Strong Public Health Research Articles

Ideal Cardiovascular Health and Risk of Cardiovascular Events or Mortality: A Systematic Review and Meta-Analysis of Prospective Studies.

Cardiovascular diseases (CVD) remain the leading cause of morbidity and mortality worldwide, hence significant efforts have been made to establish behavior and risk factors associated with CVD. The American Heart Association proposed a 7-metric tool to promote ideal cardiovascular health (CVH). Recent data demonstrated that a higher number of ideal CVH metrics was associated with a lower risk of CVD, stroke, and mortality. Our study aimed to perform a systematic review and meta-analysis of prospective studies investigating the association of ideal CVH metrics and CVD, stroke, and cardiovascular mortality (CVM) in the general population. Medline and Scopus databases were searched from January 2010 to June 2022 for prospective studies reporting CVH metrics and outcomes on composite-CVD, coronary heart disease, myocardial infarction, stroke, and CVM. Each CVH metrics group was compared to another. Twenty-two studies totaling 3,240,660 adults (57.8% men) were analyzed. The follow-up duration was 12.0 ± 7.2 years. Our analysis confirmed that a higher number of ideal CVH metrics led to lower risk for CVD and CVM (statistically significant for composite-CVD, stroke, and CVM; p < 0.05). Conclusion: Even modest improvements in CVH are associated with CV-morbidity and mortality benefits, providing a strong public health message about the importance of a healthier lifestyle.

Do patents really foster innovation in the pharmaceutical sector? Results from an evolutionary, agent-based model

The role of the patent system in the pharmaceutical sector is highly debated also due to its strong public health implications. In this paper we develop an evolutionary, agent-based model of the pharmaceutical industry to explore the impact of different configurations of the patent system upon innovation and competition. The model is able to replicate the main stylized facts of the drug industry as emergent properties. We perform policy experiments to assess the impact of different Intellectual Property Rights (IPR) regimes changing the breadth and length of patents. Results tend to point against a strong patent system. Simulation experiments suggest that the extent and duration of patents shall, if anything, be set to minimum levels. This holds even when one assumes a strong response of R&D incentives to appropriability conditions and when taking into account information disclosure effects triggered by patents.

Multisectoral action towards sustainable development goal 3.d and building health systems resilience during and beyond COVID-19: Findings from an INTOSAI development initiative and World Health Organization collaboration.

This article is part of the Research Topic 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict'. As the world faces global health crises such as pandemics, epidemics, climate change and evolving disease burdens and population demographics, building strong and resilient public health systems is of critical importance. The need for an integrated approach to building health system resilience; the widening of inequalities; and fears of vulnerable populations being left behind are critical issues that require Supreme Audit Institutions (SAIs) enquiry as independent public oversight bodies. Each country has a Supreme Audit Institution with a remit to audit public funds as an effective, accountable, and inclusive institution. Government audits are key components of effective public financial management and Good Governance. SAIs contribute to the quality of government engagement and better state-society relations through their work. As SAIs provide independent external oversight and contribute to follow up and review of national targets linked to the Sustainable Development Goals (SDGs) in their respective countries, they can play an important role in national recovery efforts. WHO and INTOSAI Development Initiative (IDI) have been collaborating in facilitating SAIs' audits of strong and resilient national public health systems linked to the national target of SDG 3.d in 40 countries across Africa, Americas, Asia and Oceania between 2021 and 2022. This paper aims to convey key lessons learned from the joint multisectoral collaboration for facilitating the 3.d audits that can contribute to building health systems resilience in ongoing recovery efforts. The collaboration included facilitation of the audits through professional education and audit support using a health systems resilience framework. The 3.d audits are performance audits and follow IDI's SDG Audit Model (ISAM). Following the ISAM implies that the SAI should focus on a whole-of-government approach, policy coherence and integration, and assess both government efforts at 'leaving no one behind' and multi-stakeholder engagement in implementing the chosen national SDG target linked to 3.d. WHO's Health Systems Resilience team has supported IDI and SAIs by delivering training sessions and reviewing working papers and draft reports of the SAIs from a health systems resilience perspective. IDI has provided the technical expertise on performance audits through its technical team and through in-kind contributions from mentors from many SAIs in the regions participating in the audit. In the 3.d audit, SAIs can ask how governments are acting to enhance capacity in some or all of the following, depending on their own national context and risk: forecasting, preventing and preparing for public health emergencies (PHEs) and threatsadapting, absorbing and responding to PHEs and threatsmaintaining essential health services in all contexts (including during emergencies/crises). The audits are expected to highlight current capacities of health systems resilience; the extent to which a whole-of-government approach and policy coherence have been utilised; and government efforts related to multistakeholder engagement and leaving no one behind in building health systems resilience related to progressing towards achieving the national target linked to 3.d by 2030. An overall positive achievement noted was that undertaking a complex health audit in the middle of a pandemic is possible and can contribute to building health systems resilience and recovery efforts. In their review of audit plans, draft summaries, and other work by the SAIs, both WHO and IDI have observed that SAIs have used the training and supplementary materials and applied various parts of it in their audits. This collaboration also demonstrates key considerations needed for successful partnership across multisectoral partners at global, regional and national levels. Such considerations can be applied in different contexts, including socioeconomic and health system recovery, to ensure whole-of-society and whole-of-government action in building health systems resilience and monitoring and evaluation to maintain and accelerate progress towards the national target linked to SDG3.d, health security and universal health coverage (UHC), as well as broader socioeconomic development.

