE; (2) Applied Social Sciences Index and Abstracts; (3) The Cochrane Library (including The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, Health Technology Assessment Database); (4) Cumulative Index to Nursing and Allied Health Literature; (5) Science Citation Index; (6) Social Science Citation Index; (7) PsycINFO; (8) Evidence for Policy and Practice Information and Co-ordinating Centre; (9) SPORTDiscus; (10) Social Policy and Practice; (11) Health Management Information Consortium; and (12) Sociological Abstracts. We also searched for grey literature, checked reference lists of included papers and screened other reviews. Review methods A systematic review of quantitative and qualitative literature was carried out between February 2014 and April 2015. The searches aimed to identify, first, evidence of effectiveness of interventions for older adults at the point of transition to retirement and, second, data relating to perceptions of barriers and facilitators to intervention effectiveness. A meta-synthesis of the two types of evidence was also carried out to provide further interpretation of the review findings. Results A systematic search of the literature identified a large number of potentially relevant studies. Of these, 103 studies examining the effectiveness of interventions and 55 qualitative papers met the criteria for inclusion. A review of the effectiveness literature indicated a dearth of studies that investigate interventions that specifically examine the transition to retirement. More general studies in older adults indicated that a range of interventions might be effective for people around retirement age. The qualitative literature indicated the importance of considering the appeal and enjoyment, and social aspects, of interventions. Although there were a range of different measures in use, many were self-reported and few studies included an evaluation of sedentary time. A meta-synthesis across the data types indicated that elements reported as significant by participants did not always feature in the interventions. Limitations Owing to the lack of evidence relating to the retirement transition, we examined the literature relating to older adults. The applicability of these data to people around retirement age may need consideration. Conclusions Although the retirement transition is considered a significant point of life change, only a small volume of literature has reported interventions specifically in this period. The included literature suggests that interventions should take account of views and preferences of the target population and evaluate effectiveness by measuring meaningful outcomes and using a control group design. Study registration This study is registered as PROSPERO CRD42014007446. Funding The National Institute for Health Research Public Health Research programme.

Bristol Girls Dance Project: a cluster randomised controlled trial of an after-school dance programme to increase physical activity among 11- to 12-year-old girls

Abstract: Background: Many children do not meet UK physical activity (PA) guidelines. Girls are less active than boys, and the age-related decline in activity is steeper for girls. Dance is the favourite form of PA among adolescent girls in the UK. Participation in after-school dance classes could significantly contribute to girls’ PA. Therefore, after-school dance may be effective for increasing PA levels. Objectives: To determine the effectiveness and cost effectiveness of a dance-based intervention to increase the objectively assessed mean weekday minutes of moderate- to vigorous-intensity physical activity (MVPA) of Year 7 girls (11- and 12-year olds) 1 year after baseline measurement. Design: Two-arm cluster randomised controlled trial and economic evaluation. Year 7 girls in participant schools received a ‘taster’ session and were invited to participate. Up to 33 girls per school were able to participate. Schools were randomly assigned (equal numbers) to intervention or control arms. Setting: A total of 18 mainstream secondary schools across greater Bristol. Participants: Year 7 girls in participating schools who could participate in physical education. Intervention: Nine intervention schools received an after-school dance intervention (40 × 75-minute sessions) underpinned by self-determination theory, which attempts to improve intrinsic motivation for being active, and delivered by external dance instructors. Control schools continued as normal. Main outcome measures: The main outcome was accelerometer-assessed mean minutes of MVPA at T2. Measures were assessed at baseline (T0), the end of the intervention (T1) and at T0 + 52 weeks (T2). Results: Baseline MVPA levels were high. A total of 508 girls were included in the primary analysis, which found no difference in weekday MVPA between trial arms. There was no effect on secondary accelerometer outcomes. Data were subjected to a per-protocol analysis and no effect was found. However, at T1, girls who attended dance classes had 4.61 minutes more of MVPA and 14.27 minutes more of light-intensity activity between 15.00 and 17.00 on the days on which they attended intervention sessions. The intervention was inexpensive at £73 per participant (£63 when excluding dance instructor travel) but was not cost-effective owing to the ineffectiveness of the intervention. The European Quality of Life-5 Dimensions Youth survey data were unresponsive to changes in the sample. The process evaluation reported that girls in attendance enjoyed the sessions, that exertion levels were low during sessions and that attendance was low and declined. Fidelity to the session-plan manual was low but theoretical fidelity (to self-determination theory) was good. Qualitative information provides information for improving future interventions. Conclusions: The intervention was enjoyed by participants. However, there was no difference in the MVPA levels (which were high at baseline) of girls allocated to receive dance compared with girls receiving the control. High baseline MVPA levels indicate that the study appealed to an already active cohort and, therefore, may not have targeted those most in need of an intervention. Dance is an enjoyable activity for adolescent girls and could be further trialled as a means by which to increase PA. Research might consider the impact of dividing the intervention period into smaller blocks.

