Comprehensive Public Health Policy Research Articles

Associations between diabesity and mortality over 7 years: a Maltese population-level case study

Abstract Introduction Diabesity presents a growing global epidemic. Demographic and socioeconomic associations have been documented, yet, the literature on mortality risk associated with diabesity is scarce. The aim of this study was to assess whether diabetes and/or diabesity increas the risk of all-cause mortality across a period of 7 years at a population level. Methods A nation-wide health examination survey in Malta was conducted between 2014 and 2016. This collected sociodemographic information, bio-anthropometric measurements (waist circumference, body mass index [BMI], body adiposity index [BAI]) and blood samples. Mortality information was acquired in 2021 by cross-referencing with the national mortality register. Statistical analysis was conducted using chi-square tests and Cox proportional hazard models. Results A mortality rate of 1.67% was observed (n = 3947), with diabetes and obesity being responsible for 6.06% and 3.03% of deaths, respectively. Examining the deceased individuals alongside their baseline characteristics (2014-2015) revealed that 25.76% (CI95%: 16.75 - 37.44) had diabetes, and 30.30% (CI95%: 20.55 - 42.22) were obese. Diabetes was associated with significant mortality risk (HR: 2.65 CI95%: 1.20 - 5.85; p = 0.02), while diabesity showed borderline significance (p = 0.06). After adjustment for potential confounding factors the mortality risk linked to diabetes remained significant and BAI was the only anthropometric measurement positively associated with mortality. Conclusions These findings emphasise the urgency for comprehensive public health policies targeting the concurrent prevention and management of diabetes and obesity at a population level. Our results also indicate that incorporating body adiposity index (BAI) into risk assessment protocols may provide valuable insights into mortality risk prediction and inform tailored interventions. Key messages • Diabetes and a high BAI score were significantly associated with mortality in the Maltese population, while diabesity had moderate significance, emphasising the urgency of tackling this epidemic. • These findings call for broad health policies to address diabesity at a population level and suggest integrating BAI into risk assessment for better mortality prediction and tailored interventions.

Unmet Dental Care Needs of The Low-Income Elderly in South Korea: Applying the Andersen behavioural model.

Retirement reduces income and increases dental care needs for the elderly, but there are few studies on unmet dental care needs among the low-income elderly. This study aimed to identify actors associated with unmet dental care needs of low-income elderly people in South Korea. Secondary analysis of 2020 KNHANES data relating to 1,016 elderly individuals (65+) below median income. Unmet dental care needs were higher for women at 28.9% (p ⟨0.001), those with a middle school education at 28.5% (p ⟨ 0.05), individuals who rated their health as "poor" at 31.3%, those reporting feelings of depression at 44.8% (p ⟨ 0.001), individuals who rated their oral health as "poor" at 36.2% (p ⟨ 0.001), and those who experienced toothache at 37.2% (p ⟨ 0.001). In regression analysis women (Risk Ratio = 1.59, 95% CI 1.09-2.32), people with depression (RR = 2.29, 95% CI 1.01-5.15), those who perceived their oral health as "poor" (3.20, 95% CI 1.90-5.32) and those toothache (1.88, 95% CI 1.27-2.76) had higher unmet dental needs. Substantial unmet dental care needs exist among the low-income retired elderly. Comprehensive public oral health policies and community programs are needed for this population group.

The Chilean exposome-based system for ecosystems (CHiESS): a framework for national data integration and analytics platform.