Strategies to Operationalize Health Equity in Island Area Health Departments.

Strategies to Operationalize Health Equity in Island Area Health Departments.

Health Disparities for Canada's Remote and Northern Residents: Can COVID-19 Help Level the Field?

This paper reviews major structural drivers of place-based health disparities in the context of Canada, an industrialized nation with a strong public health system. Likelihood that the COVID-19 pandemic will facilitate rejuvenation of Canada's northern and remote areas through remote working, advances in online teaching and learning, and the increased use of telemedicine are also examined. The paper concludes by identifying some common themes to address healthcare disparities for northern and remote Canadian residents.

Unmasking racial avoidance: Experimental evidence on parental school choice and public health policies during the Covid-19 pandemic

BackgroundCOVID-19 drastically changed the school choice landscape as families considered schools with varying public health protocols as well as academic and demographic characteristics. Our understanding of families’ preferences during the pandemic is limited, however, because it primarily derives from surveys asking parents about a single school characteristic. ObjectiveWe aimed to understand how families' preferences for schools’ racial composition and public health policies may interdepend. MethodsWe conducted an original school choice survey experiment with U.S. White parents in August 2021. Parents indicated their willingness to enroll their student in hypothetical schools with experimentally randomized school quality ratings, racial and socioeconomic demographics, and COVID mitigation strategies (i.e. instructional modalities, mask and vaccination mandates). ResultsWe find novel causal evidence that White parents' preferences for schools’ racial demographics and public health policies are interdependent. Among otherwise similar schools, parents expressed stronger preferences to avoid Black, Latinx, and Asian schools when there were fewer COVID mitigation policies. Relatedly, parents required more stringent COVID protocols for their children to attend predominantly Black, Latinx, and Asian schools while showing no preferences for COVID policies among predominantly White schools. The interdependence of preferred racial demographics and public health polices was amplified among White parents who held stigmatizing beliefs about Asian populations carrying the COVID virus and pro-White sentiments. Although Democrats expressed stronger preferences for schools with more COVID mitigation strategies than Republicans, for White parents across the political spectrum school racial composition and COVID mitigation preferences interdepended. ConclusionsThis study suggests families may leverage flexible student assignment policies and schools of choice to enroll in or avoid schools based on both preferred public health policies and racial demographics. Districts should consider how adopting strong public health policies during infectious disease outbreaks may help mitigate hardened racial avoidance and school racial segregation.