Age, Race and Regional Disparities in Colorectal Cancer Incidence Rates in Georgia between 2000 and 2012.

Abstract: Colorectal cancer (CRC) incidence rates and mortality have been decreasing in the United States. Currently, states in the South have the smallest reduction in CRC mortality. The trends of CRC incidence rates in Georgia in comparison to the United States have not been investigated. We analyzed age-adjusted incidence rates of CRC in Georgia and the United States from 2000 to 2012 using data from SEER 18 registries. Age-adjusted incidence rates (95% CI) were calculated as cases per 100,000 to the 2000 US Standard population. CRC incidence rates were calculated for groupings based on age at time of diagnosis, race, sex, and geographic location within Georgia. Incidence rates were higher in males compared to females in Georgia. In Georgians age 50-64, incidence rates were higher compared to the US, while those ages 65+ displayed lower incidence rates. Black Georgians age 50-64 generally exhibited higher incidence rates of CRC and lower rates of decrease in incidence compared to other races in Georgia. Asian/Pacific Islander females age 50-64 in Georgia exhibited an increasing trend in incidence rate. Whites and blacks Georgians age 50-64 displayed higher incidence rates compared to the US, while Asian/Pacific Islanders displayed lower incidence rates. Greater incidence rates of CRC in rural and Greater Georgia were seen across all races when compared to overall rates in Georgia. Efforts should be made to address disparities in Georgia based on race and geographic location. Increased screening by colonoscopy or fecal occult blood testing, reduction of risk factors and promotion of healthy lifestyles can reduce CRC incidence rates.

Economic Effects of Non-Communicable Diseases on Household Income in Kenya: A Comparative Analysis Perspective

Abstract: Introduction: Non-Communicable Diseases (NCDs) have been on the increase in Kenya over the past decade. This rising trend has led NCDs to account for over 30% of the annual total disease-related deaths in the country. Between 2005 and 2009, major NCDs (cancer, cardiovascular diseases, respiratory ailments and diabetes) accounted for over half of the top 20 causes of disease-related deaths in Kenya. The high expenditures for managing NCDs expose households to risks of financial catastrophe and poverty. Methodology:The paper has adopted an econometric method to investigate the effects of NCDs on household income in Kenya. Further, the paper establishes the comparative analysis of NCDs with illnesses due to communicable diseases (CDs) in order to argue for the potential effect of NCDs, relative to other illnesses, on households’ income. Sample design and possible heterogeneity arising from unobserved households’ characteristics correlated with household income levels has been addressed. To achieve this, Kenya Household Health Expenditure and Utilization Survey of 2007 data is utilized. Findings, Conclusions and Policy Recommendations: The key finding is that, while general ailments reduce household income by 13.63%, NCDs reduce household income by 28.64%. NCDs are associated with a 23.17% reduction in household income relative to a household affected by communicable disease. Another key finding is that, although all types of ailments have negative effects on household income and welfare, NCDs have more severe impacts. The key policy recommendation is for the government to put in place a health financing strategy for NCDs, and especially one that subsidizes the cost of care and treatment of NCDs.