The double burden of diseases and scarce resources in developing countries highlight the need to change the conceptualization of health problems and translational research. Contrary to the traditional paradigm focused on genetics, the exposome paradigm proposed in 2005 that complements the genome is an innovative theory. It involves a holistic approach to understanding the complexity of the interactions between the human being’s environment throughout their life and health. This paper outlines a scalable framework for exposome research, integrating diverse data sources for comprehensive public health surveillance and policy support. The Chilean exposome-based system for ecosystems (CHiESS) project proposes a conceptual model based on the ecological and One Health approaches, and the development of a technological dynamic platform for exposome research, which leverages available administrative data routinely collected by national agencies, in clinical records, and by biobanks. CHiESS considers a multilevel exposure for exposome operationalization, including the ecosystem, community, population, and individual levels. CHiESS will include four consecutive stages for development into an informatic platform: (1) environmental data integration and harmonization system, (2) clinical and omics data integration, (3) advanced analytical algorithm development, and (4) visualization interface development and targeted population-based cohort recruitment. The CHiESS platform aims to integrate and harmonize available secondary administrative data and provide a complete geospatial mapping of the external exposome. Additionally, it aims to analyze complex interactions between environmental stressors of the ecosystem and molecular processes of the human being and their effect on human health. Moreover, by identifying exposome-based hotspots, CHiESS allows the targeted and efficient recruitment of population-based cohorts for translational research and impact evaluation. Utilizing advanced technologies such as Artificial Intelligence (AI), Internet of Things (IoT), and blockchain, this framework enhances data security, real-time monitoring, and predictive analytics. The CHiESS model is adaptable for international use, promoting global health collaboration and supporting sustainable development goals.

Impact of a Nyakaza Move-for-Health Intervention Programme among Adolescents in a Resource-Constrained South African Community

Adolescents in resource-constrained environments face increasing sedentary lifestyles and obesity rates, necessitating effective interventions for promoting physical activity and combating non-communicable diseases. This study evaluates the impact of a 12 week Nyakaza Move-for-Health intervention on physical activity, anthropometry, cardiorespiratory fitness, and behaviour change among adolescents in KwaZulu-Natal, South Africa. One hundred twenty-eight adolescents participated, with assessments including self-reported physical activity, anthropometric indices, and cardiorespiratory fitness measures. The intervention significantly increased physical activity levels. The treatment group’s mean score was 2.2 (0.4) at baseline and 2.6 (0.4) (F (14, 79) = 4.884, p = <0.001, η2 = 0.156) at the endline. The body mass index decreased (mean = 22.4 (4.6) at baseline and 21.9 (4.2) at endline; p = 0.025, partial eta squared = 0.025, η2 = 0.004). The intervention programme significantly affected the WHR (mean = 0.80 (0.10) at baseline and 0.76 (0.9) at endline; p < 0.001, partial eta squared = 0.327, η2 = 0.100) and the predicted maximal oxygen uptake (VO2 max) for the treatment group (mean = 42.4 (8.7) at baseline and mean = 43.6 (8.7) at endline; p < 0.711, partial eta squared = 0.017, η2 = 0.033). Focus group discussions indicated shifts in knowledge, attitudes, and motivation towards physical activity. Power analysis revealed strong observed power (PA: 0.983, BMI: 0.098, WHR: 0.887), indicating the robustness of the intervention’s effects. These findings underscore the effectiveness of the intervention in improving physical health outcomes. It is recommended that longitudinal studies be conducted to assess the long-term sustainability and impact of such interventions on adolescents’ health outcomes, thereby informing the development of comprehensive public health policies and programmes to promote physical activity and combat non-communicable diseases in similar settings.

Public health policies in dental traumatology: A call for action!

Traumatic dental injuries (TDI) are a prevalent public health concern, requiring preventive measures as well as timely and appropriate interventions to prevent adverse outcomes and optimize patients' prognosis. Although dental trauma injuries require prompt clinical intervention, some challenges persist in effectively managing these injuries. In dental traumatology, the implementation of public health policies assumes critical importance, these policies play an important role in addressing preventive measures and mitigating the repercussions of TDI. This review aims to emphasize the importance of developing comprehensive public health policies in dental traumatology, recognizing the strategic importance of this approach and its benefits. By proactively addressing issues associated with dental injuries, these policies have extensive implications for individual quality of life and public health in general. Furthermore, this review will present a suggested structured framework for the development of public health policies, encompassing key domains including prevention, intervention, and education in dental traumatology. The creation and implementation of these policies will address dental trauma through prevention programs, research, and development, and will provide a significant step toward enhancing the well-being of the population and dental trauma victims' prognosis promoting a more resilient healthcare system.