Seasonality of meteorological factors influencing the COVID-19 era in coastal and inland regions of Bangladesh

We aim to explore the seasonal influences of meteorological factors on COVID-19 era over two distinct locations in Bangladesh using a generalized linear model (GLM) and wavelet analysis. GLM model findings show that summer humidity drives COVID-19 transmission to coastal and inland locations. During the summer in the coastal area, a 1 °C earth’s skin temperature increase causes a 41.9% increase in COVID (95% CL 86.32%-2.54%) transmission compared to inland. Relative humidity was recorded as the highest at 73.97% (95% CL, 99.3%, and 48.63%) for the coastal region, while wind speed and precipitation reduced confirmed cases by −38.62% and −22.15%, respectively. Wavelet analysis showed that coastal meteorological parameters were more coherent with COVID-19 than inland ones. The outcomes of this study are consistent with subtropical climate regions. Seasonality and climatic similarity should address to estimate COVID-19 trends. High societal concern and strong public health measures may decrease meteorological effect on COVID-19.

Effect of Electronic Nudges on Influenza Vaccination Rate in Older Adults With Cardiovascular Disease: Prespecified Analysis of the NUDGE-FLU Trial.

Influenza vaccines have been demonstrated to effectively reduce the incidence of influenza infection and potentially associated risks of cardiovascular events in patients with cardiovascular disease (CVD). Despite strong guideline and public health endorsements, global influenza vaccination rates in patients with CVD are highly variable. This prespecified analysis of NUDGE-FLU (Nationwide Utilization of Danish Government Electronic Letter System for Increasing Influenza Vaccine Uptake) examined the effect of digital behavioral nudges on influenza vaccine uptake based on the presence of CVD. NUDGE-FLU was a randomized, pragmatic, nationwide, register-based trial that included Danish citizens 65 years of age or older during the 2022 to 2023 influenza season. Households were randomized in a 9:1:1:1:1:1:1:1:1:1 ratio to usual care or 9 electronic letters with designs based on behavioral concepts. Danish nationwide registers were used to collect baseline and outcome data. The primary end point was receipt of an influenza vaccine on or before January 1, 2023. The effects of the intervention letters were examined according to the presence of CVD and across cardiovascular subgroups that included heart failure, ischemic heart disease, and atrial fibrillation. Of 964 870 NUDGE-FLU participants from 691 820 households, 264 392 (27.4%) had CVD. During follow-up, 83.1% of participants with CVD versus 79.2% of participants without CVD received an influenza vaccination (P<0.001). Compared with usual care, a letter emphasizing the potential cardiovascular benefits of influenza vaccination increased vaccination rates; this effect was consistent in participants with CVD (absolute difference, +0.60 percentage points [99.55% CI, -0.48 to 1.68]) and without CVD (+0.98 percentage points [99.55% CI, 0.27-1.70; P for interaction=0.41). A repeated letter strategy with a reminder follow-up letter 14 days later was also effective in increasing influenza vaccination, irrespective of CVD (CVD: absolute difference, +0.80 percentage points [99.55% CI, -0.27 to 1.86]; no CVD: +0.67 percentage points [99.55% CI, -0.06 to 1.40]; P for interaction=0.77). Effectiveness of both nudging strategies was consistent across all major CVD subgroups. None of the other 7 nudging strategies were effective, regardless of CVD status. Electronic letter interventions emphasizing the potential cardiovascular benefits of influenza vaccination and using a reminder letter strategy were similarly beneficial in increasing influenza vaccination rates among older adults with and without CVD and across cardiovascular subgroups. Electronic nudges may improve influenza vaccine uptake in individuals with CVD. URL: https://www. gov; Unique identifier: NCT05542004.