The Efficacy of HIV and Sex Education Interventions among Youths in Developing Countries: A Review

Abstract: Introduction: Human Immunodeficiency Virus (HIV) and Sexually Transmitted Infections (STIs) among youths represent an important public health challenge in developing countries. The incidence of HIV peaked in the 1990’s and saw a decline from 2005. What was done to prompt the decline? To answer this question selecting studies between 1990 and 2005 was appropriate to assess whether the drop in HIV incidence in developing countries was as a result of education interventions. School based interventions are widely used to change young people’s attitudes towards early sexual activity and to prevent the transmission of HIV/STIs, and have been implemented by countries across the world. Methods: Electronic databases were searched to identify studies in HIV/STI education interventions conducted in schools in developing countries published from 1990 to 2005. Studies from 1990 effectively gave a clearer explanation of whether education interventions contributed to the genesis of the decline. In addition to assessing HIV incidence, the reviewer also included studies performed on sexually transmitted infections (STIs) as knowledge on STI prevention could lead to preventing HIV transmission. Studies were eligible if they had an appropriate comparison group; published in English and full text retrieved. Twenty-eight full text articles were assessed for eligibility, 17 articles met the inclusion criteria and 11 articles were rejected due to, not addressing HIV or sex education programmes in schools or were abstracts only. The Cochrane Effective Practice and Organization of Care tool for randomized controlled trials (RCTs), non-randomized controlled trials (NRCTs) and controlled before and after (CBA) studies was used to critically appraise studies. Results: All 17 studies reviewed established positive effects on knowledge. Programmes have similar characteristics and were more effective if they were conducted by adults. Conclusions: The overall conclusion of evidence gathered was that curriculum based programmes on HIV and sex education could be effective in changing the behavior of young people in developing countries if conducted properly. They were also effective in increasing knowledge on problems associated with risky sexual activity among young people. Further research is needed to assess the long-term positive effects of such programmes in schools in developing countries.

Psychological Wellbeing in the Face of Adversity among American Indians: Preliminary Evidence of a New Population Health Paradox?

Abstract: Our objective was to determine self-reported psychological wellbeing of American Indians (AIs). Data are from two surveys, a) 218 adults from the 2011 - 2012 Mino Giizhigad study including Ojibwe adults in Minnesota and Wisconsin, and b) 146 AI women aged 15 - 35 years from the 2011 Sacred Journey study residing in the Pacific Northwest. Reports of AI mental wellness/positive mental health were on par with or higher than found in previous studies with non-AI samples despite simultaneously disparate rates of AI anxiety, depressive symptoms, and differential exposure to sociohistorical stressors. Results are a paradoxical mismatch between mental wellness and mental stressors consistent across two separate, diverse samples of AI adults.

Factors Associated with Exclusive Breastfeeding Practices among Women in the West Mamprusi District in Northern Ghana: A Cross-Sectional Study

Abstract: Exclusive breastfeeding promotion is one of the most important health initiatives today. The World Health Organization recommends that all babies and young children are breastfed exclusively for their first six months of life and then given nutritious complementary food with continued breastfeeding up to two years of age. The benefits of exclusive breastfeeding have been espoused by several studies. Despite the education and promotion of exclusive breastfeeding by the Ghana Health Service and other agencies some mothers do not exclusively breastfeed their children for the first six months of life. This study, therefore, sought to investigate the factors that are associated with the practice of exclusive breastfeeding among women in the West Mamprusi district of Ghana. A 15x20 community-based cross sectional study was conducted in the district using simple random sampling in selecting 300 breastfeeding mothers with infants 0-6 months of age. Multistage cluster sampling procedure was used in selecting the study communities. Bivariate and multivariate analyses were done to find the determinants of exclusive breastfeeding in the study sample. Results indicated the prevalence of exclusive breastfeeding was 84.3%. Factors that were associated with exclusive breastfeeding were household wealth index (P<0.001, OR=12.3, 95%, CI: 35.43-36.7), antenatal care attendance (P<0.001, OR=10.44, 95%, CI: 32.42-37.21), knowledge of exclusive breastfeeding (P<0.002, OR=7.43, 95%, CI: 0.69-4.54) and place of delivery (P<0.006, OR=12.52, 95%, CI: 12.52-13.56). It emerged that majority of the women practised exclusive breastfeeding. Educational level of mothers did not have any influence on the practice of exclusive breastfeeding and was not significantly associated with the practice of exclusive breastfeeding. Antenatal care attendance on the other hand had a significant influence on the practice of exclusive feeding. The study recommends that information and education on exclusive breastfeeding among women not attending ANC and those who do not deliver in a facility be intensified in the entire district.