SCOPING REVIEW OF PSYCHOLOGICAL RESEARCH AND PUBLICATIONS RELATED TO THE EFFECTS OF THE COVID-19 PANDEMIC AND THE MEASURES TAKEN

Publications of 21 scientific studies from the field of psychology and psychiatry related to the effects that the spread of COVID-19 has on mental health and the measures taken by mental health professionals to control the negative consequences on the psyche of people are presented. In this regard, the aim of the article is to present a summary of the main subjects in scientific research in the field of mental health. The article differentiates five main problem areas in relation to people's mental health and emotional response to COVID-19: in terms of age; gender differences; personality characteristics; professional activity and behaviour; telepsychiatry and telepsychology. The analysis of the publications shows that the effects can be divided into two categories: short-term and long-term, and in both categories the effects can be positive and negative; the authors emphasize the phenomenology of subjective experiences. Most researchers draw the following conclusions: the COVID-19 pandemic has provoked high levels of stress, mental instability, PTSD, depression, cognitive and neurological disorders; vulnerable groups (elderly people, young people, health professionals, people with mental health problems before the pandemic, homeless people and refugees) have more mental health problems during the pandemic and are slower to recover. Another important conclusion from the 21 studies studied is that it is necessary to formulate recommendations to improve people's mental health, to involve mental health professionals in the development of comprehensive public health policies and to support health care workforce as well as to improve public health prevention strategies, especially during health crises.

Prevalence and predictors of lifetime amphetamine use among in-school adolescents in Sierra Leone.

ObjectiveThis study examined the prevalence of amphetamine use and its associated factors among in-school adolescents in Sierra Leone.DesignData for the study was sourced from the 2017 Sierra Leone Global School-based...

Relationship between food insecurity and malnutrition in schoolchildren from low- and middle-income countries - A systematic review.

The objective of this review is to study the relationship between food insecurity (FI) and malnutrition in schoolchildren from low-and middle-income countries (LMIC). The review was conducted using the databases PubMed, MEDLINE, CENTRAL, LILACS and SCiELO during the months of March to April 2022 without language or publication date restrictions. The search strategy consisted of combinations of text words and controlled vocabulary (MeSH terms and DeCS) related to "schoolchildren", "low- and middle-income countries" and "food insecurity". Fifteen studies were included in this review. Studies assessing FI and undernutrition in LMIC schoolchildren have indicated that FI is associated with lower height-for-age and higher prevalence of undernutrition overall. Only two studies identified a positive risk association between FI and overweight and obesity, the remaining studies suggested that schoolchildren with FI have a lower risk of overweight and obesity than those without FI. The review suggests a link between FI and undernutrition in schoolchildren from LMIC, with controversial results on overweight and obesity. Comprehensive public health policies should consider contextual and population-specific factors in addressing FI's impact on nutritional status.

Risk of all-cause mortality is associated with multiple health-related lifestyle behaviors and does not differ between urban and rural areas in Korea.

Urban-rural inequities in health and mortality exist in Korea, a highly centralized developed country. The potential impact of multiple health-related lifestyle behaviors on mortality and difference between urban and rural areas is not fully understood. This study aimed to investigate the effect of high-risk health behaviors on all-cause mortality among residents living in urban and rural in Korea. Cross-sectional analyses were conducted on 8,298 adults aged 40 yrs and older from the Korea National Health and Nutrition Examination Survey 2013-2015. High-risk behaviors were defined as having poor diet quality, current smoking, high-risk drinking, or insufficient physical activity. Mortality status was linked to the Cause of Death data followed up to December 31, 2019. The associations between all-cause mortality and high-risk behaviors were evaluated using Cox proportional hazard regression models adjusted for age, sex, education, income, and survey year. Population attributable fractions (PAFs) were calculated, and effect modification analysis was conducted. Participants were stratified by residential area (urban or rural). During the follow-up (median: 5.4 yrs), 313 deaths occurred. A higher proportion of rural residents than urban residents engaged in multiple high-risk behaviors (28.9% vs. 22.6%; P < 0.0001). As individual factors, a greater risk of mortality was associated with poor diet quality, current smoking, and inadequate physical activity, and these tendencies persisted in rural residents, especially for diet quality. Multiple high-risk behaviors were positively associated with a higher risk of mortality in Koreans living in urban and rural areas. PAF (95% confidence interval) was 18.5% (7.35-27.9%) and 29.8% (16.1-40.2%) in urban and rural residents, respectively. No additive or multiplicative effect of the region was observed. The higher prevalence of multiple high-risk lifestyle behaviors in rural residents may explain the higher mortality in rural areas compared to urban areas. Comprehensive public health policies to improve health-related behaviors in rural populations may be needed.