Kampung Sungai to Kerala: A deadly zoonotic trail encroaching diverse geography

Background: Nipah virus is an emerging zoonotic virus which causes fatal encephalitis in South-East Asia region since 1999. Thereafter, it is prevalent almost every year in the different parts of Bangladesh and India. The aims of this analysis to describe the epidemiological patterns of the Nipah infection and also to highlight the factors for the recurrent outbreak in this region.&#x0D; Materials &amp; methods: Intensive web searching was done for documents and journals on Nipah Virus infection and Nipah outbreak from 1999 to 2018. A total of 279 research documents were found and about 40 papers, especially the PubMed indexed sources and newsletters distributed by different public health agencies were selected for the meta-analysis. Information gathered from the selected journals and documents were described in text and figures.&#x0D; Results: The analysis revealed that fruit bats of the Pteropus genus are the natural hosts of the virus. After documentation of only outbreak in Malaysia in 1999, Nipah virus struck in Meherpur in 2001 for the first time and thereby, creating a public health issue every year. Very recently, this deadly zoonotic virus caused fatality in Kerala, India which is far away from its usual prevalent region. It starts with the ingestion of Nipah infected raw date palm sap and direct contact with the infected person. Early diagnosis and strict isolation is the mainstay to prevent an outbreak. Strong public health measures can able to reduce both the frequency and mortality of the disease.&#x0D; Conclusions: Nipah virus infection is now one of the ten priority diseases listed by the World Health Organization considering its high fatality rate. However, effective health education and infection control practice is still considered as the mainstay of prevention of future Nipah outbreak.&#x0D; AKMMC J 2021; 12(1) : 52-57

Australians' experiences of COVID-19 during the early months of the crisis: A qualitative interview study.

The COVID-19 crisis has wrought major changes to people's lives across the globe since the beginning of the outbreak in early 2020. The "Australians' Experiences of COVID-19" qualitative descriptive study was established to explore how Australians from different geographical areas and social groups experienced the COVID-19 crisis. Three sets of semi-structured interviews, each with a diverse group of 40 adults across Australia, were completed between 2020 and 2022. This article reports findings from the first set of interviews, conducted by telephone in mid-2020. The participants discussed their experiences of living through this period, which was characterized by strong public health measures to contain the spread of COVID, including a national lockdown and border closures. Interview fieldnotes and verbatim transcripts were used to conduct an interpretive thematic analysis. The analysis is structured around the following five themes covering the quotidian and affective aspects of participants' lives in the early months of the COVID crisis: "disruption to routines;" "habituating to preventive measures;" "social isolation and loneliness;" "changes to work and education;" and "little change to life." A sixth theme concerns how participants responded to our question about what they imagined their lives would be like after the pandemic: "imagining post-COVID life." The crisis affected participants' experience of daily life variously according to such factors as their social circumstances and obligations as well as their histories of illness, making visible some of the unequal social and economic effects of the pandemic across different genders, ages, localities and socioeconomic groups. Our participants fell into three roughly equal groups: (i) those who found the lockdown and associated restrictions very difficult; (ii) those who reported feeling barely affected by these conditions; and (iii) those who found benefits to the "slowing down" of life during this period.

“Community members have more impact on their neighbors than celebrities”: leveraging community partnerships to build COVID-19 vaccine confidence

BackgroundVaccines are a strong public health tool to protect against severe disease, hospitalization, and death from COVID-19. Still, inequities in COVID-19 vaccination rates and health outcomes continue to exist among Black and Latino populations. Boston Medical Center (BMC) has played a significant role in vaccinating medically underserved populations, and organized a series of community-engaged conversations to better understand community concerns regarding the COVID-19 vaccine. This paper describes the themes which resulted from these community-engaged conversations and proposes next steps for healthcare leaders.MethodsWe accessed nine publicly available recordings of the community-engaged conversations which were held between March 2021 and September 2021 and ranged from 8 to 122 attendees. Six conversations prioritized specific groups: the Haitian-Creole community, the Cape Verdean community, the Latino community, the Black Christian Faith community, guardians who care for children living with disabilities, and individuals affected by systemic lupus erythematosus. Remaining conversations targeted the general public of the Greater Boston Area. We employed a Consolidated Framework for Implementation Research-driven codebook to code our data. Our analysis utilized a modified version of qualitative rapid analysis methods.ResultsFive main themes emerged from these community-engaged conversations: (1) Structural factors are important barriers to COVID-19 vaccination; (2) Mistrust exists due to the negative impact of systemic oppression and perceived motivation of the government; (3) There is a desire to learn more about biological and clinical characteristics of the COVID-19 vaccine as well as the practical implications of being vaccinated; (4) Community leaders emphasize community engagement for delivering COVID-19 information and education and; (5) Community leaders believe that the COVID-19 vaccine is a solution to address the pandemic.ConclusionThis study illustrates a need for community-engaged COVID-19 vaccine messaging which reflects the nuances of the COVID-19 vaccine and pandemic without oversimplifying information. In highlighting common concerns of the Greater Boston Area which contribute to a lack of confidence in the COVID-19 vaccine, we underscore important considerations for public health and healthcare leadership in the development of initiatives which work to advance health equity.