Active for Life Year 5: a cluster randomised controlled trial of a primary school-based intervention to increase levels of physical activity, decrease sedentary behaviour and improve diet

Abstract: Background Previous studies of the effect of school-based interventions to improve healthy behaviours have had important limitations. Objective To investigate the effectiveness of a school-based intervention to increase physical activity, reduce sedentary behaviour and increase fruit and vegetable consumption. Design Cluster randomised controlled trial. Setting Sixty English primary schools. Participants Children in year 4 (aged 8–9 years) at recruitment, year 5 (aged 9–10 years) during the intervention and immediate follow-up and year 6 (aged 10–11 years) during 1 year of follow-up. Intervention Active for Life Year 5 (AFLY5) included teacher training, lesson plans, materials for 16 lessons, parent-interactive homework and written materials for school newsletters and parents. Main outcome measures Primary outcome measures included accelerometer-assessed levels of physical activity and sedentary behaviour, and child-reported consumption of fruit and vegetables. Secondary outcome measures included child-reported screen viewing; consumption of snacks, high-fat food and high-energy drinks; body mass index; and waist circumference. Results We recruited 60 schools (2221 children). At the immediate follow-up, no difference was found between children in intervention and control schools for any of the three primary outcomes. The intervention was effective on three of the nine secondary outcomes; children in intervention schools reported spending less time screen viewing at weekends [–21 minutes per day, 95% confidence interval (CI) –37 to –4 minutes per day], eating fewer servings of snacks per day (–0.22, 95% CI –0.38 to –0.05 servings of snacks per day) and drinking fewer servings of high-energy drinks per day (–0.26, 95% CI –0.43 to –0.10 servings of high-energy drinks per day) than the children in control schools. The results remained consistent 1 year later. The intervention increased children’s perception of maternal efforts to limit the time they spent screen viewing and children’s knowledge about healthy physical activity and fruit and vegetable consumption, with these two mediators explaining approximately one-quarter of the effect of the intervention on screen viewing. The intervention did not affect other mediators. The cost of implementing the intervention from a provider perspective was approximately £18 per child. Process evaluation showed that AFLY5 was implemented with a high degree of fidelity. Teachers supported the aims of AFLY5, but their views of the programme itself were mixed. Limitations Responses to parental questionnaires for the economic evaluation were low and we struggled to engage all teachers for the process evaluation. Although the participating schools included a range of levels of socioeconomic deprivation, class sizes and rural and urban settings, we cannot assume that results generalise to all primary schools. Conclusions AFLY5 is not effective at increasing levels of physical activity, reducing sedentary behaviour and increasing fruit and vegetable consumption in primary school children, but may be effective in reducing time spent screen viewing at weekends and the consumption of snacks and high-energy drinks. Future work Our findings suggest that school-based interventions are unlikely to have a major impact on promoting healthy levels of physical activity and healthy diets in primary school children. We would recommend trials of the effect and cost-effectiveness of more intensive family and community interventions. Trial registration Current Controlled Trials ISRCTN50133740. Funding This project was funded by the National Institute for Health Research Public Health Research programme and will be published in full in Public Health Research; Vol. 4, No. 7. See the NIHR Journals Library website for further project information.