Changes in alcohol consumption habits and risk of atrial fibrillation: a nationwide population-based study.

Heavy alcohol consumption is an established risk factor for atrial fibrillation (AF). However, the association between habitual changes in heavy habitual drinkers and incident AF remains unclear. The aim of this study was to evaluate whether absolute abstinence or reduced drinking decreases incident AF in heavy habitual drinkers. Atrial fibrillation-free participants with heavy alcohol consumption registered in the Korean National Health Insurance Service database between 2005 and 2008 were enrolled. Habitual changes in alcohol consumption between 2009 and 2012 were classified as sustained heavy drinking, reduced drinking, and absolute abstinence. The primary outcome measure was new-onset AF during the follow-up. To minimize the effect of confounding variables on outcome events, inverse probability of treatment weighting (IPTW) analysis was performed. Overall, 19 425 participants were evaluated. The absolute abstinence group showed a 63% lower incidence of AF (IPTW hazard ratio: 0.379, 95% confidence interval: 0.169-0.853) than did the sustained heavy drinking group. Subgroup analysis identified that abstinence significantly reduced incident AF in participants with normal body mass index and without hypertension, diabetes, dyslipidaemia, heart failure, stroke, chronic kidney disease, or coronary artery disease (all P-value <0.05). There was no statistical difference in incident AF in participants with reduced drinking compared with sustained heavy alcohol group. Absolute abstinence could reduce the incidence of AF in heavy alcohol drinkers. Comprehensive clinical measures and public health policies are warranted to motivate alcohol abstinence in heavy drinkers.

Multimorbidity and social determinants of health in the US prior to the COVID-19 pandemic and implications for health outcomes: a cross-sectional analysis based on NHANES 2017–2018

Multimorbidity increases the risk of all-cause mortality, and along with age, is an independent risk factor for severe disease and mortality from COVID-19. Inequities in the social determinants of health contributed to increased mortality from COVID-19 among disadvantaged populations. This study aimed to evaluate the prevalence of multimorbid conditions and associations with the social determinants of health in the US prior to the pandemic.Methods Data from the 2017–18 cycle of NHANES were used to determine the prevalence of 13 chronic conditions, and the prevalence of having 0, 1, or 2 or more of those conditions, among the US adult population aged ≥ 20 years. Multimorbidity was defined as having 2 or more of these conditions. Data were stratified according to demographic, socioeconomic and indicators of health access, and analyses including logistic regression, performed to determine the factors associated with multimorbidity.Results The prevalence of multimorbidity was 58.4% (95% CI 55.2 to 61.7). Multimorbidity was strongly associated with age and was highly prevalent among those aged 20–29 years at 22.2% (95% CI 16.9 to 27.6) and continued to increase with older age. The prevalence of multimorbidity was highest in those defined as Other or multiple races (66.9%), followed in decreasing frequency by rates among non-Hispanic Whites (61.2%), non-Hispanic Blacks (57.4%), Hispanic (52.0%) and Asian (41.3%) groups.Logistic regression showed a statistically significant relationship between multimorbidity and age, as expected. Asian race was associated with a reduced likelihood of 2 or more chronic conditions (OR 0.4; 95% CI 0.35 to 0.57; P < 0.0001). Socioeconomic factors were related to multimorbidity. Being above the poverty level (OR 0.64; 95% CI 0.46 to 0.91, p = 0.013); and a lack of regular access to health care (OR 0.61 (95% CI 0.42 to 0.88, p = 0.008) were both associated with a reduced likelihood of multimorbidity. Furthermore, there was a borderline association between not having health insurance and reduced likelihood of multimorbidity (OR 0.63; 95% CI 0.40 to 1.0; p = 0.053).Conclusions There are high levels of multimorbidity in the US adult population, evident from young adulthood and increasing with age. Cardiometabolic causes of multimorbidity were highly prevalent, especially obesity, hyperlipidemia, hypertension, and diabetes; conditions subsequently found to be associated with severe disease and death from COVID-19. A lack of access to care was paradoxically associated with reduced likelihood of comorbidity, likely linked to underdiagnosis of chronic conditions. Obesity, poverty, and lack of access to healthcare are factors related to multimorbidity and were also relevant to the health impact of the COVID-19 pandemic, that must be addressed through comprehensive social and public policy measures. More research is needed on the etiology and determinants of multimorbidity, on those affected, patterns of co-morbidity, and implications for individual health and impact on health systems and society to promote optimal outcomes. Comprehensive public health policies are needed to tackle multimorbidity and reduce disparities in the social determinants of health, as well as to provide universal access to healthcare.