Rigorous theory-based intervention research is the bold action needed to address oral health disparities and inequities.

The Consensus Statement about behavioral and social sciences in oral health encourages future research to draw on testable theories that specify causal pathways that reflect the complex nature of oral health. In this commentary, we amplify the importance of explicit and well-specified theory in oral health intervention research, acknowledging that problematic use of theory has limited its utility in developing effective public health interventions. Also, we affirm the need to focus on determinants of oral health-and health inequities-most likely to drive meaningful change, and to understand the causal pathways that connect drivers of change from the individual to the global level. We view theory-based, causal mechanisms research as a powerful approach to building successful public health interventions, and suggest resources to inspire such research, including exemplary studies, methodologies, and collaborative initiatives that facilitate strong theory-based public health research.

Towards applying the essential public health functions for building health systems resilience: A renewed list and key enablers for operationalization.

The COVID-19 pandemic, climate change-related events, protracted conflicts, economic stressors and other health challenges, call for strong public health orientation and leadership in health system strengthening and policies. Applying the essential public health functions (EPHFs) represents a holistic operational approach to public health, which is considered to be an integrated, sustainable, and cost-effective means for supporting universal health coverage, health security and improved population health and wellbeing. As a core component of the Primary Health Care (PHC) Operational Framework, EPHFs also support the continuum of health services from health promotion and protection, disease prevention to treatment, rehabilitation, and palliative services. Comprehensive delivery of EPHFs through PHC-oriented health systems with multisectoral participation is therefore vital to meet population health needs, tackle public health threats and build resilience. In this perspective, we present a renewed EPHF list consisting of twelve functions as a reference to foster country-level operationalisation, based on available authoritative lists and global practices. EPHFs are presented as a conceptual bridge between prevailing siloed efforts in health systems and allied sectors. We also highlight key enablers to support effective implementation of EPHFs, including high-level political commitment, clear national structures for institutional stewardship on EPHFs, multisectoral accountability and systematic assessment. As countries seek to transform health systems in the context of recovery from COVID-19 and other public health emergencies, the renewed EPHF list and enablers can inform public health reform, PHC strengthening, and more integrated recovery efforts to build resilient health systems capable of managing complex health challenges for all people.

Doctor-patient bilateral matching considering diagnosis and treatment perception in the absence of public health resources.

The public health crisis is one of the main threats affecting the sustainable development of the economy and strengthening the rational allocation of medical resources is essential for building a strong public health system. Therefore, the study of the doctor-patient bilateral matching has important theoretical and practical significance and perception of diagnosis and treatment is taken as a key consideration in the research. Based on the current situation of the medical industry and the main contradiction between supply and demand of medical services, an evaluation index of doctor-patient satisfaction is constructed in this paper. Then, based on the different forms of evaluation, calculate the doctor's satisfaction and patient's satisfaction respectively. Taking maximizing the overall satisfaction of doctors and patients, maximizing the number of patients and minimizing the workload difference between doctors as the decision-making objectives, considering the upper limit of doctors' working hours as the constraint condition, a multi-objective decision-making model is constructed and solved by NSGA-II algorithm to realize the matching between doctors and patients. Finally, through the comparison with NSGA-III algorithm in three dimensions: the degree of convergence to the reference set, the propagation range of the solution and the running time of the algorithm, it is proved that NSGA-II algorithm has good performance in solving the matching problem of medical service supply and demand.