Application of Multilevel Binary Logistic Regressions Analysis in Determining Risk Factors of Diarrheal Morbidity among under Five Children in Ethiopia

Abstract: Diarrheal disease is the most common cause of illness and the second leading cause of child death in the world. The burden is greatest in the developing world including Ethiopia. The purpose of this study has been to identify socio-economic, demographic, environmental and nutrition proximate predictors that affecting diarrheal morbidity of under-five children in Ethiopia. In this research data from the Ethiopian Demographic and Health Survey conducted in 2011 was used. Multiple and multilevel binary logistic regressions were employed for data analysis. The prevalence of diarrhea, stunting, wasting, and underweight among under-five children were 15.6%, 37%, 10.2% and 35.3% respectively. Both in multiple binary logistic regression and multilevel logistic regression, it was found that age of child, maternal working status, duration of breast feeding, stunting, wasting, and underweight were significant determinants of childhood diarrhea. From multilevel logistic regression, it was found that the random intercept and fixed coefficients model provided the best fit for the data under consideration. The variance of the random component related to the intercept term was found to be statistically significant implying differences in prevalence of diarrhea among the regions. However, the significant predictors did not show underlying variation from region to region. Therefore, the concerned body should give implement on nutritional intervention activities at all level of the community and Efforts should be invested to educate parents about the importance of breastfeeding and initiate to adopt the culture of breastfeeding their children to reduce the exposure of children to diarrhea. Researchers should use multilevel models than traditional regression methods when their data structure is hierarchal as like in EDHS data.

Assessment of Indoor Air Quality in Neonatal Intensive Care Units in Government Hospitals in Gaza Strip, Palestine

Abstract: This study was conducted to assess indoor air quality (IAQ) in three neonatal intensive care units (NICUs), which were chosen to geographically represent the Gaza strip. The study collected both: objective temperature and air quality measures ofcarbon dioxide (CO2), carbon monoxide (CO), temperature, relative humidity (RH%) and suspended particles (PM10, PM2.5); and clinical staff perceptions of indoor air quality and its impact. The study conducted daily air quality measurements between 4 March until 22 March 2013, and gathered 108 questionnaires. The study showed that the average concentrations of carbon dioxide were often close to the maximum standard of the United States Environmental Protection Agency, and sometimes exceed the limit, especially in the NICU of Shifa Hospital. Temperature fell within normal ranges, but approached recommended limits at Shifa Hospital. Carbon monoxide and suspended particle concentrations and relative humidity were within the standards recommended by the Environmental Protection Agency in all three NICUs. More than half of the clinical staff (60%) suffered from sick building syndrome, 83% suffer from tiredness and fatigue, and 76% suffer from headache. Nearly 85% believe that these symptoms are related to their workplace, and 71% report disappearance of the symptoms after they leave work. We conclude that indoor air quality merits more attention from the Ministry of Health, and that NICU staff be engaged around issues of environmental health.

Determining Risk Factors of Malnutrition among under – Five Children in Sheka Zone, South West Ethiopia Using Ordinal Logistic Regression Analysis

Abstract: Malnutrition continues to be an important public health problem not only in developing country but also in the world. In Ethiopia, child malnutrition rate is one of the most serious public health problems and highest in the world. The aim of this research is to assess prevalence of malnutrition and associated factors among under – five year’s children in Sheka Zone. A community based cross sectional study was conducted on 628 children from April 1-6, 2015. Multistage sampling method was used to select the study subjects. Data was collected using a pre-tested structured questionnaire by trained data collectors. Based on weight – for – age anthropometric index (Z – score) child nutrition status is categorized into three groups severely undernourished (< -3.0), moderately undernourished (-3.0 to -2.01) and nourished (-2.0). Since nutrition status is ordinal, an OLR model – proportional odds model (POM) is used to find predictors of both malnutrition and severe malnutrition. Prevalence of malnutrition in the study area is 29.0 underweight, 37.6 stunting and 16.1 wasting, and also 11.5%, 17.5% and 71% were severely underweight, mildly underweight and nourished respectively. The OLR(POM) model showed that child feeding status, duration of breast feeding, size of child at birth, had fever in the last two weeks, timing of child put to the breast, had diarrhea in the last two weeks, and preceding birth interval were the significant predictors of child malnutrition. Therefore, the concerned body should give implement on nutritional intervention activities at all level of the community especially on children’s feeding status, time when a child is to be put in to the breast after birth, and Children who were small in size at the time of birth.