Determinants of Pneumonia mortality in Bogota, Colombia: A spatial econometrics approach

Bogota, the capital and largest city of Colombia, constantly fights against easily transmitted and endemic–epidemic diseases that lead to enormous public health problems. Pneumonia is currently the leading cause of mortality attributable respiratory infections in the city. Its recurrence and impact have been partially explained by biological, medical, and behavioural factors. Against this background, this study investigates Pneumonia mortality rates in Bogota from 2004 and 2014. We identified a set of environmental, socioeconomic, behavioural, and medical care factors whose interaction in space could explain the occurrence and impact of the disease in the Iberoamerican city. We adopted a spatial autoregressive models framework to study the spatial dependence and heterogeneity of Pneumonia mortality rates associated with well-known risk factors. The results highlight the different types of spatial processes governing Pneumonia mortality. Furthermore, they demonstrate and quantify the driving factors that stimulate the spatial spread and clustering of mortality rates. Our study stresses the importance of spatial modelling of context-dependent diseases such as Pneumonia. Likewise, we emphasize the need to develop comprehensive public health policies that consider the space and contextual factors.

Reducing or reproducing inequalities in health? An intersectional policy analysis of how health inequalities are represented in a Swedish bill on alcohol, drugs, tobacco and gambling

BackgroundAccording to post-structural policy analyses, policies and interventions aiming at reducing social inequalities have been found to be part in producing and reifying such inequalities themselves. Given the central role of health inequalities on the public health policy agenda globally it seems important to examine the way policy on health inequalities may potentially counteract the goal of health equity. The aim of this intersectional policy analysis, was to critically analyze the representation of health inequalities in a government bill proposing a national strategy on alcohol, drugs, tobacco and gambling, to examine its performative power, and to outline alternative representations.MethodA post-structural approach to policy analysis was combined with an intersectional framework. The material was analyzed through an interrogating process guided by the six questions of the “What’s the problem represented to be?” (WPR) approach. Thus, the underlying assumptions of the problem representation, its potential implications and historical background were explored. In a final step of the analysis we examined our own problem representations.ResultsThe recommendations found in the gender and equity perspective of the bill represented the problem of health inequalities as a lack of knowledge, with an emphasis on quantitative knowledge about differences in health between population groups. Three underlying assumptions supporting this representation were found: quantification and objectivity, inequalities as unidimensional, and categorization and labelling. The analysis showed how the bill, by opting into these partly overlapping assumptions, is part of enacting a discourse on health inequalities that directs attention to specific subjects (e.g., vulnerable) with special needs (e.g., health care), in certain places (e.g., disadvantaged neighborhoods). It also showed how underlying processes of marginalization are largely neglected in the bill due to its focus on describing differences rather than solutions. Finally, we showed how different intersectional approaches could be used to complement and challenge this, potentially counteractive, problem representation.ConclusionsThe problem representation of health inequalities and its underlying assumptions may have counteractive effects on health equity, and even though some of its strengths are raised, it seems to be profoundly entangled with a system resisting the kind of change that the bill itself advocates for. If carefully used, intersectionality has the potential to support a more comprehensive and inclusive equality-promoting public health policy and practice.

Determining Factors Influencing Specialty Preferences of Iranian Medical Doctors: A Qualitative Study.