The 1889-90 flu pandemic in Greece: a social, cultural and economic history with lessons for the 21st century.

The 1889-1892 influenza pandemic is the first flu outbreak that can be demonstrated to have been truly worldwide in scope. Its initial spread, along with the successive waves, coincided with an uneasy period of economic and political instability in Greece. Greek historians have largely ignored this outbreak in a national setting and have exclusively focused on the economic crisis and social unrest of that era. As in other countries, it seems that in Greece, too, the case fatality ratio was low, but morbidity and public health issues gained importance. Culturally, it triggered the creation of a new terminology around disease and proved an inspiration for satirical magazines. The economic distress of large parts of the population contributed to the design of health measures of only limited impact, with the press being the main source for dissemination of new health information. Despite being separated by 130 years, the 1889 influenza pandemic and the COVID-19 pandemic share some striking similarities. They both spread across transport lines and were followed by spotty and multifocal subsequent waves, disproportionately affected the poorest and most vulnerable, and led to neologisms, strong public health debates, and shifts in employment habits and measures. As we move forward into the 21st century, it is essential that we are able to reflect on such shared trends over decades, which are true because of common and interactive co-determinants of infectious disease outbreak emergence and spread and our responses to them.

Workforce Anxiety Due to Covid-19 Pandemic: The Mediation Effect of Personal Finance among Private Labor Force in Kerala

The COVID-19 pandemic hit at its worse on the economic and social conditions of the workers across the world. Studying how COVID-19 has created anxiety among the private workforce in Kerala can contribute significant input to the policymakers. The place of this research is also important as Kerala is a state with a strong public health care system and a sizeable number of workers from Kerala are employed in the private sector. The objectives of this study are to measure the direct impact of COVID-19 on workforce anxiety and to analyze the mediation effect of personal finance on workforce anxiety during the COVID-19 pandemic. Principal Component Analysis was done to identify the influential variables under each factor. After ensuring the reliability, validity, and consistency of the questions, the regression analysis was carried out. The statistical software’s IBM SPSS Statistics 20 and PROCESS macro 3.5 were used for data analysis. The initial hypothesis (H1) of this study was COVID-19 has a direct relationship with the worker's anxiety. The result of the regression analysis confirmed this assumption. The mediating role of personal finance during the impact of COVID-19 on the worker's anxiety was tested through the bootstrapping method and the indirect effect of COVID-19 on the worker's anxiety through personal finance is also positive and significant. This study is suggesting numerous measures to the policymakers and to the corporate for addressing the worker's anxiety in the social and economic levels.

A retrospective study of hepatitis B vaccination in preterm birth and low birth weight infants born to hepatitis B surface antigen-positive mothers: Time to close the policy-practice gap

ABSTRACT National Immunization Program-version 2016 (ISIV-NIP-v2016) recommended a 4-dose hepatitis B vaccine (HepB) schedule for preterm birth (PTB) and low birth weight (LBW) infants born to HBsAg-positive mothers. However, the implementation of this immunization strategy in the past five years has not been fully evaluated in China. We reviewed the data of pregnant women and live-born infants from 24 hospitals between 2016 and 2021 in Lu’an, Anhui province, to estimate the prevalence of PTB, LBW, and hepatitis B virus (HBV) infected pregnant women. We analyzed the vaccination status of HepB and HBIG among PTB and LBW infants born to HBsAg-positive mothers. A total of 160 222 pregnant women and 159 613 live-born infants were included in this study. The estimated prevalence of PTB, LBW and HBV-infected pregnant women was 3.86% (range: 3.28%-5.10%), 2.77% (range: 2.12%-3.66%), and 3.27% (range: 3.03%-3.49%), respectively. We screened 340 PTB and LBW infants born to HBsAg-positive mothers between 2016 and 2020. We found that the coverage of HepB and HBIG among them was 100% and 99.39%. However, the timely vaccination rate of the HepB birth dose was only 78.59% and only four children (1.22%) received the 4-dose HepB as recommended by ISIV-NIP-v2016. The 4-dose of HepB for PTB and LBW infants born to HBsAg-positive mothers recommended by ISIV-NIP-v2016 was not fully implemented. A strong public health intervention should be taken to close the policy-practice gap in China in the future.