Awareness status and associated risk factors of hypertension among adult patients attending Yala sub-county hospital, Siaya county, Kenya

Abstract: Hypertension affects approximately 26% of the adult population worldwide and is a significant risk factor for cardiovascular diseases, stroke and renal failure. In Kenya, hypertension accounts for approximately 64% of stroke cases. However, information regarding its prevalence, awareness status and associated risk factors among patients seeking healthcare from hospitals in Kenya is unknown. Yala sub county hospital is one of the largest sub-county rural hospitals in Siaya County. In the past four years it had experienced increased number of patients diagnosed with high blood pressure (BP). But due to frequent breakages of BP monitoring machines and fewer medical staff at the outpatient department could make the reported data on hypertension not to be relied upon. This might lead to the true prevalence rate of the problem being underestimated. Moreover, lack of awareness regarding the disease status increases incidence of complications and mortality. The aim of the present study was to determine the prevalence, awareness and determinants of hypertension among adult patients attending Yala sub-county hospital, in Gem sub-county, Kenya. This was a hospital based cross-sectional study conducted on 393(144 males and 249 females) randomly sampled patients aged 18 years and above between February and March 2015. Study participants were considered to be hypertensive when they presented with a systolic blood pressure (BP) of 140mmHg and above and/or a diastolic BP of 90mmHg and above. Individuals who reported being on regular anti-hypertensive therapy were also grouped together with the cases. Data on demographics, social economic, exposure history to various potential risk factors for hypertension and awareness was collected using a pre-tested Questionnaire. Logistic regression analysis was used to identify factors associated with hypertension. The prevalence of hypertension in the study participants was at 36.9% (145/393) (male 38.9%, 56/144, females 35.7%, 89/249; p = 0.533). Out of all the hypertensive cases 85(58.6%) were found to be aware of their status and out of the 85 cases 75(88.1%) were on medication but only 21 of them (28.4%) had controlled blood pressure (systolic blood pressure 30 years OR= 12.0 (2.7 - 52.3), body mass index (overweight, OR= 2.98 (1.85 - 4.79) and Obesity, OR= 4.23 (2.15 to 8.30), current tobacco smoking OR= 2.63 (1.32 - 5.23), high waist circumference, OR= 2.39 (1.57 - 3.64). Increasing education level was however associated with decreased likelihood of suffering hypertension. These findings suggest that in the Gem community hypertension is most prevalent among adults aged 30 years and above and the risk factors are the same as those that have been reported in other population (body mass index, obesity, high waist circumference, tobacco smoking and low education levels). Approximately half of the hypertensive cases were aware of their status and the available hypertension medications did not fully control the high pressure in all the cases. Therefore, there is need to have community screening programs, instituting awareness raising programmes through health promotion to target individuals at risk and interventions aiming at reducing the associated factors identified in this study.

Socio-Demographic Factors Influencing Nutritional Status of Children (6-59 Months) in Obunga Slums, Kisumu City, Kenya

Abstract: Background: Poor nutrition remains a direct critical factor in child mortality in Africa. A lot of focus has been given to the rural population as poverty setting. However, urban slums display more serious poverty conditions which manifest in poor stunting rates, yet this has been ignored in the realm of scientific writing. This study explored the socio-demographic factors in relation to nutritional status indices mainly stunting, wasting and underweight. Materials and Methods: The study was conducted within Urban Slums using cross-sectional analytical design using a sample of 400 eligible households from total eligible households within the slum. Data was collected using structured questions and analysis done using descriptive and inferential statistics mainly odds ratio. Results: The results show strong association between income and stunting (OR=0.47; CI=0.24-0.91) and underweight (OR=0.44; CI=0.22-0.92). Wasting was strongly associated with Age of the mother (OR=1.07; CI=1.01-1.33) and mother’s education (OR=0.34; CI=0.14-0.83). Religion and sex of the child were ruled out based on the analysis outcome. Conclusions: These results may explain social perspective of nutritional status and suggest two critical factors that interventions should give much attention in order to ensure well being. Income, mother’s age and mother’s education are very critical in child health interventions. However, there is need to continue establishing new perspective of social components within similar settings beyond the boundary of Obunga.