Background: The medical specialty choice of physicians directly affects the healthcare system, community wellbeing, and their own professional life. It is therefore important to identify its underlying factors to predict such medical career choices and to draw up a comprehensive evidence-based public health policy and health human resources planning. The present qualitative study aimed to identify these determinants of career choices through semi-structured interviews with medical doctors in the context of country-specific social and cultural characteristics.Methods: The present qualitative study was carried out in 2019-2020 at Shiraz University of Medical Sciences (Shiraz, Iran). The target population was medical students, junior doctors, and medical residents. The purposive sampling method was used to recruit the participants and sampling continued until data saturation, i.e., no new information could be extracted. Data were collected through individual, face-to-face, semi-structured interviews and analyzed using the conventional content analysis method. Inductive thematic analysis was used to interpret the data based on which a thematic map was developed illustrating the factors influencing medical specialty preferences in Iran. Data trustworthiness was assessed according to the criteria proposed by Guba and Lincoln.Results: Analysis of the interview data resulted in three main themes and fourteen sub-themes. The main themes were “Personal determinants”, “Career-related factors”, and “Interpersonal influences”. The most important sub-themes were personal interests, income, and prestige.Conclusion: The determinants influencing the specialty preferences of Iranian medical doctors are identified. Our findings will facilitate the development of a comprehensive evidence-based public health policy, health human resources planning, and appropriate medical education policy.

Knowledge, Attitude, and Practice on Cervical Cancer and HPV Vaccination among Medical Students in Jakarta, Indonesia: A Cross-Sectional Study

BACKGROUND: Cervical cancer is the second-most common cancer in Indonesian women. While the cervical cancer screening has been integrated in Indonesian primary health-care facilities, the HPV vaccination has not yet become a national program. AIM: The objective of this research was to measure the knowledge, attitude, and behavior of medical students in Jakarta toward cervical cancer and its prevention. The result of this study could be implemented to develop a more comprehensive national educational program and public health policy. METHODS: We conducted a cross-sectional study on medical students at 10 different universities in Jakarta, Indonesia. Student’s knowledge, attitude, and behavior were collected through a self-administered online questionnaire consist of a total of 27 questions concerning cervical cancer epidemiology, pathogenesis, screening, diagnosis, and prevention. RESULTS: A total of 2159 medical students participated in this study. More than half (55%) of the students obtained satisfactory knowledge score. The students’ knowledge regarding HPV vaccination was low. However, 87.2% of them agreed to get the HPV vaccination. Only 7.0% had participated in cervical cancer screening program and only 16.8% had received HPV vaccination. Female gender, second or third year of study, and three universities had better odds to have good practice score. CONCLUSION: The knowledge and attitude score did not reflect on student’s practice on cervical cancer and its prevention. Effort to increase the awareness toward cervical cancer should be endorsed through university curriculum and public health policy.

Malnutrition and Anemia: A Health Burden among Tea Garden Workers in West Tripura District, Tripura, India

Introduction: The tea garden workers are an underestimated group of our society and are considered to be the most nutritionally vulnerable community. This study was undertaken to study the nutritional status of the male and female tea garden workers of West Tripura district, Tripura, India. Methods: In this cross-sectional study, a total of 409 tea garden workers including both sexes (males: 197; females: 212) of age group 18–60 years were selected. A questionnaire for on-ground data collection was administered along with the assessment of dietary intake and dietary quality, anthropometric data measurements, physiological measurements, hematological and biochemical estimation. Results: Most of the workers were vegetarian, and about two-thirds of the participants consumed two meals per day. None of the subjects was in the habit of taking packed lunch in routine, and maximum respondents (males: 84.26%; female: 83.96%) were in the habit of keeping fast. Skipping meals was also common in a vast number of the participants (males: 83.24%; females: 84.90%). A maximum number of participants complained of anorexia, headache, breathlessness on exertion, lethargic feeling, pale conjunctiva, pale skin, and flat nails. A very high prevalence of anemia (males: 94.91%; females: 99.04%) was observed among the workers. The present study also revealed dietary inadequacies, particularly regarding protein, energy, calcium, and all micronutrients (iron, β-carotene, folic acid) except vitamin C. A positive significant (P &lt; 0.05) correlation was observed between hemoglobin and various daily dietary intakes of blood-forming nutrients. Conclusion: The present study reveals the prevalence of anemia among tea garden workers, especially female workers. Nutritional insufficiency might be one of the important factors in this process. This study suggests that a comprehensive public health policy should be developed so that the tea garden workers’ health and nutritional needs can be addressed.