Compulsion to consume highly processed foods: addiction or 'para-addiction'.

Compulsion to consume highly processed foods: addiction or 'para-addiction'.

Cancer situation in China: what does the China cancer map indicate from the first national death survey to the latest cancer registration?

Over the past four decades, the Chinese government has conducted three surveys on the distribution of causes of death and built cancer registration. In order to shine a new light on better cancer prevention strategies in China, we evaluated the profile of cancer mortality over the forty years and analyzed the policies that have been implemented. We described spatial and temporal changes in both cancer mortality and the ranking of major cancer types in China based on the data collected from three national surveys during 1973-1975, 1990-1992, 2004-2005, and the latest cancer registration data published by National Central Cancer Registry of China. The mortality data were compared after conversion to age-standardized mortality rates based on the world standard population (Segi's population). The geographical distribution characteristics were explored by marking hot spots of different cancers on the map of China. From 1973 to 2016, China witnessed an evident decrease in mortality rate of stomach, esophageal, and cervical cancer, while a gradual increase was recorded in lung, colorectal, and female breast cancer. A slight decrease of mortality rate has been observed in liver cancer since 2004. Lung and liver cancer, however, have become the top two leading causes of cancer death for the last twenty years. From the three national surveys, similar profiles of leading causes of cancer death were observed among both urban and rural areas. Lower mortality rates from esophageal and stomach cancer, however, have been demonstrated in urban than in rural areas. Rural areas had similar mortality rates of the five leading causes of cancer death with the small urban areas in 1973-1975. Additionally, rural areas in 2016 also had approximate mortality rates of the five leading causes with urban areas in 2004-2005. Moreover, stomach, esophageal, and liver cancer showed specific geographical distributions. Although mortality rates have decreased at most of the hotspots of these cancers, they were still higher than the national average levels during the same time periods. Building up a strong primary public health system especially among rural areas may be one critical step to reduce cancer burden in China.

Together for better health in Germany. Towards a public health strategy

Abstract In Germany, the responsibility for public health is divided both between federal levels and between sectors, and there is no national or general strategy for public health. However, a strategy is essential for achieving the overarching goal of ensuring the best possible health for all people, including preventing and addressing significant health challenges such as pandemics and climate change. In 2016, Zukunftsforum Public Health (Future Forum Public Health) was established with the primary goal to enhance coherence and collaboration between public health stakeholders from academia, policy and practice. According to the principle of health in all policies, it also aims to promote collaboration across federal levels and political sectors. Within the platform provided by Future Forum, the public health community agreed that a strategy was necessary for strengthening and uniting the disparate field of German public health even though no official mandate for developing a strategy existed. Thus, Future Forum launched a grassroots process to identify key elements for a strong and resilient public health system, based on the essential public health operations (EPHOs), as defined by WHO Europe. For each of the ten EPHOs, the key issues paper “Towards a Public Health Strategy - Together for Better Health in Germany” presents a description of the current situation and challenges, an introduction to the key players, a definition of the aims and objectives, and concrete proposals on how to achieve these. Through its participative nature, the process of developing the key issues itself was an important factor for strengthening the public health community. This process highlights that even where national public health strategies and structures are missing, grassroots public health movements can be effective in strengthening the public health community as well as producing a visible set of recommendations for a resilient public health system. Key messages • Based on WHO’s essential public health operations, Future Forum Public Health developed a key issues paper with guidelines for a resilient public health system. • The participative process leading to the key issues paper was itself an important factor for networking and strengthening Germany’s public health community.