Development and evaluation of an intervention providing insight into the tobacco industry to prevent smoking uptake: a mixed-methods study

Abstract: Background Smokers who start smoking at an early age are less likely to quit and more likely to die from their habit. Evidence from the US Truth® campaign suggests that interventions focusing on tobacco industry practices and ethics may be effective in preventing smoking uptake. Objectives In an exploratory study, to develop, pilot and provide preliminary evidence of the acceptability and effectiveness of Operation Smoke Storm, a school-based intervention based on the premise of the Truth® campaign, to prevent smoking uptake. Design Mixed-methods, non-randomised controlled study. Component 1 was delivered to Year 7 students, and student focus groups and teacher interviews were conducted to refine the lessons and to develop components 2 and 3. The revised Year 7 lessons and accompanying family booklet were delivered to new Year 7 students 1 year later in one school only; Year 8 students in both schools received the booster session. Setting and participants Students in Years 7–8 (aged 11–13 years) in two UK schools. Intervention A three-component intervention comprising (1) three 50-minute classroom-based sessions in Year 7 in which students acted as secret agents to uncover industry practices through videos, quizzes, discussions and presentations; (2) an accompanying family booklet containing activities designed to stimulate discussions about smoking between parents and students; and (3) a 1-hour interactive classroom-based booster session for Year 8 students, in which students learnt about tobacco marketing strategies from the perspectives of an industry executive, a marketing company and a health campaigner. Main outcome measures Odds ratios to compare the self-reported prevalence of ever smoking and susceptibility to smoking in Year 8 students after the delivery of the booster session in study schools compared with students in local control schools. Qualitative data on acceptability of the intervention. Results The combined prevalence of ever smoking and susceptibility increased from 18.2% in Year 7 to 33.8% in Year 8. After adjusting for confounders there was no significant difference in the odds of a Year 8 student in an intervention school being an ever smoker or susceptible never smoker compared with controls [adjusted odds ratio (aOR) 1.28, 95% confidence interval (CI) 0.83 to 1.97; p = 0.263] and no significant difference in the odds of ever smoking (aOR 0.82, 95% CI 0.42 to 1.58; p = 0.549). Students mostly enjoyed the intervention and acquired new knowledge that appeared to strengthen their aversion to smoking. Teachers liked the ‘off-the-shelf’ nature of the resource, although they highlighted differences by academic ability in the extent to which students understood the messages being presented. Use of the family component was low but it was received positively by those parents who did engage with it. Limitations Logistical difficulties meant that students’ responses in Year 7 and Year 8 could not be linked; however, baseline smoking behaviours differed little between intervention and control schools, and analyses were adjusted for confounders measured at follow-up. Conclusions Operation Smoke Storm is an acceptable resource for delivering smoking-prevention education but it does not appear to have reduced smoking and susceptibility. Future work The lack of a strong signal for potential effectiveness, considered alongside logistical difficulties in recruiting and working with schools, suggests that a fully powered cluster randomised trial of the intervention is not warranted.