Anxiety and Depression amongst African-Americans Living in Rural Black Belt Areas of Alabama: Use of Social Determinants of Health Framework

Abstract The present study utilised the social determinants of health (SDH) framework to see whether indicators of the framework have an impact on anxiety and depression of people living in rural Black Belt communities in Alabama. Data from a convenient sample of 159 African-Americans aged 18 or older were from two sites in rural Alabama. The levels of anxiety and depression were measured by the Patient Health Questionnaire-9 (PHQ9). Multiple linear regression model was used to examine the association between SDH and anxiety and depression level of participants. The mean PHQ9 score of participants was 5.57 out of twenty-seven. Four SDH were significantly related to PHQ9 levels amongst participants: participants with higher food insecurity scores, higher transportation needs and higher threats to interpersonal safety tended to have higher scores in PHQ9. Moreover, health literacy levels were negatively associated with PHQ9 scores amongst participants. Our study highlights understanding SDH specifically for residents in rural communities that are socially and culturally isolated is important for developing preventive approaches that enhance access to mental health treatments. A comprehensive public health policy that incorporates our study findings is needed for the rural areas of the USA.

Cardiovascular risk factors and social determinants in a population study in Rio de Janeiro, Brazil

Abstract Background The association of cardiovascular (CV) diseases and their risk factors with socioeconomic status has been well described, but its influence is often underestimated in epidemiological studies in Brazil. Objective To evaluate the relationship between the main CV risk factors and socioeconomic indicators in a population of adults registered in a Family Health Care (FHC) unit in a great urban center - Rio de Janeiro, Brazil. Methods Cross-sectional population study that included adults aged between 20 and 50 years living in the area covered by the FHC unit in Rio de Janeiro. Demographic data (gender and age), socioeconomic data (education level, profession, employment), CV risk factors (smoking, sedentary lifestyle, obesity, hypertension, diabetes, dyslipidemia) were recorded. The metabolic profile is evaluated through laboratory tests. Those who studied up to high school were considered poorly educated. Results 604 individuals were enrolled [39% male, mean age: 38.8 ± 8,9 years] The median of schooling was 12 years. 288 individuals had high schooling, 44.5% were male. A total of 130 individuals did not study or work. Women with low education had a higher risk of smoking, obesity and hypertension with no difference regarding labor or study activities. Otherwise, men with low education had a higher risk of sedentary lifestyle and hypertension. Among men, not working or studying increased the risk of smoking and hypertension. Conclusions We found an inverse association between socioeconomic conditions and the prevalence of CV risk factors. Women are more affected by low schooling, while men are more affected by their working occupation. The study suggests that socioeconomic factors influence the CV risk, affecting men and women differently, pointing to the need for more comprehensive public health policies that effectively reverse this situation. Key messages We found an inverse association between socioeconomic conditions and the prevalence of CV risk factors. Socioeconomic factors influence cardiovascular risk differently according to gender.

Impact of sugar-sweetened beverage tax on dental caries: a simulation analysis

BackgroundThe tiered sugar-sweetened beverage (SSB) tax was implemented in Thailand to encourage industries to reduce sugar content in beverages, and consequently reduce sugar consumption in the population. The aim of the study is to explore the expected impact of the new SSB tax policy in Thailand, a middle-income country in Asia, and other alternative policies on oral health outcomes as measured by the prevalence and severity of dental caries among the Thai population.MethodsA qualitative system dynamics model that captures the complex interrelationships among SSB tax, sugar consumption and dental caries, was elicited through participatory stakeholder engagement. Based on the qualitative model, a quantitative system dynamics model was developed to simulate the SSB tax policy and other alternative scenarios in order to evaluate their impact on dental caries among Thai adults from 2010 to 2040.ResultsUnder the base-case scenario, the dental caries prevalence among the Thai population 15 years and older, is projected to increase from 61.3% in 2010 to 74.9% by 2040. Implementation of SSB tax policy is expected to decrease the prevalence of dental caries by only 1% by 2040, whereas the aggressive policy is projected to decrease prevalence of dental caries by 21% by 2040.ConclusionsIn countries where a majority of the sugar consumed is from non-tax sugary food and beverages, especially Asian countries where street food culture is ubiquitous and contributes disproportionately to sugar intake, SSB tax alone is unlikely to have meaningful impact on oral health unless it is accompanied with a comprehensive public health policy that aims to reduce total sugar intake from non-SSB sources.