Evaluation of Patients’ Satisfaction Towards the Primary Health Care Services in the Old City of Jerusalem, Palestine

Abstract: The evaluation of patients’ satisfaction has become an important issue in the assessment of health care system because it is a key determinant of healthcare quality. Providers of health care service in the Old City of Jerusalem are divided into three main categories: Israelis, Palestinians and international organizations, but all of them are operating under the Israeli administration. Consequently, the comparison between different health care providers in the city led to different level of satisfaction among the patients. This study aims to assess the patients’ satisfaction as a tool to monitor and evaluate the quality of the primary health care services in the Old City of Jerusalem by investigating the main factors that affect the patient satisfaction and identifying the main problems facing the health sector in the city. A combination of quantitative and qualitative methods was applied to this research using questionnaires and interviews to collect primary data. Descriptive statistics and multiple regression analysis were used to evaluate patients’ satisfaction in the Old City of Jerusalem. Study findings showed dissatisfaction of the Arab community in the city towards some of the health care services such as emergency services, x-ray services, provision of bone specialist services and working hours of health care centers. The result of the regression analysis showed four factors that have effects on patients’ satisfaction in the Old City of Jerusalem which includes hierarchically, time and access, physical environment in the health care centers, cost and health insurance, and comprehensiveness and quality of the health care. Therefore, there is a critical need to improve the health services sector in the Old City of Jerusalem. Both Israeli and Palestinian authorities as well as the nongovernmental health organizations in the Old City of Jerusalem should pay more attention towards improving the quality of health care centers by providing more facilities and doctors especially bone specialists, obstetricians, pediatricians, x-ray departments and laboratory services, so that the people in the study area do not have to go outside of the walls to get these health services.

The Inextricable Effect of Health Worker’s Attitude on Primary Health Care Implementation in South-South Nigeria

Abstract: This study was designed to investigate the negative effect of health workers attitude on primary health care implementation in south-south Nigeria. The descriptive cross sectional survey design was utilized for the study. Three research questions and three hypotheses guided the study. A sample size of one thousand one hundred and twenty (1,120) primary health care workers, which is 10% of the total population, was used for the study. Multi-stage sampling procedure was adopted to pick the desired number of respondents for the study. A self-structured questionnaire with a modified 4-point Likert type scale of strongly agree (SA)-4points, Agree (A)-3points, strongly disagree (SD)-2points, Disagree (D)-1point was used for data collection. The reliability of the instrument was determined through the test-retest method with the use of Pearson product moment correlation and a reliability coefficient of 0.81 was established. The data generated from the study were coded, analyzed using the Statistical Package for Social Sciences (SPSS) batch system and hypotheses tested using Z-test and ANOVA statistical tools. Descriptive statistics of mean was used to answer the research questions and a criterion mean of 2.50 was established in taking decision concerning the research questions. However, the result of the analyzed data from the opinions of respondents pointed to the fact that majority of them agreed that, the three variables under consideration pose challenge to primary health care implementation in south-south Nigeria and it was recommended that health workers should be retrained on the basic principles of interpersonal communication while delivering health services to the people.

The Threats of Globalization on Global Public Health with Specific Reference to Tobacco Control

Abstract: The context of Globalization in health is viewed as a concerted global effort towards the prevention, elimination and eradication of disease, and the promotion of human health worldwide. As a result, the domestic and international spheres of public health policy are becoming more intertwined and inseparable. The spread of global tobacco products may indicate one of the instances of globalization of the spread of non-communicable diseases. The tobacco epidemic kills around six million people a year, and more than five million of those deaths are the result of direct tobacco consumption, while more than 600 000 are the result of non-smokers being exposed to second-hand smoke. This is one of the major public health challenges ever faced in the world. Tobacco and Cigarette smoking have negative effect on nearly every organ of the body, causes many diseases, and reduces the health of smokers in general. Smoking and passive smoking cause more than 20 major categories of fatal and disabling disease, including lung and other cancers. It is projected that tobacco use will cause 8.4 million deaths by 2020, 70% of which will occur in developing countries. Of the 100 million projected tobacco-related deaths over the next 20 years, about half will be of people in the productive ages of 35-69. In general, 9% of women in developing countries and about 22% in developed countries currently smoke. Without robust and sustained initiatives, these figures are expected to rise dramatically, with today's 250 million women smokers rising to 340 million by 2020. This article discusses the key problems and opportunities of globalization and how it could be used to control tobacco production within the global public health.