Nalmefene in alcohol‐dependent patients with a high drinking risk: A limited efficacy in reducing alcohol consumption

Nalmefene authorization in Europe for reducing alcohol consumption in alcohol-dependent patients with high or very high drinking risk level and maintaining a high drinking risk level 2 weeks after initial assessment was granted on the grounds of controversial data. There had been no randomized controlled trial (RCT) conducted in the target population at that point. The market authorization was based on data from subgroup analyses of the pivotal studies: ESENSE1 (NCT00811720), ESENSE2 (NCT00812461), and SENSE (NCT00811941). However, subgroup analyses are only exploratory. It is therefore reasonable to question if the new RCT assessing the efficacy of nalmefene in patients with a high drinking risk1 can add to the previous body of evidence. We argue that this study shares the weaknesses of the previous phase 3 trials that led to questioning the efficacy of nalmefene in reducing alcohol consumption.2 Overall, although the effect sizes observed on the consumption outcomes were higher than in the previous studies, the clinical relevance of such differences remains questionable. Regarding total alcohol consumption, the difference in the adjusted change from baseline between nalmefene 20 mg and placebo (expressed in least square mean) at 6 months was −11 g of alcohol/day (i.e., about a 100-mL glass of wine). It is also not known how much these differences were due to attrition bias. Compared to placebo (89.4%), the treatment completion rates were significantly lower in the nalmefene 20-mg (76.2%, P < 0.001) and nalmefene 10-mg (75.5%, P < 0.001) groups. Whereas a loss to follow-up of 5% or lower is usually of little concern, such a loss of >20% prevents good-quality intention-to-treat analysis and can cause biased estimates of the treatment effect.3, 4 The rate of discontinuation due to adverse events was higher in the groups receiving nalmefene than in the placebo group (18.1%, 18.5%, and 4.5%, respectively, for nalmefene 20-mg, nalmefene 10-mg, and placebo). These characteristics were already observed in a meta-analysis of the initial trials submitted to the European Medicine Agency.5 In addition, a primary outcome assessed at 12 weeks and a follow-up ending at 24 weeks is too short to evaluate a drug intending to reduce harm. No RCT has assessed the efficacy of nalmefene in the long term. Only one RCT has assessed the efficacy of nalmefene after 1 year of treatment, and showed limited and inconsistent efficacy on consumption outcomes.5 Currently, the harm-reduction approach is based on models that are basically an extrapolation of the results from subgroup analyses of the previous pivotal RCT beyond the trial time horizon.6 Moreover, it is unlikely that a slight reduction in consumption, even if sustained, could be clinically relevant considering that the model is dealing with patients who had experienced high consumption for a long time, which is different to subjects with excessive use. None of the previous trials demonstrated any benefit of nalmefene on harm related to alcohol use, and the current study failed to show significant effect of nalmefene on health-related quality of life (i.e., Alcohol Quality of Life Scale, Short Form – 36 Health Survey, and EuroQol - 5 Dimension) at 24 weeks. In several European countries, such as in Germany, agencies for efficiency in health care have concluded that studies of nalmefene showed no additional benefit for alcohol dependence compared to naltrexone, another opioid antagonist that was an earlier and less costly comparator therapy.7 A recent independent indirect comparison concluded a lack of advantage of nalmefene versus naltrexone.8 Long-term psychosocial interventions by trained professionals remain the cornerstone of successful care.9 Further, treatment would be a Sisyphean task and would demonize vulnerable people who cannot stop their problem drinking if no comprehensive public health policy for alcohol control is implemented. Finally, readers must be aware that a Californian winery, Ridge Vineyards Inc., is a subsidiary company of Otsuka Holdings Co., Ltd. In conclusion, it should be recalled that the clinical significance of a statistically significant difference on a surrogate outcome should be critically appraised. A.B. and F.N. served as unpaid experts for several taskforces for the French drug agency (Agence Nationale de Sécurité du Médicament et des Produits de Santé), none of which were related to the topic. A.B. was a late co-investigator for NCT01738282 trial (baclofen) but did not recruit. C.P. has no conflict of interest to declare.